Skip Navigation LinksHome > December 2000 - Volume 93 - Issue 6 > Permanent Loss of Cervical Spinal Cord Function Associated w...
Anesthesiology:
Case Reports

Permanent Loss of Cervical Spinal Cord Function Associated with Interscalene Block Performed under General Anesthesia

Benumof, Jonathan L. M.D.*

Free Access
Article Outline
Collapse Box

Author Information

PERFORMING an interscalene block (ISB) during general anesthesia (GA) for postoperative shoulder surgery analgesia is a common procedure. Although epidural, 1–3 subarachnoid, 4–6 and motor nerve root 7 injections have been reported during the performance of ISB, there have been no cases reported in the peer-reviewed literature of injection of local anesthetic solution into the substance of the cervical spinal cord. Although injection of local anesthetic solution into the cervical spinal cord would be unlikely in awake patients, performing the block in anesthetized patients may increase the risk .
This report describes four cases in which the performance of ISB during GA was followed by total spinal anesthesia and extensive permanent loss of bilateral cervical spinal cord function, and in which magnetic resonance imaging (MRI) showed syrinx or cavity formation in the cervical spinal cord. Each of the patients in the cases was involved in a separate medical malpractice law suit. In the first three cases the author was an expert witness, and in the fourth case the medical data was taken from the defense-expert timeline of clinical events and findings (obtained by interrogatory questioning of patient 2); in each case the relevant MRI was supplied by the plaintiff’s attorney.
Back to Top | Article Outline
Case Reports
Case 1
The patient was a 39-yr-old woman, 172 cm, 109 kg, who presented for right shoulder arthroscopic repair of a rotator cuff tear. A cervical spine MRI 16 months before surgery was normal. Medical and surgical histories were unremarkable. After sedation with use of midazolam and methohexital administered in divided doses over 6 min to eliminate head and neck movement, the patient was unconscious but spontaneously breathing. The right interscalene groove was palpated and right upper extremity (RUE) muscle twitches were obtained via a 2-in (5.0 cm) 22-gauge Stimuplex (B. Braun Medical, Bethlehem, PA) needle at 0.81 mA. Alternating negative aspirations with 5-ml injections, a total of 40 ml of a solution containing 0.75% mepivacaine and 0.25% bupivacaine in 1:200,000 epinephrine was injected. Less than 30 s after the injection was completed, the patient became apneic, oxygen saturation as measured by pulse oximetry (Spo2) decreased from 96% to 60%, blood pressure decreased by 25%, and heart rate was unchanged. The patient easily underwent ventilation via mask, was tracheally intubated, and stabilized within 2 min. The 45-min surgery was performed uneventfully while the patient underwent ventilation with positive pressure with 0.4% isoflurane in oxygen. Two and one half hours post-ISB, the patient opened her eyes to command and began spontaneous ventilation; 3 h post-ISB the patient was extubated. After extubation, the patient had complete loss of motor and sensory function of the RUE and allodynia and burning pain of the left upper extremity; the fully evolved neurologic deficit also included bilateral lower extremity weakness, in the right much more than in the left. Cervical spine MRI performed 3 weeks and 9 months post-ISB showed a syrinx or cavity in the central portion of the right half of the C4–C7 spinal cord (fig. 1).
Fig. 1
Fig. 1
Image Tools
Back to Top | Article Outline
Case 2
The patient was a healthy 52-yr-old woman, 155 cm, 86 kg, who underwent arthroscopic repair of a right rotator cuff tear during GA. At the end of the operation, and with the patient breathing spontaneously during GA, a right ISB was performed using a 2-in (5.0 cm) 22-gauge Stimuplex needle, 1.0 mA stimulation, and 20 ml bupivacaine, 0.25% (alternating negative aspirations with injections). After the injection, a decrease in blood pressure of 25% was responsive to 10 mg intravenous ephedrine, but the patient became apneic, was unresponsive to noxious stimuli, and had dilated pupils. One hour post-ISB, the patient awakened, and 2 hours post-ISB the patient was extubated. However, the patient had no motor or sensory function in the left upper extremity and had significant weakness of the RUE. MRI of the cervical spine 20 h post-ISB showed myelomalacia extending from C1–T1 and a 7 × 7 × 10 mm intradural, but extramedullary, right anterolateral mass at the T2 level, which slightly compressed the spinal cord. Spinal tap on postoperative day 3 showed intensely xanthrochromic cerebral spinal fluid. Cervical spine MRI 25 months post-ISB showed one continuous C2–T1 intramedullary cervical spinal cord lesion and slight enlargement of the T2 extramedullary mass (fig. 2). The fully evolved neurologic deficit at 25 months consisted of weakness and atrophy of the upper extremities, in the left more than in the right, loss of pain and temperature in both upper extremities, preservation of touch, vibration and proprioception in both upper extremities, and preservation of motor and sensory function in both lower extremities. The T2 extramedullary mass was resected at 28 months post-ISB and was diagnoses as a meningioma; the patient’s neurologic status was unchanged.
Fig. 2
Fig. 2
Image Tools
Back to Top | Article Outline
Case 3
A healthy 52-yr-old man, 167 cm, 93 kg, underwent an open repair of a 2-yr-old right rotator cuff tear during GA. After the completion of surgery, all anesthetics were discontinued. While the patient was still unconscious, a right ISB with a 1.5-in (3.75 cm) 25-gauge needle was thought to have been performed by “walking” the needle off the posterior aspect of the C6 transverse process and injecting 15 ml of a solution containing 1% lidocaine and 0.5% bupivacaine without epinephrine by alternating three negative aspirations with three 5-ml injections. During the ISB, patient coughing, straining, and neck movement with the needle in situ necessitated administration of 75 mg intravenous sodium thiopental and resumption of 1.0% isoflurane. After ISB, isoflurane was discontinued and the patient underwent suctioning and extubated. However, after 5–10 min of ventilation via mask, the patient remained apneic, unconscious, and unresponsive to noxious stimuli and the pupils were dilated fully. The patient was reintubated and taken to the intensive care unit. Approximately 1 h post-ISB the patient started to breathe spontaneously and open his eyes to command, and, 3 h post-ISB, the patient was extubated and awake and alert. However, he had no motor or sensory function in his RUE, whereas the left upper extremity had a moderate decrease in finger and wrist strength. MRI of the cervical spine on postoperative day 7 showed extensive edema and hemorrhage (clotted blood) throughout the cervical spinal cord (fig. 3A). MRI at 15 months post-ISB showed a syrinx in the central aspect of the right spinal cord extending the entire length of the cervical spinal cord (fig. 3B). The fully evolved motor and sensory deficits were improved slightly compared with the initial examination and were consistent with the location of the syrinxes in the cervical spinal cord.
