Management of the patient with suspected perioperative nerve injury

Management of the Patient with Suspected Perioperative Nerve Injury

@EMARIANOMD@EMARIANOMD

Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of MedicineStanford University School of MedicineChief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System

Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury

Financial DisclosuresFinancial Disclosures Halyard Health, B Braun – Halyard Health, B Braun –

Unrestricted educational program Unrestricted educational program funding paid to my institutionfunding paid to my institution

The contents of the following The contents of the following presentation are solely the presentation are solely the responsibility of the speaker without responsibility of the speaker without input from any of the above input from any of the above companies.companies.


DisclaimerDisclaimer This presentation is intended for This presentation is intended for

educational purposes only and is not educational purposes only and is not meant to be reproduced or meant to be reproduced or redistributed for commercial redistributed for commercial purposespurposes


Learning ObjectivesLearning Objectives Discuss potential risks for Discuss potential risks for

perioperative nerve injuryperioperative nerve injury Estimate occurrence rates of various Estimate occurrence rates of various

regional anesthesia complicationsregional anesthesia complications Evaluate the patient with suspected Evaluate the patient with suspected

nerve injury and recommend nerve injury and recommend appropriate testingappropriate testing


Incidence of ComplicationsIncidence of Complications SOS Regional Anesthesia Hotline ServiceSOS Regional Anesthesia Hotline Service 10-month prospective study10-month prospective study Voluntary reporting: Voluntary reporting: 487487/8,150 /8,150

anesthesiologists agreed to participateanesthesiologists agreed to participate 56 major complications reported out of 56 major complications reported out of

158,083 regional anesthesia procedures158,083 regional anesthesia procedures– 78,104 central neuraxial (CNB)78,104 central neuraxial (CNB)– 50,223 peripheral (PNB)50,223 peripheral (PNB)

Auroy Y, et al. Anesth Auroy Y, et al. Anesth 2002;97:12742002;97:1274


CNB Complications (Non-CNB Complications (Non-OB)OB)

CardiaCardiac c

Arrest Arrest

Resp Resp FailureFailure

SeizurSeizuree

Nerve Nerve InjuryInjury

DeathDeath

SpinalSpinal 2.52.5 0.60.6 0.30.3 2.52.5 0.80.8EpidurEpiduralal

00 00 1.81.8 00 00

*Values expressed as n/10,000*Values expressed as n/10,000



Spinal ComplicationsSpinal Complications Retrospective review of 4767 Retrospective review of 4767

consecutive spinal anestheticsconsecutive spinal anesthetics Postdural puncture headache (1.3%)Postdural puncture headache (1.3%)

– 38/63 resolved with conservative 38/63 resolved with conservative treatmenttreatment

Persistent paresthesia (0.13%)Persistent paresthesia (0.13%) Infection (0.04%)Infection (0.04%)

– 2 cases: disc space infection, paraspinal 2 cases: disc space infection, paraspinal abscessabscess

Horlocker TT, et al. A&A Horlocker TT, et al. A&A 1997;84:578 1997;84:578


PNB ComplicationsPNB ComplicationsCardiaCardia

c c Arrest Arrest

Resp Resp FailurFailur

ee

SeizurSeizuree

Nerve Nerve InjuryInjury

Interscalene Interscalene (3,459)(3,459)

00 00 00 2.92.9

Supraclav (1,899)Supraclav (1,899) 00 00 5.35.3 00Axillary (11,024)Axillary (11,024) 00 00 0.90.9 1.81.8Lumbar plexus Lumbar plexus (394)(394)

25.425.4 50.850.8 25.425.4 00

Femoral (10,309)Femoral (10,309) 00 00 00 2.92.9Popliteal (952)Popliteal (952) 00 00 00 31.531.5*Values expressed as n/10,000*Values expressed as n/10,000



Neurologic ComplicationsNeurologic Complications Spinal anesthesia (n=12)Spinal anesthesia (n=12)

– 9 developed peripheral neuropathy9 developed peripheral neuropathy– 3 developed cauda equina3 developed cauda equina– 3/12 with sequelae > 6 mos 3/12 with sequelae > 6 mos (all 3 (all 3

reported paresthesia)reported paresthesia) Peripheral nerve block (n=12)Peripheral nerve block (n=12)

– 9/12 employed nerve stimulation9/12 employed nerve stimulation (3/9 (3/9 reported needle current < 0.5 mA)reported needle current < 0.5 mA)

– 7/12 with sequelae > 6 mos 7/12 with sequelae > 6 mos Auroy Y, et al. Anesth Auroy Y, et al. Anesth

