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Fortuitous Diagnosis of Preexisting Neuropathy During Ultrasound-Guided Regional Anesthesia Performance: A Case Report

Marty, Philippe MD; Basset, Bertrand MD; Marquis, Constance MD; Merouani, Medhi MD; Rontes, Olivier MD; Delbos, Alain MD

doi: 10.1213/XAA.0000000000000500
Case Reports: Case Report
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Ultrasound-guided regional anesthesia requires the anesthesia provider to interpret new information. This article reports on the case of a 38-year-old man scheduled for a fifth metacarpal fracture repair. Ultrasound nerve examination revealed abnormal pathology of the axillary brachial plexus consisting of an increased volume of the terminal nerves of the brachial plexus. Ultrasound scanning initiated the subsequent diagnosis of multifocal motor neuropathy. Regional anesthesia was abandoned in favor of general anesthesia. Ultrasonography training needs to be expanded in the coming years to include awareness of the abnormal pathology, as it might impact the choice of anesthetic procedure and patient outcome.

From the Department of Anesthesia, Clinique Medipole Garonne, Toulouse, France.

Accepted for publication December 14, 2016.

Funding: This work should be attributed to the Department of Anesthesiology, Clinique Medipole Garonne, Toulouse, France. Support was provided solely from institutional and department sources from department of Anesthesiology, Clinique Medipole Garonne, Toulouse, France.

The authors declare no conflicts of interest.

Address correspondence to Philippe Marty, MD, Department of Anesthesia, Clinique Médipole Garonne, 31036, Toulouse, France. Address e-mail to philippemarty@hotmail.com.

If regional anesthesia was still underused 10 years ago, its use has boomed during the past decade.1 Its use has spread for anesthesia and postoperative pain management.2 Regional anesthesia appears to be the gold standard for postoperative pain care because it is associated with better pain relief and fewer side effects such as nausea, vomiting, and sedation.3

Regional anesthesia procedures have been advanced during the past decade resulting from the development of ultrasound technology. Ultrasound-guided regional anesthesia (USGRA) provides increased patient safety by reducing the volume of local anesthetics used and in reducing mechanical complications.4 Some studies also report a trend toward greater rates of regional anesthesia success with USGRA when compared with nerve stimulation or other methods.5

The development of USGRA has been accompanied by the need for the provider to interpret new information, as nerves, vessels, and many other structures are more clearly identifiable. There is a lack of data regarding the appearance of nerves under ultrasound. This article describes a man who presented with abnormal imaging during ultrasound scanning and how it modified the anesthetic strategy and patient outcome.

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CASE REPORT

Written consent for the educational publication of this case was collected from the patient after obtaining informed consent.

A 38-year-old, American Society of Anesthesiologists physical status I, 75-kg man was transferred to our orthopedics and traumatology department for a fifth metacarpal closed fracture repair. Surgery was scheduled for reduction and internal fixation on the same day. The patient reported no abnormal medical history, allergies, or medications. No laboratory testing was performed. After a discussion with the patient, an axillary block was planned.

Routine perioperative monitoring was established after the patient’s arrival to the operating room. The initial vital signs were oxygen saturation 98%, arterial blood pressure 127/69 mm Hg, and heart rate 97 beats/min. The axillary block procedure began with ultrasound nerve scanning (Sonosite Export, Bothell, WA). Abnormal appearance of the brachial plexus was apparent with an increased volume and altered echogenicity of the nerves of the brachial plexus (Figure). After careful questioning, the patient reported a preexisting light motor deficit without any sensory deficit that began several months before his injury. The presence of an undiagnosed preexisting neuropathy was considered due to the atypical ultrasound imaging and the clinical signs of neurologic deficit.

Figure.

Figure.

The decision was made to deliver a general anesthetic to avoid potential local anesthetic nerve toxicity. Fracture reduction and osteosynthesis of the fifth metacarpal were performed with the patient under general anesthesia, and postoperative pain relief was achieved with paracetamol (1 g every 6 hours), ketoprofen (100 mg twice a day), and rescue analgesia with tramadol tablets.

The patient was then referred to a neurologist. The diagnosis of multifocal motor neuropathy (MMN) was established due to persistent multifocal partial conduction blocks and the presence of high-titer anti-GM1 serum antibodies.6 MMN is an acquired immune-mediated neuropathy characterized by chronic or stepwise progressive asymmetrical limb weakness without sensory deficits.

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DISCUSSION

USGRA is an innovative approach to perform regional anesthesia, allowing a safe and effective procedure.4 Today, however, the anesthesiologist has to deal with new information arising from the ultrasound. In this case report, ultrasonography allowed the diagnosis of MMN based on atypical aspect of nerves.

This case report emphasizes that neurologic diseases can modify the ultrasonographic aspect of nerves. Recent studies report an abnormal aspect on ultrasound in the case of preexisting neurologic disease such as diabetes or compression.7–9 A lack of data still exists, however, regarding ultrasound nerve aspect because echography is not yet a common complementary examination used by either neurologists or radiologists and is a recent tool in the hands of anesthesiologists.

There is limited evidence regarding the performance of regional anesthesia in patients with chronic neuropathy.10 The question of decompensation of preexisting neurologic pathologies with local anesthetics or adjuvants is still a matter of debate.11 In the case of an abnormal nerves aspect on ultrasound, alternatives to regional anesthesia should be considered and discussed with the patient.

Ten years ago, recognizing nerves with ultrasound was a challenge in itself. Today, improvement of technologies and practices not only allow the accurate visualization of nerves but also their peripheral structures such as vessels or ganglion. This has led to better ultrasound anatomy expertise. The next step is probably to deal with abnormal aspects of structures we are able to see. The use of ultrasound raises new issues. Are we responsible for the medical care of abnormal structures we have recognized during USGRA? Are we responsible for abnormal structures we haven’t recognized?

As echography becomes a real part of the anesthesiologist’s routine, appropriate training should be considered to attain a better knowledge of the different structures we are now able to see. Ultrasonographic education of peripheral nervous system has to be improved in the coming years because it might have an impact on the choice of anesthetic procedure and patient outcome.

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DISCLOSURES

Name: Philippe Marty, MD.

Contribution: This author helped perform all recordings during ultrasound nerve tracking, and write the manuscript.

Name: Bertrand Basset, MD.

Contribution: This author was the physician in charge.

Name: Constance Marquis, MD.

Contribution: This author helped write the manuscript.

Name: Medhi Merouani, MD.

Contribution: This author helped write the manuscript.

Name: Olivier Rontes, MD.

Contribution: This author helped perform all recordings during ultrasound nerve tracking, and write the manuscript.

Name: Alain Delbos, MD.

Contribution: This author helped write the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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