Fig. 3
Fig. 3
Image Tools
Back to Top | Article Outline
Case 4
A 38-yr-old woman, 160 cm, 71 kg (body mass index = 27.8 kg), required arthroscopic repair of a right rotator cuff tear. The patient was in good health and had an unremarkable medical and surgery history. GA (propofol bolus and infusion, vecuronium, nitrous oxide, isoflurane) and the 100-min surgery were uneventful. During GA, a right ISB was performed with a 2-in (5.0 cm) 22-gauge Stimuplex needle, 1.0 mA nerve stimulation, and 35 ml bupivacaine, 0.5%, with 1:200,000 epinephrine injected in divided doses (alternating with negative aspirations). For the first 2.5 h after ISB the patient was apneic, remained unconscious and unreactive to painful stimuli, had dilated nonreactive 7-mm pupils, and was hemodynamically stable. Five hours post-ISB, the patient was extubated awake and alert; however, the patient had extensive loss of RUE motor and sensory function and left upper extremity burning pain and allodynia. Cervical spinal cord MRI at 18 h post-ISB showed central intramedullary hemorrhage extending to C5–C7 and at 14 months post-ISB showed myelomalacia and syrinx formation in most of the cervical spinal cord.
Back to Top | Article Outline
Discussion
In each of these four patients ISB performed during GA was followed by the same three in-series events: spinal anesthesia, loss of cervical spinal cord function, and radiologic evidence of severe cervical spinal cord damage. Several possible mechanisms are responsible for ISB-induced cervical spinal cord damage in these patients. First, there is an experimental basis for proposing peripheral intraneural injection and retrograde intraneural dissection of local anesthetic into the cervical spinal cord theory of causation, 8,9 including increased toxicity of undiluted (with cerebrospinal fluid) local anesthetic. 10 In addition, during GA a patient would be unable to protest the pain of an intraneural injection. However, the principle practical arguments against such a cause consist of the absence of damage to structures outside the cervical spinal cord and the technical improbability of achieving such an injection. 11,12 Second, in patient 2, the T2 meningioma could have caused cephalad pooling of local anesthetic if the local anesthetic had gained access to the cerebrospinal fluid space. The principle arguments against pooling of local anesthetic above the T2 meningioma consist of absence of a rim lesion, absence of a T2 lesion, the presence of asymmetrical central cord damage, and the nontoxicity of 0.25% bupivacaine topically applied to the spinal cord. 10
Third, in all four patients, all clinical and radiologic data are explained well by injection of local anesthetic solution directly into the substance of the cervical spinal cord at C6. Indeed, this cause explains why the lesions in all four patients are centered on C6. Although the tip of a 22-gauge needle may be expected to cause some damage to the spinal cord, most of the damage caused by direct injection of fluid into the spinal cord probably is a result of the phenomena of pressure and separation of cells or neurons, and the extent of neurologic damage is likely to be proportional to the volume of local anesthetic injected into the spinal cord. 9–11 The clinical symptomatology caused by the fluid injected into the substance of the cervical spinal cord depends on the path that the fluid follows away from the point of injection.
In patients 1 and 2 the principal argument against “intracord” injection was that a 1.5- to 2.0-in (3.75- to 5.00-cm) needle could not reach the spinal cord by passing through the C6 intervertebral foramen. However, four considerations make it probable that the needle could pass into the cervical spinal cord. First, indentation of the skin line and compression of the deeper tissue by palpation of the interscalene groove can shorten the skin-line-to-spinal-cord distance considerably. In addition, the interscalene groove can be palpated with much more force in a patient during GA than in an awake patient. Second, previous reports of injection of local anesthetic solution into the motor nerve root and axial subarachnoid space 4–7 show that the tip of the needle can get very close to the cervical spinal cord. Third, the brachial plexus is very close to halfway between the skin line and cervical spinal cord. 13–15 Because the distance from the interscalene groove skin line to the brachial plexus in the majority of patients is less than 1 in (2.5 cm), and in healthy patients is approximately 0.5 in (1.25 cm), 12–15 it follows that the cervical spinal cord will be within 2 in (5.0 cm) of the skin line in the majority of patients. Unfortunately, MRI in individual cases cannot be used to determine the IS-groove-to-spinal-cord distance because the lateral border of the neck at the C6 level is formed by the trapezius muscle, and the IS groove is well within (mesiad to) the trapezius muscle, or the IS groove cannot be identified by MRI. Fourth, in patient 3, sudden and unexpected forceful movement of the patient’s neck may have caused the 1.5-in (3.75 cm) needle to forcefully go through the C6 intervertebral foramen and penetrate the cervical spinal cord.
If the clinical and radiologic lesions in these four patients were caused by intracord injection of local anesthetic, there are several clinical lessons to be learned or relearned. The lessons include the following: GA can be considered as a relative contraindication for ISB, ISB needles greater than 1.0–1.25 in should not be inserted, ISB needles less than 1.5 in (< 3.75 cm) should be used, the physician should ensure the patient does not unexpectedly move, the ISB needle should have a definite caudad direction at the C6 level, and in obese patients landmarks may be obscure. With these lessons in mind, the risk of intracord injection during ISB should be minimized.
The author thanks attorneys Edwin Krieger, Thomas Ryan, Michael McNally, and Mark Kamitomo for assistance in obtaining the relevant MRIs, and neuroradiologist doctors John Arrington, Colin Bramford, and Charles Kerber for accurate labeling of the MRIs.
Back to Top | Article Outline
References
1. Kumar A, Battit GE, Froese AB, Long MC: Bilateral cervical and thoracic epidural blockade complicating interscalene brachial plexus block: A report of two cases. A nesthesiology 1971; 35: 650–2