2002;97:12742002;97:1274


Meta-Analysis of Nerve Meta-Analysis of Nerve InjuryInjury

Data from 32 studies (1/1/95 - Data from 32 studies (1/1/95 - 12/31/05) in adult patients 12/31/05) in adult patients

Rates of occurrence (any Rates of occurrence (any neuropathy):neuropathy):– CNB = <4:10,000 or CNB = <4:10,000 or 0.04% 0.04% – PNB = <3:100 or PNB = <3:100 or 3%*3%*

Permanent neurological injuryPermanent neurological injury– CNB = 0-7.6:10,000CNB = 0-7.6:10,000– PNB = insufficient data (1 case)PNB = insufficient data (1 case)

Brull R, et al. A&A Brull R, et al. A&A 2007;104:9652007;104:965

*Depends on nerve block *Depends on nerve block sitesite


Rates of Occurrence (Nerve Rates of Occurrence (Nerve Injury)Injury)

Rate Rate (per 10,000)(per 10,000)SpinalSpinal 3.783.78EpiduralEpidural 2.192.19

Rate Rate (per 100)(per 100)InterscaleneInterscalene 2.842.84AxillaryAxillary 1.481.48FemoralFemoral 0.340.34SciaticSciatic 0.410.41

Brull R, et al. A&A Brull R, et al. A&A 2007;104:9652007;104:965


Interscalene ComplicationsInterscalene Complications Prospective observational study (n=520)Prospective observational study (n=520)

AcuteAcute N (%)N (%)CNS intoxicationCNS intoxication 1 (0.2)1 (0.2)PneumothoraxPneumothorax 1 (0.2)1 (0.2)

Non-AcuteNon-Acute N (%)N (%)Peripheral neuropathyPeripheral neuropathy 1 (0.2)1 (0.2)Plexus damage > 9 mosPlexus damage > 9 mos 1 (0.2)1 (0.2)

Borgeat A, et al. Anesth Borgeat A, et al. Anesth 2001;95:8752001;95:875


Complications of Continuous Complications of Continuous PNBPNB

1,422 consecutive 1,422 consecutive adult patients adult patients

8 university 8 university hospitals in hospitals in France and France and BelgiumBelgium

Data collected Data collected over 1 yearover 1 year

Capdevila X, et al. Anesth Capdevila X, et al. Anesth 2005;103:10352005;103:1035


Serious Adverse Events from Serious Adverse Events from CPNBCPNB

12 direct adverse events (0.8%): 12 direct adverse events (0.8%): all all resolved without sequelaeresolved without sequelae– Hypotension (3, all lumbar plexus)Hypotension (3, all lumbar plexus)– Systemic toxicity (2)Systemic toxicity (2)– Respiratory distress (4, all interscalene)Respiratory distress (4, all interscalene)– Neuropathy (3, all FNB and 2/3 under GA)Neuropathy (3, all FNB and 2/3 under GA)

One case of psoas muscle abscess in a One case of psoas muscle abscess in a diabetic: recovered with IV abx, and diabetic: recovered with IV abx, and no bacteremiano bacteremia



CPNB Complications and CPNB Complications and RisksRisks

Risk FactorRisk Factor Odds Ratio (95% CI)Odds Ratio (95% CI)NeurologiNeurologiccEventsEvents

ICU stayICU stay 9.89.8 (2.0-38.5) (2.0-38.5)Age <40yAge <40y 3.93.9 (1.6-9.8) (1.6-9.8)BupivacaineBupivacaine 2.72.7 (1.1-6.8) (1.1-6.8)

InfectiousInfectiousEventsEvents

Infusion >2dInfusion >2d 4.64.6 (1.6-15.9) (1.6-15.9)Male genderMale gender 2.12.1 (1.1-4.1) (1.1-4.1)



Mechanism of Nerve InjuryMechanism of Nerve Injury

Hadzic A, et al. RAPM Hadzic A, et al. RAPM 2004;29:4172004;29:417

Kapur E, et al. Acta 2007;51:101Kapur E, et al. Acta 2007;51:101Selander D, et al. Acta Selander D, et al. Acta 1977;21:1821977;21:182

Intraneural Intraneural Injection?Injection?

Long Bevel Long Bevel Needle Needle 1414°°??

Bevel Bevel OrientationOrientation

??

Rice AS, et al. BJA 1992;69:433Rice AS, et al. BJA 1992;69:433

Hi Injection Hi Injection Pressure?Pressure?

