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Novel Axillary Block Management for Tendon Transfer Surgery: A Case Report

Garnaud, Thierry MD*; Toulemonde, Julien MD

doi: 10.1213/XAA.0000000000000954
Case Reports
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The outcome of upper limb tendon transfer surgery is improved when the patient is able to voluntarily contract specific muscles during the surgical procedure. Tumescent local anesthesia is suitable, but we describe an alternative option that involves the novel management of an axillary block. A 47-year-old man, injured in a motor vehicle crash, exhibited a thumb extensor deficit because of severe muscular trauma to the forearm. He underwent a tendon transfer of the fourth superficial flexor tendon to the extensor pollicis longus under an axillary block. First, individual injections of ropivacaine were performed around the musculocutaneous, radial, and ulnar nerves with ultrasound guidance. Second, a perineural catheter was placed near the median nerve and lidocaine injected. Voluntary flexor muscle contraction reappeared in time for the surgeon to adjust his suture tension.

From the *Department of Anesthesiology, Rodez General Hospital, Rodez, France

Departement of Orthopedic Surgery, Orthopedic Surgery, Rodez General Hospital, Rodez, France.

Accepted for publication November 21, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Thierry Garnaud, MD, Department of Anesthesiology, Rodez General Hospital, Ave de l’Hôpital, 12000 Rodez, France. Address e-mail to tgarnaud@orange.fr.

Upper limb orthopedic surgery and particularly tendon surgery require precise surgical repair control. Specifically, the ability to delineate tendon course and adjust suture tension leads to a better functional result.1–3 Tumescent local anesthesia is typically recommended in this situation to keep the patient awake during surgery and allows him to have a voluntary muscular contraction that will enable the surgeon to perform intraoperative functional tests. General anesthesia and peripheral nerve blocks classically administered do not allow such conditions. We present a case where a novel approach to axillary block management provided better anesthesia to the forearm and permitted timely appearance of voluntary contraction of the transposed flexor muscle.

Written consent has been obtained from the patient for publication.

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CASE DESCRIPTION

A 47-year-old inpatient man was injured in a motor vehicle crash. He had a thumb extensor deficit because of a severe muscular trauma of the forearm. The surgeon proposed to proceed to a tendon transfer of the fourth superficial flexor tendon to the extensor pollicis longus. The patient was admitted in a preanesthetic room before surgery to perform an axillary block in 2 steps (Figure 1). First, a single puncture with a 21-gauge, 80-mm needle was used, guided by an ultrasound-guided in-plane approach with neurostimulation, to inject 5 mL of ropivacaine (4.75 mg/mL) around the musculocutaneous nerve, then the radial nerve, and finally the ulnar nerve. We took care to check with ultrasound that the spread of the injected ropivacaine did not reach the median nerve. Secondarily, a perineural catheter was placed in the vicinity of the median and medial cutaneous nerves by an ultrasound-guided, out-of-plane approach, but no local anesthetic was injected at this time. Fifteen minutes later, the patient had a sensory-motor block to ulnar, radial, and musculocutaneous nerves. We confirmed that the median nerve and the medial cutaneous nerve of the forearm were not affected by the previous local anesthetic injection and diffusion by testing responses to touch, pinprick, and cold and for spontaneous motor activity (Figure 2). The completion of this procedure took ≤20 minutes.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

As soon as the patient entered the operating room, 15 mL of a 1.33% lidocaine solution (10 mL of 1% lidocaine plus 5 mL of 2% lidocaine without epinephrine) was injected through the perineural catheter. The volume was chosen knowing that the lidocaine diffusion could not be checked with the ultrasound and subsequently would not be as precise as a needle injection. We reduced the lidocaine concentration to minimize the potential of median nerve motor block when the surgeon wanted to perform his functional testing. A tourniquet was inflated to 250 mm Hg, and the patient was mildly sedated with midazolam 2 mg IV to reach a Ramsay score of 2 or 3 (2: awake, cooperative, oriented, and calm; 3: responds to command only). No other medications were given intraoperatively.

The surgeon performed 3 incisions: 2 on the anterior and posterior sides of the lower half of the right forearm and 1 along the palmar crease of the fourth metacarpophalangeal joint. During the surgical dissection, we observed a complete motor block of the hand. Once tendon transfer was achieved across the interosseous membrane, the tourniquet was deflated (50 minutes inflation time). Five minutes later, the patient described paresthesias and was able to flex his first 3 fingers and his wrist. The surgeon then asked the patient to contract the transposed flexor muscle to adjust his suture tension and control the tendon excursion (Supplemental Digital Content, Video, http://links.lww.com/AACR/A245, which shows the intraoperative surgical functional test). Subsequently, the tourniquet was reinflated to allow the surgeon to complete his surgery. An additional 5 mL of lidocaine 2% was injected through the perineural catheter.

The postoperative period was uneventful. The perineural catheter was used for pain control for the next 2 days with repeated boluses of 0.2% ropivacaine at the patient’s request. We observed no anesthetic motor block of the upper limb during this time. The catheter was then removed. At discharge, the patient reported that he was highly satisfied with his intraoperative and postoperative experience. At 6 months, the patient was able to extend his thumb and grasp effectively.