2. Scammell SJ: Inadvertant epidural anesthesia as a complication of interscalene brachial plexus block. Anaesth Intensive Care 1979; 7: 56–7

3. Dutton R, Eckhardt W, Sunder N: Total spinal anesthesia after interscalene block of the brachial plexus. A nesthesiology 1994; 80: 939–41

4. Ross S, Scarborough C: Total spinal anesthesia following brachial plexus block. A nesthesiology 1973; 39: 458

5. Edde R, Deutsch S: Cardiac arrest after interscalene brachial plexus block. Anesth Analg 1977; 56: 446–7

6. Passannante AN: Spinal anesthesia and permanent neurologic deficit after interscalene block. Anesth Analg 1996; 82: 873–4

7. Barutell C, Vidal F, Raich M, Montero A: A neurological complication following interscalene brachial plexus block. Anaesthesia 1980; 35: 365–7

8. French JD, Strain WH, Jones GF: Mode of extension of contrast substances injected into peripheral nerves. J Neuropathol Exp Neurol 1948; 7: 47–58

9. Selander D, Sjostrand J: Longitudinal spread of intraneurally injected local anesthetics: An experimental study of the initial neural distribution following intraneural injections. Acta Anaesthesiol Scand 1978; 22: 622–34

10. Selander D, Brattsand R, Lundborg G, Nordborg C, Olsson Y: Local anesthetics: Importance of mode of application, concentration and adrenaline for the appearance of nerve lesions. Acta Anaesthesiol Scand 1979; 23: 127–36

11. Winnie AP: Plexus Anesthesia: Perivascular Techniques of Brachial Plexus Block, volume 1. New York, WB Saunders, 1993, pp 242–56

12. Selander D, Dhuner KG, Lundborg G: Peripheral nerve injury due to injection needles used for regional anesthesia. Acta Anaesthesiol Scand 1977; 21: 182–8

13. Winnie AP: Interscalene brachial plexus block. Anesth Analg 1970; 49: 455–6

14. Gray’s Anatomy, 27th edition. Edited by Goss CM. Philadelphia, Lea and Febiger, 1959, p 428, figure 431

15. Grant JCB: An Atlas of Anatomy, 4th edition. Baltimore, Williams & Wilkins, 1956, figure 508

Cited By:

This article has been cited 95 time(s).

Arthroscopy-the Journal of Arthroscopic and Related Surgery
Ultrasonography- or Electrophysiology-Guided Suprascapular Nerve Block in Arthroscopic Acromioplasty: A Prospective, Double-Blind, Parallel-Group, Randomized Controlled Study of Efficacy
Ko, SH; Kang, BS; Hwang, CH
Arthroscopy-the Journal of Arthroscopic and Related Surgery, 29(5): 794-801.
10.1016/j.arthro.2013.01.011
CrossRef
Anaesthesist
Peripheral regional anesthesia in patients under general anesthesia. Risk assessment with respect to parasthesia, injection pain and nerve damage
Kessler, P; Steinfeldt, T; Gogarten, W; Schwemmer, U; Buttner, J; Graf, BM; Volk, T
Anaesthesist, 62(6): 483-488.
10.1007/s00101-013-2190-x
CrossRef
Journal of Clinical Anesthesia
Perioperative interscalene blockade: An overview of its history and current clinical use
Long, TR; Wass, CT; Burkle, CM
Journal of Clinical Anesthesia, 14(7): 546-556.
PII S0952-8180(02)00408-7
CrossRef
Journal of Clinical Anesthesia
Comment on "Perioperative interscalene blockade: An overview of its history and current clinical use"
Benumof, JL
Journal of Clinical Anesthesia, 15(6): 489.