30+ 30+ YearYear

ss


Bevel and Orientation Bevel and Orientation Rabbit model: nerves impaled with 14Rabbit model: nerves impaled with 14° °

vs. 45° beveled needles, evaluated vs. 45° beveled needles, evaluated after 2hafter 2h11

– Neuronal injury: Neuronal injury: 90%90% (14 (14°°) vs. 53% () vs. 53% (45°45°))– Injuries more severe with Injuries more severe with transversetransverse

orientation vs. parallelorientation vs. parallel Rat model: long- (LB) vs. short-beveled Rat model: long- (LB) vs. short-beveled

(SB) needles, evaluated at 7d and 28d(SB) needles, evaluated at 7d and 28d22

– LB parallel less damaging than LB/SB LB parallel less damaging than LB/SB transversetransverse

– SB injuries more severe at 28d vs. LBSB injuries more severe at 28d vs. LB1. Selander D, et al. Acta 1. Selander D, et al. Acta 1977;21:1821977;21:182

2. Rice AS, et al. BJA 2. Rice AS, et al. BJA 1992;69:4331992;69:433


Intraneural InjectionIntraneural Injection Myth #1:Myth #1: using traditional techniques, using traditional techniques,

intraneural injection is a rare eventintraneural injection is a rare event– 21/26 pts with paresthesia-seeking ax block21/26 pts with paresthesia-seeking ax block11

Myth #2:Myth #2: when using a nerve stimulator, when using a nerve stimulator, a twitch at > 0.5 mA = extraneurala twitch at > 0.5 mA = extraneural– 45% of intraneural insertions stim > 0.5 mA45% of intraneural insertions stim > 0.5 mA22

Myth #3:Myth #3: intraneural = nerve injury intraneural = nerve injury– When pressure < 12 psi, recovery in 24 hWhen pressure < 12 psi, recovery in 24 h33

1. Bigeleisen PE. Anesth 1. Bigeleisen PE. Anesth 2006;105:7792006;105:779

3. Kapur E, et al. Acta 3. Kapur E, et al. Acta 2007;51:1012007;51:1012. Chan, VWS, et al. A&A 2. Chan, VWS, et al. A&A

2007;104:12812007;104:1281


Chemical Neurotoxicity of Chemical Neurotoxicity of LALA

IntrafascicularIntrafascicular injection worse than injection worse than intraneural extrafascicular injectionintraneural extrafascicular injection11

PerineuralPerineural injection of common LA injection of common LA (lido, bupiv, mepiv, tetra, procaine) (lido, bupiv, mepiv, tetra, procaine) does not result in axonal degenerationdoes not result in axonal degeneration22

Reduction in nerve blood flow with Reduction in nerve blood flow with topicaltopical lidocaine lidocaine ± epinephrine± epinephrine33

– 19% (1% plain), 39% (2% plain), 19% (1% plain), 39% (2% plain), 78%78% (2% (2% with epinephrinewith epinephrine 1:200k) 1:200k)33

2. Gentili F, et al. Neurosurg 2. Gentili F, et al. Neurosurg 1980;6:2631980;6:263

1. Gentili F, et al. Neurosurg 1. Gentili F, et al. Neurosurg 1979;4:2441979;4:244

3. Myers RR, et al. Anesth 3. Myers RR, et al. Anesth 1989;71:7571989;71:757


Many Contributing FactorsMany Contributing FactorsPatient:Patient: CNS disorderCNS disorder Extreme BMIExtreme BMI

Male Male DiabetesDiabetesAgeAge PositioningPositioning

Surgery:Surgery: Trauma/stretchTrauma/stretch BleedingBleedingTourniquetTourniquet InfectionInfectionInflammationInflammation Cast Cast

compressioncompressionAnesthesiAnesthesia:a:

LA toxicityLA toxicity VasoconstrictionVasoconstriction

Perineural Perineural edemaedema

Needle traumaNeedle traumaNeal JM, et al. RAPM Neal JM, et al. RAPM

2002;27:4022002;27:402


Nerve Injury and “Double Nerve Injury and “Double Crush”Crush”

Theory: preexisting nerve lesions may Theory: preexisting nerve lesions may predispose nerve to further injurypredispose nerve to further injury11

Nerve block-induced injury = 2Nerve block-induced injury = 2ndnd crush? crush?– Case reports: ISB and cisplatin-induced Case reports: ISB and cisplatin-induced

neurotoxicityneurotoxicity22 and multiple sclerosis and multiple sclerosis33

– Retrospective review: 2/567 pts with Retrospective review: 2/567 pts with preexisting neuropathy had progressive preexisting neuropathy had progressive symptoms after CNBsymptoms after CNB44

Clinical evidence not conclusiveClinical evidence not conclusive1. Upton AR, et al. Lancet 1973;2:3591. Upton AR, et al. Lancet 1973;2:359

2. Hebl JR, et al. A&A 2001;92:2492. Hebl JR, et al. A&A 2001;92:2493. Koff MD, et al. Anesth 2008;108:3253. Koff MD, et al. Anesth 2008;108:3254. Hebl JR, et al. A&A 2006;103:12944. Hebl JR, et al. A&A 2006;103:1294


