1178 CHAPTER 41 Regional anaesthesia

Regional anaesthesia and nerve

injury1,2 (see also pp32–33)
• Estimates of the incidence of nerve damage associated with regional
anaesthesia vary. From the evidence available, it seems that the
incidence of temporary nerve damage (neurapraxia) is in the order
of 1:100–1:200 and that of permanent nerve damage is in the range
1:5000–1:10 000. However, the likelihood of nerve damage depends
upon a number of factors, including how the nerve block is performed,
which nerve block is performed, and the age of the patient and their
comorbidities.
• Nerve–needle contact can cause nerve damage, and therefore careful
technique is very likely to be associated with a low incidence of nerve
damage: the needle should always be advanced slowly and gently, and
if the patient complains of paresthesia or significant pain, it should be
withdrawn, and injection should not be performed. Visualisation of the
nerves and needle with US should allow the anaesthetist to achieve a
very low incidence of nerve–needle contact, thereby minimising the
chances of nerve damage.
• Although this is intuitively correct, evidence from large-scale studies to
support this contention is currently lacking.
• Direct injection of fluid into a nerve—intraneural injection—can be
associated with high pressures in the nerve that can lead to ischaemic
damage. The hallmarks of intraneural injection are held to include high
injection pressures, pain on injection, low current thresholds when
using a PNS, failure of the evoked contractions to disappear at the start
of LA injection, and swelling of the nerve if visualised with US. If any of
these are encountered, injection should cease immediately.
• Recent studies suggest that intraneural injection is not always painful,
not always difficult, and not always dangerous. Indeed, it seems likely
that a high proportion of lower limb PNBs using a PNS are in fact
intraneural injections. Notwithstanding this evidence, intraneural
injections should be avoided.
• Nerve damage can also be caused by ischaemia due to hypotension
and vascular occlusion, pressure from haematomas, poor patient
positioning, stretching by the surgeon, and the position of the patient’s
limbs.
• Some blocks seem to be associated with a higher incidence of nerve
damage.
• Upper limb blocks seem to attract a higher incidence of reported
injury. This may be due to a greater chance of minor neurological
deficits being appreciated or may relate to the fact that there is a
greater ratio of nerve tissue to connective tissue in upper limb nerves
than in lower limb nerves.
• Publications suggest that the interscalene brachial plexus block is
the PNB that has the highest capacity to be associated with nerve
injury. There has been speculation about whether this is related to the
relative tethering of the nerves to the cervical spine, from where they
have just emerged at the location of the block. Whatever the reason
for this apparent excess incidence of nerve damage, particularly good
 REGIONAL ANAESTHESIA AND NERVE INJURY 1179

training and expertise is required to perform this block safely, and great
caution should be exercised when placing a needle anywhere near the
upper reaches of the brachial plexus.
• Publications suggest that children only very rarely suffer nerve damage
from regional anaesthesia, and that the incidence of nerve damage
in pregnant women undergoing spinal and/or epidural anaesthesia is
similarly low. Obese patients seem to be at greater risk than their
non-obese counterparts, and there is a substantial excess incidence
of adverse sequelae in elderly patients undergoing spinal and epidural
anaesthesia and analgesia. It is likely that the elderly, patients with
diabetes, and those with pre-existing neurological conditions are
at a higher risk of nerve damage.
• The management of nerve damage involves its early recognition
and referral to a neurologist. Nerve conduction studies, magnetic
resonance imaging, and electromyography can all assist in identification
of the severity and location. There is little that can be done to hasten
the recovery of nerve function or to minimise the extent of the nerve
damage once harmed. However, damage resulting from pressure from
other structures or spinal abscesses and haematomas can be helped by
surgery.
• Recovery of neurological function is mercifully the norm. More than
90% of cases of nerve damage resulting from regional anaesthesia
recover within 3 months and >99% within a year.
• Patients should be told of the incidence of nerve damage; whether to
undergo regional anaesthesia or general anaesthesia is their choice. It
is always useful to ask the patient about their jobs and passions. Slight
damage to the brachial plexus will have more of a potential impact
on the life of a professional or enthusiastic amateur violinist than on a
lawyer! The disclosure and consent process should be recorded in the
patient’s notes.
Awake or asleep?
• The debate about whether nerve blocks should only be placed in
awake or lightly sedated patients, or whether it is acceptable to
perform blocks on anaesthetised patients, has raged for some time and
shows no signs of abating.
• Supporters of ‘awake blocks’ argue that nerve–needle contact is
associated with pain and paresthesia, and that the insertion of a needle
and the subsequent injection of LA into the nerve is usually painful and
often dangerous. Therefore, an awake or lightly sedated patient may
warn you of nerve–needle contact. Similarly, awake-block supporters
argue that their patients might warn them of the early signs of LA
toxicity as a result of inadvertent intravascular injection, thus allowing
them to cease injection before plasma LA levels rise to cardiotoxic
or convulsive levels. Those anaesthetists happy to perform blocks
on the anaesthetised patient argue that the important hallmarks of
intraneural injection are sufficiently present to protect the patient
provided the anaesthetist is aware of them and responds appropriately:
visualisation of intraneural needle placement and LA injection with US;
low threshold currents if using a PNS; failure of evoked contraction
1180 CHAPTER 41 Regional anaesthesia

disappearance on injection of LA; difficulty of injection. Paediatric

anaesthetists argue that for many of their patients, ‘awake’ is not an
option; they are perhaps fortunate that the incidence of nerve damage
associated with PNBs in children is very low indeed.
• Although it is likely that the majority of anaesthetists believe that
neuraxial blocks should not be performed on anaesthetised patients,
views regarding PNBs are less one-sided. What is beyond doubt is
that there is currently no hard evidence definitively to support either
the ‘awake’ or the ‘asleep’ camps. The American Society of Regional
Anesthesia (ASRA) recently advised its members not to perform
blocks on anaesthetised patients when possible. The guidance also
called attention to the suspicion that the performance of a PNB after
a marked paresthesia has been produced may increase the chances of
nerve damage even though the needle is withdrawn and reinserted.
Although not medicolegally binding on anaesthetists outside of the
USA, the opinions expressed and the information presented in support
is worth both reading and heeding. In the authors’ opinion, the ASRA
advice should be followed.
• The performance of PNBs on the non-anaesthetised patient need
not be unpleasant for the patient. Many anaesthetists successfully
use sedation with small doses of a benzodiazepine (midazolam) and/
or an opioid (fentanyl) or infusions of small amounts of propofol or
remifentanil. The increasing use of US for nerve location is known to
increase patient comfort if the evoked contractions produced by nerve
stimulators are avoided, and it is therefore relatively easy to perform
US-guided blocks on patients who are wide awake.

1 Neal JM, Bernardscm, Hadzic A, et al. (2008). ASRA practice advisory on neurologic
complications in regional anesthesia and pain medicine. Regional Anesthesia and Pain Medicine,
33, 404–415.
2 Szypula K, Ashpole KJ, Bogod D, Yentis SM, Mihai R, Scott S, Cook TM (2010). Litigation related
to regional anaesthesia: an analysis of claims against the NHS in England 1995–2007. Anaesthesia,
65(5), 443–452.