Acta Anaesthesiologica Scandinavica
Ultrasound-guided interscalene and supraclavicular blocks
Zbigniew, KN
Acta Anaesthesiologica Scandinavica, 51(): 60-61.

Anaesthesia
Upper limb blocks
Russon, K; Pickworth, T; Harrop-Griffiths, W
Anaesthesia, 65(): 48-56.
10.1111/j.1365-2044.2010.06277.x
CrossRef
Anesthesia and Analgesia
How can we possibly prevent complications related to peripheral nerve blocks?
Chelly, JE
Anesthesia and Analgesia, 93(4): 1080-1081.

Anesthesia and Analgesia
Visual loss and ophthalmoplegia after shoulder surgery
Bhatti, MT; Enneking, FK
Anesthesia and Analgesia, 96(3): 899-902.
10.1213/01.ANE.0000047272.31849.F9
CrossRef
Regional Anesthesia and Pain Medicine
Clinical efficacy of the brachial plexus block via the posterior approach
Sandefo, I; Iohom, G; Van Elstraete, A; Lebrun, T; Polin, B
Regional Anesthesia and Pain Medicine, 30(3): 238-242.
10.1016/j.rapm.2005.01.005
CrossRef
Anesthesia and Analgesia
Transscalene brachial plexus block: A new posterolateral approach for brachial plexus block
Nguyen, HC; Fath, E; Wirtz, S; Bey, T
Anesthesia and Analgesia, 105(3): 872-875.
10.1213/01.ane.0000271916.26357.8d
CrossRef
Annales Francaises D Anesthesie Et De Reanimation
Total spinal anesthesia after interscalenic plexus block
Frasca, D; Clevenot, D; Jeanny, A; Laksiri, L; Petitpas, F; Debaene, B
Annales Francaises D Anesthesie Et De Reanimation, 26(): 994-998.
10.1016/j.annfar.2007.08.013
CrossRef
Anesthesia and Analgesia
Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children
Ganesh, A; Rose, JB; Wells, L; Ganley, T; Gurnaney, H; Maxwell, LG; DiMaggio, T; Milovcich, K; Scollon, M; Feldman, JM; Cucchiaro, G
Anesthesia and Analgesia, 105(5): 1234-1242.
10.1213/01.ane.0000284670.17412.66
CrossRef
Regional Anesthesia and Pain Medicine
Ultrasound-Guided Interscalene Block Should be Compared With the Accepted Standard for the Neurostimulation Technique
Fredrickson, MJ; Borgeat, A; Aguirre, J; Boezaart, AP
Regional Anesthesia and Pain Medicine, 34(2): 180.

Anesthesia and Analgesia
Perioperative Analgesia for Forequarter Amputation in a Child: A Dual Paravertebral Approach
Koyyalamudi, VB; Elliott, C; Gibbs, CP; Boezaart, AP
Anesthesia and Analgesia, 110(3): 761-763.
10.1213/ANE.0b013e3181c920b6
CrossRef
Regional Anesthesia and Pain Medicine
Brachial plexus anesthesia: Essentials of our current understanding
Neal, JM; Hebl, JR; Gerancher, JC; Hogan, QH
Regional Anesthesia and Pain Medicine, 27(4): 402-428.
10.1053/rapm.2002.34377
CrossRef
Anaesthesia and Intensive Care
Interscalene brachial plexus block for shoulder surgery in a patient with arthrogryposis multiplex congenita
Sreevastava, D; Trikha, A; Sehgal, L; Arora, MK
Anaesthesia and Intensive Care, 30(4): 495-498.

Journal of Bone and Joint Surgery-American Volume
Complication rates of Scalene Regional Anesthesia - reply
Weber, SC; Jain, R
Journal of Bone and Joint Surgery-American Volume, 84A(): 1892-1893.

Anesthesia and Analgesia
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
Candido, KD; Sukhani, R; Doty, R; Nader, A; Kendall, MC; Yaghmour, E; Kataria, TC; McCarthy, R
Anesthesia and Analgesia, 100(5): 1489-1495.
10.1213/01.ANE.0000148696.11814.9F
CrossRef
Anesthesia and Analgesia
Permanent loss of cervical spinal cord function associated with the posterior approach
Voermans, NC; Crul, BJ; de Bondt, B; Zwarts, MJ; van Engelen, BGM
Anesthesia and Analgesia, 102(1): 330-331.

