Case report: Neurological deficit associated with intraneural needle placement without injection

Abstract

Purpose Recent reports of painless intraneural injection of low volumes of local anesthetic without subsequent neurological deficit have led to the suggestion that deliberate subepineural injection may be a safe and therefore acceptable practice. Clinical features This report describes a case where a venous cannulation needle inadvertently penetrated a patient's median nerve. Sudden onset severe lancinating pain occurred in the median nerve sensory distribution. A subsequent thorough ultrasound examination showed the median nerve to be located immediately posterior to the targeted median cubital vein. New onset sensory symptoms (numbness, tingling, pain, and altered sensation to touch) in the distribution of the penetrated median nerve persisted for [6 weeks. Conclusion This report highlights the hazards of intraneural needle placement irrespective of an associated injection. RésuméObjectif Des comptes-rendus re´cents rapportant une injection intraneurale indolore de faibles volumes d'anesthe´sique local sans de´ficit neurologique subse´quent nous ont mene´a`l'hypothe`se qu'une injection sous l'e´pine`vre pourrait constituer une pratique se´curitaire, donc acceptable. É léments cliniques Ce compte-rendu de´crit la situation suivante : une aiguille de canulation veineuse a pe´ne´treṕ ar inadvertance le nerf me´dian d'un patient. Une douleur lancinante se´ve`re et soudaine est apparue dans la distribution sensorielle du nerf me´dian. Par la suite, nous avons re´alise´un examen approfondi par ultrason qui a re´ve´le´que le nerf me´dian se situait imme´diatement derrie`re la veine cubitale me´diane vise´e. De nouveaux symptômes sensoriels (engourdissement, picotement, douleur, et sensation alte´re´e au toucher) ont persiste´dans la distribution du nerf me´dian pe´ne´tre´durant [ 6 semaines. Conclusion Ce compte-rendu de´montre les risques d'un placement intraneural d'aiguille inde´pendamment d'une injection associe´e.

Safety of intraneural injection of local anesthetic

“…[12] A functional consequence of intraneural injection of local anesthetic was described in one. [13] In a previous study on gel-nerve contact, we have reported limping as well as a consequence of nerve trauma. [14] Histologic changes of the spinal cord following intrathecal injection in the form of axonal degeneration was observed in an experiment on rats treated with greater than 16% prilocaine or mepivacaine or with greater than 4% bupivacaine.…”

Intraneural Injection and Peripheral Nerve Injury

“…19 However, there is some conflicting information on the role of mere puncture of the fascicles. [20][21][22] A variety of cellular changes accompany needle trauma, including alterations in membrane channel expression, activation of signal transduction, neuropeptide production, and an overall increase in excitability at the dorsal horn. 13 However, nerve puncture with intravenous cannulae or electroneurography needles have been shown to result in lasting neurologic deficit.…”

Short-Term Effects of Deliberate Subparaneural or Subepineural Injections With Saline Solution or Bupivacaine 0.75% in the Sciatic Nerve of Rabbits

“…A complication of peripheral nerve blocks is the occurrence of iatrogenic nerve damage, but the incidence of long-term neurologic injuries is relatively low (3)(4)(5)(6). US-guided techniques for regional anesthesia have shown that peripheral nerves injected with local anesthetic do not inevitably suffer permanent neurological injuries (7)(8)(9)(10)(11)(12)(13)(14)(15), and some authors, contrary to other reports (16)(17)(18)(19), have challenged the risk of intraneural injections (7).…”