Similar to neuraxial injuries, the diagnosis and treatment of PNIs should be approached urgently to rule out potentially correctable lesions, such as from extrinsic or intrinsic compression (casts, dressings, compartment syndrome, visible hematoma, or occult perineural microhematoma). If a hematoma is suspected, urgent imaging or ultrasonography should be considered. Acute surgical injury should also be ruled out by engaging the surgeon in candid discussion regarding the possibility of nerve transection, excessive traction, or wayward ligatures. Indeed, 1 review reported that more than 90% of surgically explored iatrogenic nerve injuries were linked to intraoperative causes.182 The goal of timely consultation is to alleviate potentially correctable causes or nonsurgical or anesthesia-related etiologies, such as stroke. Once the need for immediate treatment has been ruled out, the diagnosis of PNI can proceed as directed by initial presenting symptoms (Fig. 3). Pure sensory deficits that occur within the territory of the peripheral block74 or a classic compression point, for example, common peroneal nerve compression at the fibular head, can be observed and are expected to resolve within days to weeks. However, neurologic consultation should be considered when the deficit involves motor function, is progressive, is characterized by recrudescence of neural blockade, or is difficult to localize and/or reconcile with the expected distribution of the anesthetic block or surgery. Electrophysiologic studies for more severe or unclear cases are typically delayed for 2 to 3 weeks, when signs of Wallerian degeneration first appear. However, early electrophysiologic studies may we worthwhile to define preexisting pathology. Bilateral studies may be indicated if occult conditions are suspected to affect the nonoperative side. Such decisions are best made in consultation with a neurologist. When no or incomplete improvement has taken place by 3 to 5 months, consideration should be given for referral to a peripheral nerve surgeon. Recommendations for the diagnosis and treatment of PNIs can be found in Tables 14 and 15.
Postsurgical inflammatory neuropathies were discussed previously in the preexisting neurologic disease section. When patients present with this symptom complex in the postsurgical period, urgent neurologic consultation is warranted.
A subset of patients who sustain perioperative nerve injury will develop chronic neuropathic pain. The pain medicine physician is often called on to provide long-term symptomatic management of these patients and to assume coordination of patient education, expectation, and physical therapy. New to this advisory are evidence-based recommendations for the care of these challenging patients, some of whom may have unanswered questions or unrealistic expectations consequent to suboptimal communication with various practitioners during the immediate postoperative episode.
Postsurgical neuropathic pain syndromes may result from surgical injury, such as intercostal neuritis after thoracotomy, or may be consequent to neural blocks administered during the perioperative period. There are several considerations for when it might be appropriate to refer patients with persistent postsurgical pain to a pain medicine specialist—severe pain out of proportion to that expected from a specific surgical procedure; pain that limits patient function; or pain that is progressive, multifocal, and/or difficult to localize. Other signs that should prompt early referral are those consistent with chronic regional pain syndrome, such as neurologic impairment in an area remote from the regional block, surgery, or compression or physical signs such as allodynia, edema, or hyperhidrosis. Readers are referred to the supporting article’s15 detailed recommendations regarding stepwise pharmacologic therapies for these patients, as well as reasonable indications for the use of diagnostic nerve blocks, such as stellate ganglion block. The evidence for neuromodulation therapy is less conclusive; the European Federation of Neurological Societies supports the use of spinal cord stimulation for chronic regional pain syndrome,183 although there are no supporting studies specific to postsurgical neuropathic pain.
In summary, the diagnosis and treatment of neuraxial injuries demands emergent stratification of those injuries that may be amenable to surgical decompression. Although the management of PNIs is less urgent (particularly when sensory predominant), practitioners are reminded that severe, progressive, or difficult-to-localize deficits demand urgent neurologic consultation to exclude potentially treatable causes such as from compressive etiologies. If a treatable cause is excluded, there is little that the physician can do to change the course of these injuries. However, pain physicians have a useful role to play in coordinating education, expectation management, and pain modulation in those patients who develop chronic neuropathic pain from their injury.
The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine provides a number of updates to the 2008 advisory. New information has been presented on the incidence of nerve injury inherent to common elective orthopedic surgeries. The advisory contains updated information regarding the pathophysiology of neuraxial and peripheral nerve injury. New or expanded information is presented, particularly with regard to spinal canal pathology, blood pressure control during neuraxial anesthetics, neurotoxicity-related neuraxial injuries, transforaminal pain medicine procedures, and the advisability of performing procedures in anesthetized or deeply sedated patients. The advisory also expands recommendations related to the diagnosis and treatment of these disorders.
Our final conclusion is very similar to that made in 2008: “Neurologic complications associated with regional anesthesia and pain medicine are rare—particularly those complications that do not involve hematoma or infection. Understanding the pathophysiology and risk factors associated with neuraxial and peripheral nerve injury may allow anesthesiologists to minimize the number of adverse neurologic outcomes. Unfortunately, even with flawless care of otherwise healthy patients by well-trained physicians, these complications are neither completely predictable nor preventable. This practice advisory offers a number of recommendations specific to common clinical scenarios encountered in everyday practice.”4
The authors of this executive summary all served as members of the practice advisory panel. The authors thank the following colleagues who made substantial contributions to this project through participation in the open forum or authorship of the individual background articles from which this executive summary was drawn:
• CEU San Pablo University, Madrid, Spain: Miguel A. Reina, MD, PhD
• Mayo Clinic College of Medicine: Adam K. Jacob, MD; William L. Lanier, MD; Jeffrey J. Pasternak, MD
• University of Maryland Medical Center, Baltimore, Maryland: Paul E. Bigeleisen, MD, participated as a panelist at the open forum
• University of Toronto, Toronto, Ontario, Canada: Zahra Abbas, BSc; Vincent WS Chan, MD, FRCPC, FRCA; Phantila Cholvisudhi, MD; Michael Drexler, MD; Tim Dwyer, MBBS, FRACS, FRCSC; Patrick DG Henry, MD, FRCSC; Johnny Lau, MD, MSc, FRCSC; Peter Salat, MD; John S Theodoropoulos, MD, MSc, FRCSC; Andrea Veljkovic, BComm, MD, FRCSC; Daniel B Whelan, MD, MSc, FRCSC
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APPENDIX 1. Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence
APPENDIX 2. Strength of Recommendations