Anesthesia and Analgesia
Safety of the posterior approach to the brachial plexus
Jack, NTM; Gielen, M
Anesthesia and Analgesia, 103(4): 1046.
10.1213/01.ane.0000239018.73597.d6
CrossRef
Regional Anesthesia and Pain Medicine
A brave new world: But we need proof! The Gaston Labat lecture, 2007
Mulroy, MF
Regional Anesthesia and Pain Medicine, 32(5): 406-411.
10.1016/j.rapm.2007.08.002
CrossRef
Regional Anesthesia and Pain Medicine
Anatomy and pathophysiology of spinal cord injury associated with regional anesthesia and pain medicine
Neal, JM
Regional Anesthesia and Pain Medicine, 33(5): 423-434.
10.1016/j.rapm.2006.10.014
CrossRef
Anaesthesia
Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques
Fredrickson, MJ; Krishnan, S; Chen, CY
Anaesthesia, 65(6): 608-624.
10.1111/j.1365-2044.2009.06231.x
CrossRef
Anasthesiologie & Intensivmedizin
Neurological complications after shoulder surgery in interscalene block
Besmer, I; Schupfer, G; Schleppers, A
Anasthesiologie & Intensivmedizin, 46(): 139-143.

European Journal of Anaesthesiology
Neuraxial blockade and patient risk
Egan, BJ; Brown, AR
European Journal of Anaesthesiology, 22(): 800-801.

Anaesthesia and Intensive Care
Ultrasound-assisted interscalene catheter placement in a child
Fredrickson, MJ
Anaesthesia and Intensive Care, 35(5): 807-808.

Muscle & Nerve
Cervical myelopathy caused by retrograde intraneural dissection of anesthetic solution
Sanders, KA
Muscle & Nerve, 37(4): 546.

Anaesthesist
Brachial plexus. Anesthesia and analgesia
Schulz-Stubner, S
Anaesthesist, 52(7): 643-656.
10.1007/s00101-003-0532-9
CrossRef
Neuromodulation
Intramedullary placement of intrathecal catheter. Report of a rare complication of intrathecal therapy
Slavin, KV
Neuromodulation, 9(2): 94-99.

Anaesthesia
Hemiplegic migraine associated with interscalene block and general anaesthesia
Cook, CJ; Jones, D
Anaesthesia, 63(6): 678-679.

Anaesthesia
Interscalene brachial plexus block: assessment of the needle angle needed to enter the spinal canal
Russon, KE; Herrick, MJ; Moriggl, B; Messner, HJ; Dixon, A; Harrop-Griffiths, W; Denny, NM
Anaesthesia, 64(1): 43-45.
10.1111/j.1365-2044.2008.05685.x
CrossRef
European Journal of Anaesthesiology
Pre-emptive analgesia produced by interscalene blockade. What failed: the block or the methods?
Blumenthal, S; Nadig, M; Borgeat, A
European Journal of Anaesthesiology, 20(): 933-934.

Current Orthopaedics
Mini-symposium: Shoulder instability - (iii) Anaesthesia for shoulder surgery
Borgeat, A; Blumenthal, S
Current Orthopaedics, 18(2): 109-117.
10.1016/j.cuor.2004.02.004
CrossRef
Anesthesia and Analgesia
Superficial Cervical Plexus Neuropathy After Single-Injection Interscalene Brachial Plexus Block
Christ, S; Rindfleisch, F; Friederich, P
Anesthesia and Analgesia, 109(6): 2008-2011.
10.1213/ANE.0b013e3181bbd98e
CrossRef
Journal of Clinical Anesthesia
Severe hypotension after interscalene block for outpatient shoulder surgery: a case report
Whitaker, EE; Edelman, AL; Wilckens, JH; Richman, JM
Journal of Clinical Anesthesia, 22(2): 132-134.
10.1016/j.jclinane.2009.02.014
CrossRef
Anaesthesist
Persistent neurological deficit of the upper extremity after a shoulder operation under general anaesthesia combined with a preoperatively placed interscalene catheter
Dullenkopf, A; Zingg, P; Curt, A; Borgeat, A
Anaesthesist, 51(7): 547-551.
10.1007/s00101-002-0331-8
CrossRef
Anaesthesia
Epidural anaesthesia as a complication of attempted brachial plexus blockade using the posterior approach
Gomez, RS; Mendes, TCBS
Anaesthesia, 61(6): 591-592.
10.1111/j.1365-2044.2006.04647.x
CrossRef
Anesthesia and Analgesia
New avenues of epidural research
Lang, SA; Tsui, B; Grau, T
Anesthesia and Analgesia, 97(1): 292-293.
10.1213/01.ANE.0000067920.62656.FE
CrossRef
British Journal of Anaesthesia
Injuries associated with anaesthesia. A global perspective
Aitkenhead, AR
British Journal of Anaesthesia, 95(1): 95-109.
10.1093/bja/aei132
CrossRef
Anesthesia and Analgesia
An ultrasonographic and histological study of intraneural injection and electrical stimulation in pigs
Chan, VWS; Brull, R; McCartney, CJL; Xu, DQ; Abbas, S; Shannon, P
Anesthesia and Analgesia, 104(5): 1281-1284.
10.1213/01.ane.0000250915.45247.24
CrossRef
Anesthesia and Analgesia
Small risk of serious neurologic complications related to lumbar epidural catheter placement in anesthetized patients
Horlocker, TT; Abel, MD; Messick, JM; Schroeder, DR
Anesthesia and Analgesia, 96(6): 1547-1552.
10.1213/01.ANE.0000057600.31380.75
CrossRef
Anesthesia and Analgesia
Regional anesthesia under general anesthesia and spinal cord injury
Benumof, JL
Anesthesia and Analgesia, 100(4): 1214.
10.1213/01.ANE.0000146665.46527.DF
CrossRef
Foot & Ankle International
Lateral trans-biceps popliteal block for elective foot and ankle surgery performed after induction of general anesthesia
Herr, MJ; Keyarash, AB; Muir, JJ; Kile, TA; Claridge, RJ
Foot & Ankle International, 27(9): 667-671.

