ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Abstract

Neurologic complications associated with regional anesthesia and pain medicine practice are extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine addresses the etiology, differential diagnosis, prevention, and treatment of these complications. This Advisory does not focus on hemorrhagic and infectious complications, because they have been addressed by other recent ASRA Practice Advisories. The current Practice Advisory offers recommendations to aid in the understanding and potential limitation of neurologic complications that may arise during the practice of regional anesthesia and pain medicine. KeywordsComplications of anesthesia; Nerve injury; Spinal anesthesia; Epidural anesthesia; Peripheral nerve block; Regional anesthesia; Pain medicine; Transforaminal block The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened a group of experts to develop a Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine. The goal of this Practice Advisory is to provide information for practitioners of regional anesthesia and pain medicine regarding the etiology, differential diagnosis, prevention, and treatment of neurologic complications. This Practice Advisory focuses on neurologic injuries apart from those caused by hemorrhagic 1 or infectious2 -6 complications, both of which have been the subject of other recent ASRA-sponsored Practice Advisories. The current report is a summation of the Practice Advisory's findings and recommendations. Anesthesiologists are strongly encouraged to read the manuscripts that accompany the present summary document, because they contain the details upon which recommendations are based. The accompanying manuscripts represent most of the subtopics discussed at the conference. The recommendations contained within this Practice Advisory represent the opinions of a small group of expert panelists and are based upon their clinical experience, review of limited scientific literature (anatomic and physiologic studies of animals and human cadavers, case reports, retrospective case series, and non-randomized trials), and open forum discussion. Importantly, in this imperfect setting of controversial topics, limited data, and bias inherent to expert opinion, the Panel consistently tended towards making conservative recommendations. We acknowledge that other experts analyzing the same information may arrive at recommendations different than ours. The recommendations contained herein are not intended to define standard practice or to ensure the avoidance of adverse outcomes. Furthermore, the recommendations are subject to change as new information becomes available. Recommendations from the Practice Advisory are not intended to replace clinical judgment, and specific risk-to-benefit discussions as they pertain to individual patients.Because neurologic injuries related to anesthesia and pain medicine practice are extremely rare, standard tools of evidence-based medicine such as randomized c...

Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound‐guided interscalene and supraclavicular nerve blocks*

“…Typical clinical recommendations and formal guidelines from the American Society of Regional Anesthesia consider direct intraneural needle trauma or injection as a risk factor for postoperative neurological complications [1] although the magnitude of such risk is controversial. For example, previous case reports noted postoperative neuropathy after ultrasound-guided unintentional intraneural injection of local anaesthetic during femoral nerve block [16], interscalene block [17] and supraclavicular block [18].…”

“…Other safety steps in our protocol may have also minimised the risk of intrafascicular injection [1]. Our patients were asked to report painful injections suggestive of intrafascicular injection and injury that would prompt repositioning of the needle.…”

“…A primary and potentially modifiable risk factor for neurological complications after nerve blockade is direct intraneural needle trauma or injection [1]. Direct nerve trauma may be particularly important during proximal brachial plexus block as these blocks have the highest incidence (1-6%) of neurological complications [2].…”

Alternative site for median nerve blockade allowing early functional rehabilitation after hand surgery

“…Peripheral nerve blockade should not be performed routinely in adults under general anesthesia. 8 The risk-tobenefit ratio of performing this procedure in anesthetized patients may be acceptable in select cases, such as in our patient, who had severe anxiety regarding painful procedures because of her past experience with poorly controlled pain. In such cases, all necessary precautions-avoidance of high-pressure injections, sufficient hydraulic separation of surrounding tissues, performance of the procedure under ultrasonography guidance-should be taken to minimize the risk of nerve injury.…”

Neurological deficit after a peripheral regional anaesthetic: flying on instruments, the black box, crash investigation and other aeronautics

“…Indeed, for this very reason, the American Society of Regional Anesthesia's Practice Advisory says specifically that 'interscalene blocks should not be performed in anesthetized or heavily sedated adult or pediatric patients' [11], but there are also case reports of painless and uneventful procedures that are followed by neurological deficits apparently attributable to injections [12].…”