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Most neuropathies are of surgical origin. However, postoperative neuropathies seem to have a lower recovery rate when regional anesthesia is associated.

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  • Discuss risk of neuropathy preoperatively, especially with patients at risk:
    • DM
    • MS
    • Extremes of body habitus
    • Methotrexate, cisplatin
    • Other preexisting neurologic abnormality
  • In these patients:
    • Evaluate risk/benefit ratio of regional anesthesia/analgesia
    • Consider using lower local anesthetic concentration and no epinephrine (decreases nerve blood flow)
  • Carefully document preoperatively any neurologic finding
  • Document:
    • Twitch (location, current, disappearance)
    • Negative aspiration
    • Ultrasound use (“no intraneural/intravascular injection”)
    • Injection pressure
    • Absence of pain/paresthesia
    • Duration/pressure of tourniquet
    • Positioning

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  • Document neurologic findings (anesthesiologist, surgeon, neurologist if consulted):
    • Nerve by nerve and/or dermatome by dermatome
    • Sensory, motor, and sympathetic (if applicable)
    • Identify level of lesion if possible
  • If neurologic consult requested, clarify that the request is for a detailed description of deficit rather than etiologic speculation

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  • Ideally electrophysiology ASAP (<72 hours), prior to Wallerian degeneration
  • Repeat after 3 weeks
  • Bilateral, upper and lower limbs, to elicit subclinical neuropathy
  • EMG for peripheral neuropathy
  • SSEP if evaluation for spinal cord and/or sensory root involvement
  • MEP if evaluation of pyramidal tracts and/or motor root involvement
  • Indicate the severity of lesion: partial versus complete
  • Indicate the level of the lesion: spinal cord, root, plexus, branch
  • Evaluate for other lesions not noted on clinical examination
  • The report should include tracings

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  • X-ray, ultrasound, MRI, CT scan as indicated clinically; CT or MRI emergently if suspicion of spinal cord compression

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Figure 129-1. Management of Postoperative Neuropathy
Graphic Jump Location
1. Sorenson EJ. Neurological injuries associated with regional anesthesia. Reg Anesth Pain Med. 2008 Sep–Oct;33:442–448.   [PubMed: 18774513]
2. Jacob AK, Mantilla CB, Sviggum HP, Schroeder DR, Pagnano MW, Hebl JR. Perioperative nerve injury after total hip arthroplasty: regional anesthesia risk during a 20-year cohort study. Anesthesiology. 2011 Dec;115(6):1172–1178.   [PubMed: 21934486]
3. Jacob AK, Mantilla CB, Sviggum HP, Schroeder DR, Pagnano MW, Hebl JR. Perioperative nerve injury after total knee arthroplasty: regional anesthesia risk during a 20-year cohort study. Anesthesiology. 2011 Feb;114(2):311–317.   [PubMed: 21239974]
4. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007 Apr;104(4):965–974.   [PubMed: 17377115]
5. Hebl JR, Horlocker TT, Kopp SL, Schroeder DR. Neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spine surgery: efficacy and neurologic complications. Anesth Analg. 2010 Dec;111(6): 1511–1519.   [PubMed: 20861423]
6. Hebl JR. Ultrasound-guided regional anesthesia and the prevention of neurologic injury: fact or fiction? Anesthesiology. 2008 Feb;108(2):186–188.   [PubMed: 18212562]
7. Hebl JR, Kopp SL, Schroeder DR, Horlocker TT. Neurologic complications after neuraxial anesthesia or analgesia in patients with preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy. Anesth Analg. 2006 Nov;103(5):1294–1299.   [PubMed: 17056972]

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