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College of Physicians and Surgeons, Columbia University, St. Luke’s-Roosevelt Hospital Center, New York, NY, admir{at}nysora.com
In Response:
We would like to thank Dr. Chelly for taking an interest in our report. However, we strongly disagree with his discounting the risks of intraneural injection and neurologic complications with peripheral nerve blocks (PNBs). His statements disagree even with his own recent teaching. In another letter to the editor he states, "It is unrealistic to believe that all complications associated with PNBs can be prevented" and that "no one is immune from complications when performing PNBs" (1). In our patient, the remote location of the surgery (ankle) from the site of block placement (upper thigh) alone eliminates the operative procedure as the cause of the injury to the common peroneal nerve (2).
Dr. Chelly’s disbelief that intraneural injection carries a risk of nerve injury also contradicts his own views in another letter to the editor where he teaches that "proper needle type should be used to reduce the risk of such complications" (1). The deleterious effects of intraneural injections should not be a matter of debate; they have been known to clinicians since the introduction of the hypodermic needle and IM injection of penicillin (3,4) and have been unequivocally and reproducibly documented in a variety of experimental settings (5).
The assertion that the high resistance to injection in our patient might have been related to "an occlusion of the bevel by the lesser trochanter" rather than intraneural injection does not make anatomical sense. Moreover, it contradicts Dr Chelly’s own data; the sciatic nerve is situated posterior to the lesser trochanter (6). Because intraneural injection may be associated with high resistance to injection, assessment of the resistance to injection is an important element of nerve block documentation (7). However, the lack of means to objectively assess resistance to injection substantially limits its value as a monitor, as was the case in our patient. Subjective assessment ("syringe feel") of resistance to injection is inaccurate and can vary greatly among practitioners, making it analogous to documenting blood pressure by assessing the "finger feel" of the radial artery pulse instead of objectively measuring blood pressure with a sphygmomanometer (8).
The occurrence of sciatic nerve injury in our patient was devastating to all involved and made us acutely aware of our limitations to detect and prevent intraneural injection. Neurologic injury after PNBs can occur even with experienced clinicians, regardless of the type of the needle or the nerve localization and premedication techniques used (2,9). This must change. The introduction of standard monitoring and the ASA publication of practice guidelines has greatly enhanced the safety of general anesthesia practice (10). Administration of PNBs, on the other hand, is based entirely on individual preferences, clinical impressions, and subjective monitoring methods. We must dispense with the current dogmas and beliefs and work to develop practice guidelines and reliable monitoring during PNBs to transform this specialty into a more exacting and reproducible clinical discipline. Without such efforts, the future of PNBs and their role in modern anesthesiology will be questionable.
References
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