Neurologic Sequelae After Interscalene Brachial Plexus Block for Shoulder/Upper Arm Surgery: The Association of Patient, Anesthetic, and Surgical Factors to the Incidence and Clinical Course

Abstract

We determined the incidence, distribution, and resolution of neurologic sequelae and the association with anesthetic, surgical, and patient factors after single-injection interscalene block (ISB) using levobupivacaine 0.625% with epinephrine 1:200,000 in subjects undergoing shoulder or upper arm surgery, or both, in 693 consecutive adult patients. After a standardized ISB, assessments were made at 24 and 48 h and at 2 and 4 wk for anesthesia, hypesthesia, paresthesias, pain/dysesthesias, and motor weakness. Symptomatic patients were monitored until resolution. Subjects reporting pain or discomfort >3 of 10 and those with motor or extending sensory symptoms received diagnostic assessment. Six-hundred-sixty subjects completed 4 wk of follow-up. Fifty-eight neurologic sequelae were reported by 56 subjects. Symptoms were sensory except for two cases of motor weakness (lesions identified distant from the ISB site). Thirty-one sequelae with likely ISB association were reported by 29 subjects, including 14 at the ISB site, 9 at the distal phalanx of thumb/index finger, 7 involving the posterior auricular nerve, and 1 clinical brachial plexopathy. Sequelae not likely associated with the ISB were reported by 27 subjects with symptoms reported in the median (n = 9) and ulnar (n = 4) nerves, surgical neuropraxias (n = 12), and motor weakness (n = 2). Symptoms resolved spontaneously (median 4 wk; range, 2-16 wk) except in the two patients with motor weaknesses and the patient with clinical brachial plexopathy, who received therapeutic interventions. Variables identified as independent predictors of neurologic sequelae likely related to ISB were paresthesia at needle insertion and ISB site pain or bruising at 24 h. In contrast, surgery preformed in the sitting position, as well as ISB site bruising, was identified as a predictor of neurologic sequelae not likely related to ISB. In conclusion, neurologic sequelae after single-injection ISB using epinephrine mainly involve transient minor sensory symptoms.

Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance

“…15,16 Therefore, it is not surprising that nearly half of the patients in our stimulation group complained of paresthesiae during block performance compared with only three patients in our ultrasound group. In a similar trial by Sauter et al, it is surprising and rather difficult to explain that 20% of patients in the ultrasound group experienced paresthesiae during block performance compared with only 2.5% of the stimulation group.…”

Transient Hypertension after an Interscalene Block-The Presentation of a Rare Complication with an Anatomical Explanation

“…The interscalene block is not left with noticeable complications too. These include pneumothorax, persistent neurological sequele (hypesthaesia, paresthaesias, pain/dysesthaesias, and motor weakness), phrenic nerve palsy, total spinal anaesthesia and cervical cord injuries [4][5][6].…”

Hypoesthesia of the Cutaneous Branch of Cervical Plexus after Shoulder Arthroscopy under General Anesthesia with Ultrasound Guided-Interscalene Block

“…The nerves injured most commonly during shoulder arthroscopy are the musculocutaneous, ulnar, radial, and dorsal digital nerves of the thumb [2,4]. Cases of the occipital nerve injury and greater auricular branch palsy are rare after arthroscopic surgery with ISB [9][10][11][12].…”

“…In conclusion, postoperative neurological deficits can be attributed to a combination of patient, anesthesia-, and surgeryrelated factors, including direct trauma, positioning, and retraction [2]. In particular, careful attention must be paid to patient positioning to prevent compression and pressure injuries to the skin and soft tissues, including nerves, particularly when the position is to be maintained for a prolonged period.…”

“…Arthroscopic shoulder surgery is associated with considerable postoperative pain [1,2]. Ultrasound guided-interscalene brachial plexus block (ISB), in conjunction with general anesthesia, is often used because it provides effective pain control [3].…”