This anesthetic technique was enabled not only by the patient’s but also the surgeon’s consent. Both accepted either general anesthesia in case of the axillary block failure or a surgical procedure performed under a complete sensory-motor block in case of a failure to preserve the median nerve motor conduction.

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DISCUSSION

When a perineural axillary block is performed under ultrasound-guided needle neurostimulation, lower volumes and lower concentrations of the local anesthetics are required.4,5 Moreover, the ultrasound in-plane approach enables specific and successive access to the musculocutaneous, radial, and ultimately ulnar nerves by directing the injecting needle underneath the axillary artery. It also enables a low-volume (5 mL) localized injection around each nerve. In our particular case, we were able to preserve the median nerve from these injections even if the local anesthetic distribution around the nerves was helicoidal.6 Indeed, axillary brachial plexus sheath anatomical studies show that septations compartmentalize the nerves and limit local anesthetic diffusion.6 Our objective was to have an intense effect to the areas that were not involved by the functional tests intraoperatively performed by the surgeon.

The catheter insertion was considered so as to modulate the local anesthetic motor effect to the median nerve. Moreover, in this patient subjected to multiple surgical procedures, an additional advantage of the catheter was its use in the context of a multimodal postoperative pain management. Local anesthetic administration through the axillary catheter is similar to a perivascular injection although less precise than a needle ultrasound-guided approach.7 This explains our decision to use a 15-mL volume to block median and medial cutaneous nerves with a probabilistic lidocaine concentration and to subsequently permit a timely recovery of median nerve-controlled muscle function (<1.5% to minimize the motor block but >1% to guarantee efficacy). The decision to use the shorter-acting lidocaine improved the odds of motor block dissipation at the appropriate time. Before the tourniquet was inflated, the patient was able to flex his fingers and wrist. It was only during the surgery that a complete motor block of the hand was observed. It is possible that tourniquet-induced ischemia contributed to our median nerve block. The patient recovered his forearm flexor muscle contraction when the tourniquet was released 65 minutes after lidocaine was administered, allowing the surgeon to perform tests to the transferred tendon (Supplemental Digital Content, Video, http://links.lww.com/AACR/A245, which shows the intraoperative surgical functional test).

One limitation of this novel approach is the difficulty to assess its reproducibility. Indeed, the interindividual anatomical variation of the brachial plexus nerves is significant.8 Among the sensory-motor nerves of the forearm and hand (median, ulnar, and radial), the median nerve is the most frequently found as an isolated feature (83%) in the superolateral quadrant of the axilla.8 In any case, it is always possible to anatomically individualize any nerve with an ultrasound-guided approach at the level of the humeral canal or the elbow.

Tendon transfer surgery implies a shift in anesthetic approach to facilitate surgical intraoperative tests and subsequently improve functional outcome. Tumescent local anesthesia, also known as Wide Awake Local Anesthesia No Tourniquet, has proved its efficiency in this context.2 Modulation of a low-concentration, short-acting local anesthetic administered through an axillary catheter is a possible alternative that should be further studied to define its indications, limits, and reproducibility.

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ACKNOWLEDGMENTS

The authors thank Chemasle Christophe, MD (Palmerston North Hospital, New Zealand), who provided medical writing services that included translating this document into English. The authors thank the patient, who accepted the diffusion of his upper limb pictures to illustrate this manuscript.

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DISCLOSURES

Name: Thierry Garnaud, MD.

Contribution: This author helped care for the patient, write and review the manuscript, and prepare the figures.

Name: Julien Toulemonde, MD.

Contribution: This author helped care for the patient, and write and review the manuscript.

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

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REFERENCES

1. Zukawa M, Osada R, Makino H, Kimura T. Active voluntary contraction of the ruptured muscle tendon during the wide-awake tendon reconstruction. Plast Reconstr Surg Glob Open. 2017;5:e1597.
2. Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction. Arch Plast Surg. 2014;41:312–316.
3. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010;126:941–945.
4. Schoenmakers KP, Wegener JT, Stienstra R. Effect of local anesthetic volume (15 vs 40 mL) on the duration of ultrasound-guided single shot axillary brachial plexus block: a prospective randomized, observer-blinded trial. Reg Anesth Pain Med. 2012;37:242–247.
5. O’Donnell BD, Iohom G. An estimation of the minimum effective anesthetic volume of 2% lidocaine in ultrasound-guided axillary brachial plexus block. Anesthesiology. 2009;111:25–29.
6. Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths. Anesthesiology. 1983;59:117–122.
7. Klaastad Ø, Smedby O, Thompson GE, et al. Distribution of local anesthetic in axillary brachial plexus block: a clinical and magnetic resonance imaging study. Anesthesiology. 2002;96:1315–1324.
8. Christophe JL, Berthier F, Boillot A, et al. Assessment of topographic brachial plexus nerves variations at the axilla using ultrasonography. Br J Anaesth. 2009;103:606–612.

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