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Management of the patient with suspected perioperative nerve injury

Management of the patient with suspected perioperative nerve injury

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At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.

At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.

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Management of the patient with suspected perioperative nerve injury

  1. 1. 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 Medicine Chief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative Care Veterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System
  2. 2. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Financial DisclosuresFinancial Disclosures  Halyard Health, B Braun – UnrestrictedHalyard Health, B Braun – Unrestricted educational program funding paid to myeducational program funding paid to my institutioninstitution The contents of the following presentationThe contents of the following presentation are solely the responsibility of the speakerare solely the responsibility of the speaker without input from any of the abovewithout input from any of the above companies.companies.
  3. 3. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury DisclaimerDisclaimer  This presentation is intended forThis presentation is intended for educational purposes only and is noteducational purposes only and is not meant to be reproduced or redistributedmeant to be reproduced or redistributed for commercial purposesfor commercial purposes
  4. 4. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Learning ObjectivesLearning Objectives  Discuss potential risks for perioperativeDiscuss potential risks for perioperative nerve injurynerve injury  Estimate occurrence rates of variousEstimate occurrence rates of various regional anesthesia complicationsregional anesthesia complications  Evaluate the patient with suspected nerveEvaluate the patient with suspected nerve injury and recommend appropriate testinginjury and recommend appropriate testing
  5. 5. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury 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 of56 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 2002;97:1274Auroy Y, et al. Anesth 2002;97:1274
  6. 6. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury CNB Complications (Non-OB)CNB Complications (Non-OB) CardiacCardiac ArrestArrest RespResp FailureFailure SeizureSeizure NerveNerve InjuryInjury DeathDeath SpinalSpinal 2.52.5 0.60.6 0.30.3 2.52.5 0.80.8 EpiduraEpidura ll 00 00 1.81.8 00 00 *Values expressed as n/10,000*Values expressed as n/10,000 Auroy Y, et al. Anesth 2002;97:1274Auroy Y, et al. Anesth 2002;97:1274
  7. 7. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Spinal ComplicationsSpinal Complications  Retrospective review of 4767 consecutiveRetrospective review of 4767 consecutive spinal anestheticsspinal anesthetics  Postdural puncture headache (1.3%)Postdural puncture headache (1.3%) – 38/63 resolved with conservative treatment38/63 resolved with conservative treatment  Persistent paresthesia (0.13%)Persistent paresthesia (0.13%)  Infection (0.04%)Infection (0.04%) – 2 cases: disc space infection, paraspinal2 cases: disc space infection, paraspinal abscessabscess Horlocker TT, et al. A&A 1997;84:578Horlocker TT, et al. A&A 1997;84:578
  8. 8. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury PNB ComplicationsPNB Complications CardiacCardiac ArrestArrest RespResp FailureFailure SeizurSeizur ee NerveNerve InjuryInjury Interscalene (3,459)Interscalene (3,459) 00 00 00 2.92.9 Supraclav (1,899)Supraclav (1,899) 00 00 5.35.3 00 Axillary (11,024)Axillary (11,024) 00 00 0.90.9 1.81.8 Lumbar plexus (394)Lumbar plexus (394) 25.425.4 50.850.8 25.425.4 00 Femoral (10,309)Femoral (10,309) 00 00 00 2.92.9 Popliteal (952)Popliteal (952) 00 00 00 31.531.5 *Values expressed as n/10,000*Values expressed as n/10,000 Auroy Y, et al. Anesth 2002;97:1274Auroy Y, et al. Anesth 2002;97:1274
  9. 9. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury 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 mos3/12 with sequelae > 6 mos (all 3 reported(all 3 reported paresthesia)paresthesia)  Peripheral nerve block (n=12)Peripheral nerve block (n=12) – 9/12 employed nerve stimulation9/12 employed nerve stimulation (3/9 reported(3/9 reported needle current < 0.5 mA)needle current < 0.5 mA) – 7/12 with sequelae > 6 mos7/12 with sequelae > 6 mos Auroy Y, et al. Anesth 2002;97:1274Auroy Y, et al. Anesth 2002;97:1274
  10. 10. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Meta-Analysis of Nerve InjuryMeta-Analysis of Nerve Injury  Data from 32 studies (1/1/95 - 12/31/05) inData from 32 studies (1/1/95 - 12/31/05) in adult patientsadult patients  Rates of occurrence (any neuropathy):Rates of occurrence (any neuropathy): – CNB = <4:10,000 orCNB = <4:10,000 or 0.04%0.04% – PNB = <3:100 orPNB = <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 2007;104:965Brull R, et al. A&A 2007;104:965*Depends on nerve block site*Depends on nerve block site