Regional Anesthesia and Pain Medicine
Continuous thoracic paravertebral block for major breast surgery
Boezaart, AP; Raw, RM
Regional Anesthesia and Pain Medicine, 31(5): 470-476.
10.1016/j.rapm.2006.03.009
CrossRef
Canadian Medical Association Journal
Anatomy is still essential
Auer, RN; McDonald, DS
Canadian Medical Association Journal, 168(7): 829.

Journal of Clinical Anesthesia
Minimal threshold for stimulating catheters
Tran, DQH; Taam, J; Cuadra-Fontaine, JCDL
Journal of Clinical Anesthesia, 20(1): 45-47.
10.1016/j.jclinane.2007.04.011
CrossRef
Acta Anaesthesiologica Scandinavica
Ultrasound-guided peripheral nerve blocks: What are the benefits?
Koscielniak-Nielsen, ZJ
Acta Anaesthesiologica Scandinavica, 52(6): 727-737.
10.1111/j.1399-6576.2008.01666.x
CrossRef
Anesthesia and Analgesia
Continuous Interscalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study
Mariano, ER; Afra, R; Loland, VJ; Sandhu, NS; Bellars, RH; Bishop, ML; Cheng, GS; Choy, LP; Maldonado, RC; Ilfeld, BM
Anesthesia and Analgesia, 108(5): 1688-1694.
10.1213/ane.0b013e318199dc86
CrossRef
Regional Anesthesia and Pain Medicine
How close is close enough? Defining the "paresthesia chad"
Neal, JM
Regional Anesthesia and Pain Medicine, 26(2): 97-99.

Regional Anesthesia and Pain Medicine
Early experience with continuous cervical paravertebral block using a stimulating catheter
Boezaart, AP; de Beer, JF; Nell, ML
Regional Anesthesia and Pain Medicine, 28(5): 406-413.
10.1016/S1098-7339(03)00221-9
CrossRef
Anaesthesia
Interscalene brachial plexus block: assessment of the needle angle needed to enter the spinal canal in cadavers using computed tomography
Russon, K; Herrick, MJ; Denny, NM; Moriggl, B
Anaesthesia, 63(8): 910-911.

Regional Anesthesia and Pain Medicine
That Which We Call a Rose by Any Other Name Would Smell as Sweet-and Its Thorns Would Hurt as Much
Boezaart, AP
Regional Anesthesia and Pain Medicine, 34(1): 3-7.
10.1097/AAP.0b013e318194cf23
CrossRef
Regional Anesthesia and Pain Medicine
Upper Extremity Regional Anesthesia Essentials of Our Current Understanding, 2008
Neal, JM; Gerancher, JC; Hebl, JR; Ilfeld, BM; McCartney, CJL; Franco, CD; Hogan, QH
Regional Anesthesia and Pain Medicine, 34(2): 134-170.
10.1097/AAP.0b013e31819624eb
CrossRef
Anesthesia and Analgesia
Continuous plexus and peripheral nerve blocks for postoperative analgesia
Liu, SS; Salinas, FV
Anesthesia and Analgesia, 96(1): 263-272.
10.1213/01.ANE.0000038477.85131.34
CrossRef
Anaesthesist
Intrathecal misplacement of an interscalene plexus catheter
Walter, M; Rogalla, P; Spies, C; Kox, WJ; Volk, T
Anaesthesist, 54(3): 215-+.
10.1007/s00101-004-0792-z
CrossRef
Muscle & Nerve
Cervical myelopathy caused by retrograde intraneural dissection of anesthetic solution
Cochrane, TI
Muscle & Nerve, 36(2): 261-263.
10.1002/mus.20782
CrossRef
Anesthesia and Analgesia
An indication for continuous cervical paravertebral block (posterior approach to the interscalene space)
Borene, SC; Rosenquist, RW; Koorn, R; Haider, N; Boezaart, AP
Anesthesia and Analgesia, 97(3): 898-900.
10.1213/01.ANE.0000072702.79692.17
CrossRef
Anaesthesia and Intensive Care
Long-term neurological complications associated with surgery and peripheral nerve blockade: outcomes after 1065 consecutive blocks
Watts, SA; Sharma, DJ
Anaesthesia and Intensive Care, 35(1): 24-31.

