Anesth Analg 2006;103:1046
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000239018.73597.d6
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
Safety of the Posterior Approach to the Brachial Plexus
Nigel T. M. Jack, FFARCS, and
Mathieu Gielen, MD, PhD
St. Maartenskliniek Nijmegen; nigel.jack{at}wxs.nl (Jack)
Radboud University Medical Centre; Nijmegen, The Netherlands (Gielen)
To the Editor:
We write in reaction to the letter by Voermans et al. (1), which describes a tragic complication of the posterior approach to the brachial plexus. Unfortunately, the letter contains a number of inaccuracies, which we feel may not be ignored.
The title of the letter would seem to us to have been more accurate if it had stated "permanent partial loss ..., " as some recovery occurred.
The posterior approach to the brachial plexus, like the lateral approach, is capable of causing serious complications (2,3). These complications are nearly always the result of errors in technique.
According to the authors, in this case, the landmarks were drawn in the sitting position, and the block was set in the supine position. The supine position is with the patient lying on the back, which would make the posterior approach to the brachial plexus more or less impossible. We presume that the lateral decubitus position is meant. The reference quoted refers to the original article by Pippa et al., but he used the sitting position, and not the lateral (4). It is unclear what the reasons were for this change in position during the procedure. Performance of the block in the lateral position is possible, but it is certainly inadvisable to draw landmarks in one position, and then carry out the injection in another as the landmarks can shift over the bony structures, especially in obese patients. Few would consider doing this for a spinal anesthetic, for example. The authors recognize that this is a potential cause of the incident.
According to the authors, a flexible 25-gauge 10-cm Stimuplex stimulating needle from B Braun was used. We are not aware of the existence of this B Braun needle, and certainly would not recommend using a 10-cm 25-gauge needle for this block, as this would be much too prone to bending during introduction. We assume that in this case a 21-gauge needle was used.
The technique was "complicated" by bony contact. This is certainly no complication: the technique as described by Pippa et al. (4) uses bony contact with the transverse process of C7 as a useful depth landmark. The needle should be withdrawn to the subcutaneous tissues, before being redirected to pass over the transverse process (5). It is unclear from the letter whether the needle was withdrawn in this way, and failure to do so may have lead to deviation toward the midline as the authors themselves suggest.
The technical description of the block is too incomplete to judge whether mistakes were made. We do not know whether the Raj test and slow incremental injection were used, and the description of the muscle twitches is not specific.
The comment that a rather large dose of local anesthetic was used is correct, but it should be pointed out that, although smaller doses are possibly just as effective, 40 mL is used in many institutions, including our own.
We object to the last sentence, in which the authors question the safety of the posterior approach, with the implication that the lateral approach may be safer. Both of the approaches are safe, provided they are carried out correctly and with a meticulous technique, and two recent articles attest to the safety of the posterior approach (6,7). A comparison of the risks of severe complications would mean a study with an impossibly large number of patients, and will probably never be performed. A regional block technique for shoulder surgery, which is known to cause severe postoperative pain, may be considered essential. The literature up until now, including this case report, does not support the use of one technique above the other on safety grounds. In this case, the letter does not give sufficient information to conclude that the technique was faulty, but the incident does serve to underline the potential dangers and the importance of training in the performance of brachial plexus blocks above the clavicle.
REFERENCES
- Voermans NC, Crul BJ, de Bondt B, et al. Permanent loss of cervical spinal cord function associated with the posterior approach. Anesth Analg 2006;102:330–1.[Free Full Text]
- Aramideh M, van den Oever HL, Walstra GJ, Dzoljic M. Spinal anesthesia as a complication of brachial plexus block using the posterior approach. Anesth Analg 2002;94:1338–9.[Abstract/Free Full Text]
- Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000;93:1541–4.[Web of Science][Medline]
- Pippa P, Cominelli E, Marinelli C, Alto S. Brachial plexus block using the posterior approach. Eur J Anaesth 1990;7:411–20.[Web of Science]
- Jack NTM. Posterior approach to the Brachial Plexus. Letter to the editor. Reg Anesth and Pain Med 2005;30:594–5.
- Sandefo I, Iohom G, Van Elstraete A, et al. Clinical efficacy of the brachial plexus block via the posterior approach. Reg Anesth Pain Med 2005;30:238–42.[Web of Science][Medline]
- Sandefo I, Iohom G, Van Elstraete A, Lebrun T, Polin B. Patient-controlled interscalene analgesia after shoulder surgery: catheter insertion by the posterior approach. Anesth Analg 2005;100:1496–8.[Abstract/Free Full Text]
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