  11. 11. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Rates of Occurrence (Nerve Injury)Rates of Occurrence (Nerve Injury) RateRate (per 10,000)(per 10,000) SpinalSpinal 3.783.78 EpiduralEpidural 2.192.19 RateRate (per 100)(per 100) InterscaleneInterscalene 2.842.84 AxillaryAxillary 1.481.48 FemoralFemoral 0.340.34 SciaticSciatic 0.410.41 Brull R, et al. A&A 2007;104:965Brull R, et al. A&A 2007;104:965
  12. 12. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury 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 2001;95:875Borgeat A, et al. Anesth 2001;95:875
  13. 13. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Complications of Continuous PNBComplications of Continuous PNB  1,422 consecutive1,422 consecutive adult patientsadult patients  8 university8 university hospitals in Francehospitals in France and Belgiumand Belgium  Data collected overData collected over 1 year1 year Capdevila X, et al. Anesth 2005;103:1035Capdevila X, et al. Anesth 2005;103:1035
  14. 14. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Serious Adverse Events from CPNBSerious Adverse Events from CPNB  12 direct adverse events (0.8%):12 direct adverse events (0.8%): allall 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 aOne case of psoas muscle abscess in a diabetic: recovered with IV abx, and nodiabetic: recovered with IV abx, and no bacteremiabacteremia Capdevila X, et al. Anesth 2005;103:1035Capdevila X, et al. Anesth 2005;103:1035
  15. 15. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury CPNB Complications and RisksCPNB Complications and Risks Risk FactorRisk Factor Odds Ratio (95% CI)Odds Ratio (95% CI) NeurologicNeurologic EventsEvents 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) InfectiousInfectious EventsEvents 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) Capdevila X, et al. Anesth 2005;103:1035Capdevila X, et al. Anesth 2005;103:1035
  16. 16. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Mechanism of Nerve InjuryMechanism of Nerve Injury Hadzic A, et al. RAPM 2004;29:417Hadzic A, et al. RAPM 2004;29:417 Kapur E, et al. Acta 2007;51:101Kapur E, et al. Acta 2007;51:101Selander D, et al. Acta 1977;21:182Selander D, et al. Acta 1977;21:182 IntraneuralIntraneural Injection?Injection? Long BevelLong Bevel Needle 14Needle 14°°?? BevelBevel Orientation?Orientation? Rice AS, et al. BJA 1992;69:433Rice AS, et al. BJA 1992;69:433 Hi InjectionHi Injection Pressure?Pressure? 30+30+ YearsYears
  17. 17. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Bevel and OrientationBevel and Orientation  Rabbit model: nerves impaled with 14Rabbit model: nerves impaled with 14° vs.° vs. 45° beveled needles, evaluated after 2h45° beveled needles, evaluated after 2h11 – Neuronal injury:Neuronal injury: 90%90% (14(14°°) vs. 53% () vs. 53% (45°45°)) – Injuries more severe withInjuries more severe with transversetransverse orientation vs. parallelorientation vs. parallel  Rat model: long- (LB) vs. short-beveledRat 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/SBLB parallel less damaging than LB/SB transversetransverse – SB injuries more severe at 28d vs. LBSB injuries more severe at 28d vs. LB 1. Selander D, et al. Acta 1977;21:1821. Selander D, et al. Acta 1977;21:182 2. Rice AS, et al. BJA 1992;69:4332. Rice AS, et al. BJA 1992;69:433
  18. 18. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury 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, awhen using a nerve stimulator, a twitch at > 0.5 mA = extraneuraltwitch 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 injuryintraneural = nerve injury – When pressure < 12 psi, recovery in 24 hWhen pressure < 12 psi, recovery in 24 h33 1. Bigeleisen PE. Anesth 2006;105:7791. Bigeleisen PE. Anesth 2006;105:779 3. Kapur E, et al. Acta 2007;51:1013. Kapur E, et al. Acta 2007;51:101 2. Chan, VWS, et al. A&A 2007;104:12812. Chan, VWS, et al. A&A 2007;104:1281
  19. 19. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Chemical Neurotoxicity of LAChemical Neurotoxicity of LA  IntrafascicularIntrafascicular injection worse thaninjection worse than intraneural extrafascicular injectionintraneural extrafascicular injection11  PerineuralPerineural injection of common LA (lido,injection of common LA (lido, bupiv, mepiv, tetra, procaine) does notbupiv, mepiv, tetra, procaine) does not result in axonal degenerationresult in axonal degeneration22  Reduction in nerve blood flow withReduction in nerve blood flow with topicaltopical lidocainelidocaine ± 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 1980;6:2632. Gentili F, et al. Neurosurg 1980;6:263 1. Gentili F, et al. Neurosurg 1979;4:2441. Gentili F, et al. Neurosurg 1979;4:244 3. Myers RR, et al. Anesth 1989;71:7573. Myers RR, et al. Anesth 1989;71:757
  20. 20. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Many Contributing FactorsMany Contributing Factors Patient:Patient: CNS disorderCNS disorder Extreme BMIExtreme BMI MaleMale DiabetesDiabetes AgeAge PositioningPositioning Surgery:Surgery: Trauma/stretchTrauma/stretch BleedingBleeding TourniquetTourniquet InfectionInfection InflammationInflammation Cast compressionCast compression Anesthesia:Anesthesia: LA toxicityLA toxicity VasoconstrictionVasoconstriction PerineuralPerineural edemaedema Needle traumaNeedle trauma Neal JM, et al. RAPMNeal JM, et al. RAPM