Journal of Shoulder and Elbow Surgery
The types and severity of complications associated with interscalene brachial plexus block anesthesia: Local and national evidence
Lenters, TR; Davies, J; Matsen, FA
Journal of Shoulder and Elbow Surgery, 16(4): 379-387.
10.1016/j.jse.2006.10.007
CrossRef
Regional Anesthesia and Pain Medicine
ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine
Neal, JM; Bernards, CM; Hadzic, A; Hebl, JR; Hogan, QH; Horlocker, TT; Lee, LA; Rathmell, JP; Sorenson, EJ; Suresh, S; Wedel, DJ
Regional Anesthesia and Pain Medicine, 33(5): 404-415.
10.1016/j.rapm.2008.07.527
CrossRef
European Journal of Anaesthesiology
Neuraxial blockade and patient risk - Reply
Bogdanov, A; Loveland, R
European Journal of Anaesthesiology, 22(): 801-802.

Ultraschall in Der Medizin
Ultrasound-guided interscalene brachial plexus anaesthesia: Differences in success between patients of normal and excessive weight
Schwemmer, U; Papenfuss, T; Greim, C; Brederlau, J; Roewer, N
Ultraschall in Der Medizin, 27(3): 245-250.
10.1055/s-2006-926591
CrossRef
Surgical and Radiologic Anatomy
A supraomohyoidal plexus block designed to avoid complications
Feigl, G; Fuchs, A; Gries, M; Hogan, QH; Weninger, B; Rosmarin, W
Surgical and Radiologic Anatomy, 28(4): 403-408.
10.1007/s00276-006-0113-0
CrossRef
Regional Anesthesia and Pain Medicine
The middle interscalene block: Cadaver study and clinical assessment
Alemanno, F; Capozzoli, G; Egarter-Vigl, E; Gottin, L; Alberto, B
Regional Anesthesia and Pain Medicine, 31(6): 563-568.
10.1016/j.rapm.2006.05.015
CrossRef
Journal of Bone and Joint Surgery-American Volume
Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk
Weber, SC; Jain, R
Journal of Bone and Joint Surgery-American Volume, 84A(5): 775-779.

Anesthesia and Analgesia
Unsolicited Paresthesias with nerve stimulator: Case reports of four patients
Mulroy, MF; Mitchell, B
Anesthesia and Analgesia, 95(3): 762-763.
10.1213/01.ANE.0000023284.95886.5A
CrossRef
Muscle & Nerve
Sensory and motor complications of local anesthetics
Gerner, P; Strichartz, GR
Muscle & Nerve, 37(4): 421-425.
10.1002/mus.20967
CrossRef
Regional Anesthesia and Pain Medicine
Nerve Expansion Seen on Ultrasound Predicts Histologic But Not Functional Nerve Injury After Intraneural Injection in Pigs
Lupu, CM; Kiehl, TR; Chan, VWS; El-Beheiry, H; Madden, M; Brull, R
Regional Anesthesia and Pain Medicine, 35(2): 132-139.
10.1097/AAP.0b013e3181d25cfe
CrossRef
Regional Anesthesia and Pain Medicine
Research in regional anesthesia: Objective versus subjective - Reply
Neal, JM
Regional Anesthesia and Pain Medicine, 26(6): 593-594.

Journal of Clinical Anesthesia
Training of residents in peripheral nerve blocks during anesthesiology residency
Chelly, JE; Greger, J; Gebhard, R; Hagberg, CA; Al-Samsam, T; Khan, A
Journal of Clinical Anesthesia, 14(8): 584-588.
10.1016/S0952-8180(02)00454-3
CrossRef
Journal of Clinical Anesthesia
Comment on "Perioperative interscalene blockade: An overview of its history and current clinical use" - Reply
Long, TR; Wass, CT; Burkle, CM
Journal of Clinical Anesthesia, 15(6): 489.

Schmerz
Pain management in shoulder surgery
Schwemmer, U; Greim, CA; Boehm, TD; Papenfuss, T; Markus, CK; Roewer, N; Gohlke, F
Schmerz, 18(6): 475-+.
10.1007/s00482-004-0329-z
CrossRef
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Failed spinal anesthesia after a psoas compartment block
Lang, SA; Prusinkiewicz, C; Tsui, BCH
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 52(1): 74-78.

Pediatric Anesthesia
Ultrasound-guided interscalene brachial plexus block in a child with femur fibula ulna syndrome
van Geffen, GJ; Tielens, L; Gielen, M
Pediatric Anesthesia, 16(3): 330-332.
10.1111/j.1460-9592.2005.01691.x
CrossRef
Muscle & Nerve
Cervical myelopathy caused by retrograde intraneural dissection of anesthetic solution - Reply
Cochrane, TI
Muscle & Nerve, 37(4): 547-548.
10.1002/mus.20927
CrossRef
Regional Anesthesia and Pain Medicine
Interscalene Perineural Catheter Placement Using an Ultrasound-Guided Posterior Approach
Mariano, ER; Loland, VJ; Ilfeld, BM
Regional Anesthesia and Pain Medicine, 34(1): 60-63.
10.1097/AAP.0b013e3181933af7
CrossRef
Anesthesiology
Performing an Interscalene Block during General Anesthesia Must Be the Exception
Borgeat, A; Ekatodramis, G; Gaertner, E
Anesthesiology, 95(5): 1302-1303.

