Severe Brachial Plexopathy after an Ultrasound-guided Single-injection Nerve Block for Total Shoulder Arthroplasty in a Patient with Multiple Sclerosis

Abstract

DESPITE the known benefits of regional anesthesia for patients undergoing joint arthroplasty, the performance of peripheral nerve blocks in patients with multiple sclerosis (MS) remains controversial. MS has traditionally been described as an isolated disease of the central nervous system, without involvement of the peripheral nerves, and peripheral nerve blockade has been suggested to be safe. However, careful review of the literature suggests that MS may also be associated with involvement of the peripheral nervous system, challenging traditional teachings. There is a paucity of evidence with regard to safety in using peripheral nerve regional anesthesia in these patients. This makes it difficult to provide adequate "informed consent" to these patients. This case report describes a patient with MS who sustained a severe brachial plexopathy after a total shoulder arthroplasty during combined general anesthesia and interscalene nerve block.

Ultrasound-guided peripheral regional blockade in patients with Charcot-Marie-Tooth disease: a review of three cases

“…32 Data from prospective randomized trials assessing the role of nerve injury following regional blockade in demyelinating conditions, are lacking. Fear of litigation, should exacerbation occur, could lead some to avoid regional anesthesia in this situation.…”

Ultrasound-Guided Regional Anesthesia and Patient Safety

“…& No RCTs or case reports address whether patients at risk for pulmonary compromise can undergo above-the-clavicle regional anesthetic block. Because HDP can still occur unpredictably, caution remains warranted in any patient unable to withstand a 30% diminution of pulmonary function (IV 30 and a volunteer who had a dysesthesia of the tibial nerve, which was present but improving after 2 months (this subject is included in the RCTs). 31 In summary, limited literature and small patient numbers suggest 3 findings concerning peripheral nerve injury and UGRA: (1) block-related paresthesia, a surrogate outcome at best, was not reduced when similar block groups were compared; (2) RCTs and large case studies report no permanent neurologic injuries, nevertheless; and (3) peripheral nerve injury associated with, but arguably unrelated to, UGRA has been reported.…”

Concerns Regarding Ultrasound-guided Regional Anesthesia

“…1 The exact chromophoric compound responsible is not known. As propofol is also excreted into the breast milk, 2 it was suspected as a cause in this case.…”

“…1 We are seeing reports of plexopathies after ultrasound-guided regional anesthesia and surgery, despite visualization of the injecting needle tip well away from neural elements. 2,3 At our institution, a case of brachial plexopathy after ultrasound-guided regional anesthesia recently occurred, resolving without sequelae. This disquiet has been increased by the knowledge that ultrasonic guidance for regional anesthesia is being accepted without any safety studies, efficacy studies, or equivalence studies for this particular application.…”