  21. 21. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Nerve Injury and “Double Crush”Nerve Injury and “Double Crush”  Theory: preexisting nerve lesions mayTheory: 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-inducedCase reports: ISB and cisplatin-induced neurotoxicityneurotoxicity22 and multiple sclerosisand multiple sclerosis33 – Retrospective review: 2/567 pts withRetrospective review: 2/567 pts with preexisting neuropathy had progressivepreexisting neuropathy had progressive symptoms after CNBsymptoms after CNB44  Clinical evidence not conclusiveClinical evidence not conclusive 1. 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;92:249 3. Koff MD, et al. Anesth 2008;108:3253. Koff MD, et al. Anesth 2008;108:325 4. Hebl JR, et al. A&A 2006;103:12944. Hebl JR, et al. A&A 2006;103:1294
  22. 22. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury 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 clear:Incidence of nerve injury not clear: 1/41851/4185 – 3/100– 3/1001-31-3  Select patients and surgeons carefullySelect patients and surgeons carefully 1. Auroy Y, et al. Anesth 2002;97:12741. Auroy Y, et al. Anesth 2002;97:1274 2. Brull R, et al. A&A 2007;104:9652. Brull R, et al. A&A 2007;104:965 3. Barrington MJ, et al. RAPM 2009;34:5343. Barrington MJ, et al. RAPM 2009;34:534
  23. 23. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Diagnosis of Nerve InjuryDiagnosis of Nerve Injury  Meticulous patient follow-up is essentialMeticulous patient follow-up is essential  Single-injection nerve blocks: callSingle-injection nerve blocks: call outpatients or visit inpatientsoutpatients or visit inpatients – Assess for recovery of gross sensation andAssess for recovery of gross sensation and motor functionmotor 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 orContinuous catheters: daily phone call or inpatient visitinpatient visit Ilfeld BM, et al. RAPM 2003;28:418Ilfeld BM, et al. RAPM 2003;28:418
  24. 24. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury If Nerve Injury is Suspected…If Nerve Injury is Suspected…  Review procedureReview procedure documentationdocumentation  Perform careful physical exam toPerform careful physical exam to assess affected areas and levelassess affected areas and level of lesionof lesion  Consider early NeurologistConsider early Neurologist consultationconsultation  If compressive hematomaIf compressive hematoma suspected, evaluate with MRI/CTsuspected, evaluate with MRI/CT Borgeat A. Minerva Anes 2005;71:353Borgeat A. Minerva Anes 2005;71:353
  25. 25. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Electrophysiological TestingElectrophysiological Testing  Electromyography (EMG):Electromyography (EMG): employs needleemploys needle electrode into muscleelectrode into muscle – Identify injury pattern (fibrillation, abnormalIdentify injury pattern (fibrillation, abnormal discharges or recruitment pattern)discharges or recruitment pattern) – May help determineMay help determine chronicitychronicity of injury: acuteof injury: acute vs. preexistingvs. preexisting  Nerve Conduction Study (NCS):Nerve Conduction Study (NCS): measuresmeasures velocity, latency, and amplitude forvelocity, latency, and amplitude for peripheral nerves, may identifyperipheral nerves, may identify focal lesionfocal lesion Borgeat A. Minerva Anes 2005;71:353Borgeat A. Minerva Anes 2005;71:353Mayfield JB. Anes Clin 2005;43:119Mayfield JB. Anes Clin 2005;43:119
  26. 26. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Classification of Nerve InjuryClassification of Nerve Injury  Neuropraxia:Neuropraxia: mild insult resulting frommild insult resulting from impulse conduction failureimpulse conduction failure – EMG normal, NCS decreased velocity and/orEMG normal, NCS decreased velocity and/or increased latenciesincreased latencies  Axonotmesis:Axonotmesis: axonal disruption withaxonal 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, poorcomplete disruption, poor prognosisprognosis Borgeat A. Minerva Anes 2005;71:353Borgeat A. Minerva Anes 2005;71:353
  27. 27. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury Testing RecommendationsTesting Recommendations  EMG/NCS in 1-3 days toEMG/NCS in 1-3 days to assess chronicity of injuryassess chronicity of injury  If EMG normal, repeat in 3-4If EMG normal, repeat in 3-4 weeksweeks  If either test abnormal,If either test abnormal, repeat in 6 monthsrepeat in 6 months  Serial studies generally notSerial studies generally not necessary—follow progressnecessary—follow progress clinicallyclinically Borgeat A. Minerva Anes 2005;71:353Borgeat A. Minerva Anes 2005;71:353Mayfield JB. Anes Clin 2005;43:119Mayfield JB. Anes Clin 2005;43:119
  28. 28. Managing Perioperative Nerve InjuryManaging Perioperative Nerve Injury SummarySummary  We discussed potential risks forWe discussed potential risks for perioperative nerve injuryperioperative nerve injury  We estimated occurrence rates of variousWe estimated occurrence rates of various regional anesthesia complicationsregional anesthesia complications  We discussed how to evaluate the patientWe discussed how to evaluate the patient with suspected nerve injury andwith suspected nerve injury and recommend appropriate testingrecommend appropriate testing

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