Anesthesiology
How to Prevent Catastrophic Complications When Performing Interscalene Blocks
Chelly, JE; Greger, J; Gebhard, R; Casati, A
Anesthesiology, 95(5): 1302.

Anesthesiology
Evaluation of the Lateral Modified Approach for Continuous Interscalene Block after Shoulder Surgery
Borgeat, A; Dullenkopf, A; Ekatodramis, G; Nagy, L
Anesthesiology, 99(2): 436-442.

PDF (280)
Anesthesiology
All Roads Do Not Lead to Rome
Borgeat, A
Anesthesiology, 105(1): 1-2.

PDF (260)
Anesthesiology
Calculation of the Permeability Coefficient Should Take into Account the Fact That Most Drugs Are Weak Electrolytes
Bernards, CM
Anesthesiology, 95(5): 1301.

Anesthesiology
Mitigation of Direct Neurotoxic Effects of Lidocaine and Amitriptyline by Inhibition of p38 Mitogen-activated Protein Kinase In Vitro and In Vivo
Lirk, P; Haller, I; Myers, RR; Klimaschewski, L; Kau, Y; Hung, Y; Gerner, P
Anesthesiology, 104(6): 1266-1273.

PDF (1937)
Anesthesiology
What Happened to the Paresthesia?
Urmey, WF; Stanton, J
Anesthesiology, 98(2): 588-590.

Anesthesiology
Attempted Interscalene Block Procedures
Bittar, DA
Anesthesiology, 95(5): 1303-1304.

Anesthesiology
Interscalene Brachial Plexus Block: Can the Risk of Entering the Spinal Canal Be Reduced?: A Study of Needle Angles in Volunteers Undergoing Magnetic Resonance Imaging
Sardesai, AM; Patel, R; Denny, NM; Menon, DK; Dixon, AK; Herrick, MJ; Harrop-Griffiths, AW
Anesthesiology, 105(1): 9-13.

PDF (680)
Anesthesiology
Comparison of the Particle Sizes of Different Steroids and the Effect of Dilution: A Review of the Relative Neurotoxicities of the Steroids
Benzon, HT; Chew, T; McCarthy, RJ; Benzon, HA; Walega, DR
Anesthesiology, 106(2): 331-338.

PDF (507)
Anesthesiology
Training Requirements for Peripheral Nerve Blocks
Hadzic, A; Vloka, JD; Santos, AC; Schwartz, AJ; Sanborn, K; Birnbach, DJ; Thys, DM
Anesthesiology, 95(5): 1303.

Anesthesiology
Inability to Consistently Elicit a Motor Response following Sensory Paresthesia during Interscalene Block Administration
Urmey, WF; Stanton, J
Anesthesiology, 96(3): 552-554.

PDF (65)
Anesthesiology
Nerve Stimulators Used for Peripheral Nerve Blocks Vary in Their Electrical Characteristics
Hadzic, A; Vloka, J; Hadzic, N; Thys, DM; Santos, AC
Anesthesiology, 98(4): 969-974.

PDF (864)
Anesthesiology
Motor Response following Paresthesia during Interscalene Block: Methodological Problems May Lead to Inappropriate Conclusions
Choquet, O; Jochum, D; Estebe, J; Dupré, L; Capdevila, X
Anesthesiology, 98(2): 587-588.

Critical Care Medicine
Regional analgesia in the critically ill
Schulz-Stübner, S; Boezaart, A; Hata, JS
Critical Care Medicine, 33(6): 1400-1407.
10.1097/01.CCM.0000165843.39713.AE
PDF (431) | CrossRef
Current Opinion in Anesthesiology
Paravertebral block: cervical, thoracic, lumbar, and sacral
Boezaart, AP; Lucas, SD; Elliott, CE
Current Opinion in Anesthesiology, 22(5): 637-643.
10.1097/ACO.0b013e32832f3277
PDF (21656) | CrossRef
European Journal of Anaesthesiology (EJA)
Is there a place for interscalene block performedafterinduction of general anaesthesia?
Bogdanov, A; Loveland, R
European Journal of Anaesthesiology (EJA), 22(2): 107-110.
10.1017/S0265021505000207
PDF (102) | CrossRef
Journal of Neurosurgical Anesthesiology
Complications of Regional Anesthesia: Nerve Injury and Peripheral Neural Blockade
Liguori, GA
Journal of Neurosurgical Anesthesiology, 16(1): 84-86.

PDF (159)
Journal of Pediatric Orthopaedics
Regional Techniques as an Adjunct to General Anesthesia for Pediatric Extremity and Spine Surgery
DeVera, HV; Furukawa, KT; Matson, MD; Scavone, JA; James, MA
Journal of Pediatric Orthopaedics, 26(6): 801-804.
10.1097/01.bpo.0000235392.26666.6b
PDF (79) | CrossRef
Back to Top | Article Outline
Keywords:
Brachial plexus block; central cord syndrome; complications; injection; intraspinal cord; local anesthetic toxicity; paralysis; syrinx.

© 2000 American Society of Anesthesiologists, Inc.

Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.
Login

Article Tools

Images

Share