++
Most neuropathies are of surgical origin. However, postoperative neuropathies seem to have a lower recovery rate when regional anesthesia is associated.
++
- 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
++
- 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
++
- 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
++
- X-ray, ultrasound, MRI, CT scan as indicated clinically; CT or MRI emergently if suspicion of spinal cord compression
++
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