What Do You Tell Patients?What Do You Tell Patients? Discuss benefitsDiscuss benefits Discuss risksDiscuss risks

– BleedingBleeding– InfectionInfection– Nerve injuryNerve injury

Incidence of nerve injury not Incidence of nerve injury not clear:clear: 1/4185 1/4185 – 3/100– 3/1001-31-3

Select patients and surgeons carefullySelect patients and surgeons carefully1. Auroy Y, et al. Anesth 1. Auroy Y, et al. Anesth 2002;97:12742002;97:1274

2. Brull R, et al. A&A 2007;104:9652. Brull R, et al. A&A 2007;104:9653. Barrington MJ, et al. RAPM 3. Barrington MJ, et al. RAPM 2009;34:5342009;34:534


Diagnosis of Nerve InjuryDiagnosis of Nerve Injury Meticulous patient follow-up is Meticulous patient follow-up is

essentialessential Single-injection nerve blocks: call Single-injection nerve blocks: call

outpatients or visit inpatientsoutpatients or visit inpatients– Assess for recovery of gross sensation Assess for recovery of gross sensation

and motor functionand motor function– Evaluate areas of residual block vs. Evaluate areas of residual block vs.

neurologic deficit by physical examneurologic deficit by physical exam Continuous catheters: daily phone call Continuous catheters: daily phone call

or inpatient visit or inpatient visit Ilfeld BM, et al. RAPM Ilfeld BM, et al. RAPM

2003;28:4182003;28:418


If Nerve Injury is If Nerve Injury is Suspected…Suspected…

Review procedure Review procedure documentationdocumentation

Perform careful physical exam Perform careful physical exam to assess affected areas and to assess affected areas and level of lesionlevel of lesion

Consider early Neurologist Consider early Neurologist consultationconsultation

If compressive hematoma If compressive hematoma suspected, evaluate with suspected, evaluate with MRI/CTMRI/CT

Borgeat A. Minerva Anes Borgeat A. Minerva Anes 2005;71:3532005;71:353


Electrophysiological TestingElectrophysiological Testing Electromyography (EMG):Electromyography (EMG): employs employs

needle electrode into muscleneedle electrode into muscle– Identify injury pattern (fibrillation, Identify injury pattern (fibrillation,

abnormal discharges or recruitment abnormal discharges or recruitment pattern)pattern)

– May help determine May help determine chronicitychronicity of injury: of injury: acute vs. preexistingacute vs. preexisting

Nerve Conduction Study (NCS):Nerve Conduction Study (NCS): measures velocity, latency, and measures velocity, latency, and amplitude for peripheral nerves, may amplitude for peripheral nerves, may identify identify focal lesionfocal lesion Borgeat A. Minerva Anes Borgeat A. Minerva Anes

2005;71:3532005;71:353Mayfield JB. Anes Clin Mayfield JB. Anes Clin 2005;43:1192005;43:119


Classification of Nerve InjuryClassification of Nerve Injury Neuropraxia:Neuropraxia: mild insult resulting mild insult resulting

from impulse conduction failurefrom impulse conduction failure– EMG normal, NCS decreased velocity EMG normal, NCS decreased velocity

and/or increased latenciesand/or increased latencies Axonotmesis:Axonotmesis: axonal disruption with axonal disruption with

connective tissue intactconnective tissue intact– EMG and NCS abnormalEMG and NCS abnormal– Neural regeneration occurs (1-3 mm/day)Neural regeneration occurs (1-3 mm/day)

Neurotmesis:Neurotmesis: complete disruption, complete disruption, poor prognosispoor prognosis



Testing RecommendationsTesting Recommendations EMG/NCS in 1-3 days to EMG/NCS in 1-3 days to

assess chronicity of injuryassess chronicity of injury If EMG normal, repeat in If EMG normal, repeat in

3-4 weeks3-4 weeks If either test abnormal, If either test abnormal,

repeat in 6 monthsrepeat in 6 months Serial studies generally Serial studies generally

not necessary—follow not necessary—follow progress clinicallyprogress clinically


Mayfield JB. Anes Clin Mayfield JB. Anes Clin 2005;43:1192005;43:119


SummarySummary We discussed potential risks for We discussed potential risks for

perioperative nerve injuryperioperative nerve injury We estimated occurrence rates of We estimated occurrence rates of

various regional anesthesia various regional anesthesia complicationscomplications

We discussed how to evaluate the We discussed how to evaluate the patient with suspected nerve injury patient with suspected nerve injury and recommend appropriate testingand recommend appropriate testing

Management of the patient with suspected perioperative nerve injury

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