Nervenschäden bei Regionalanästhesie – Nervenschäden bei peripheren Blockaden: Klinik und Inzidenz

Zusammenfassung

Bleibende Nervenschäden im Rahmen peripherer Nervenblockaden sind eine Rarität. Häufig treten die Beschwerden kombiniert auf und bessern sich noch während des Krankenhausaufenthalts. In den bisherigen Studien wurden neurologische Dysfunktionen unterschiedlich definiert, wodurch die Angaben zur Inzidenz variieren. Interskalenäre Blockaden scheinen unter den verschiedenen Lokalisationen die höchste Inzidenz aufzuweisen. Die Dysfunktionen äußern sich in Parästhesien, Taubheit, Störungen im Berührungsempfinden und/oder Muskelschwäche. Eine Reduzierung neurologischer Beschwerden durch ultraschallgestützte Blockaden konnte durch bisherige Daten nicht gezeigt werden. Patientenbezogene Risikofaktoren, extreme Lagerungen während der Operation und andere Ursachen machen es oft schwierig, einen Zusammenhang zwischen den Beschwerden und den stattgehabten Blockaden zu finden. Dennoch zählen durch Blockaden hervorgerufene Nervenschäden zu den seltenen anästhesiebezogenen Zwischenfällen.

Abstract

Persistent nerve injuries in context of peripheral nerve blocks are uncommon. Previous surveys and prospectively designed studies have specified neurological dysfunctions in different ways, which may cause the variability of data about incidence; so it has to be reckoned with about 5% after 1 week, 1% after 1 month and 0,01% after 6 months. Amongst the different locations interscalene blocks with their associated surgical procedures seem to have the highest incidence. Establishing the correlation between disabilities and the performed block technique often constitutes difficulties, especially when other reasons like patient positioning techniques, tractions, ischemia and surgery related nerve injuries have to be considered. Dysfunctions manifest as numbness, parasthesia, tingling sensation and/or amyasthenia. Fortunately long-term lesions, caused by nerve blocks are a rarity.

Kernaussagen

• Bleibende Nervenschäden aufgrund einer peripheren Blockade sind sehr selten.

• Schmerzäußerungen bei der Anlage müssen ernst genommen werden und können Hinweise auf die Schädigung eines Nervs sein.

• Eine schmerzfreie Nervenblockade schließt ein späteres Auftreten neurologischer Dysfunktionen nicht aus.

• Cave Kausalität! Oft sind die postoperativen Beschwerden nicht auf die Nervenblockade zurückzuführen. Lagerungen, Bandscheibenvorfälle etc. können Ursache sein und bedürfen differenzialdiagnostischer Abklärung.

• Vaskuläre, systemische und neurologische Grunderkrankungen sowie perioperative Maßnahmen, wie z.B. die Lagerung der Extremitäten und operationsbedingte Risiken, stellen Risikofaktoren für die Entstehung von Nervenschäden dar.

• Nach Blockaden der oberen Extremitäten ist häufiger mit passageren neurologischen Dysfunktionen zu rechnen als nach Blockaden der unteren Extremitäten.

• Für ultraschallgestützte Punktionen konnte bisher keine Reduktion der Inzidenz von Nervenschäden nachgewiesen werden.

Schlüsselwörter:

periphere Nervenschäden - Klinik - Inzidenz

Key words:

peripheral nerve injuries - clinic - incidence

• Literatur

• 1 Welch MB, Brummett CM, Welch TD et al. Perioperative peripheral nerve injuries: a retrospective study of 380.680 cases during a 10-year period at a single institution. Anesthesiology 2009; 111: 490-497
• 2 Jacob AK, Mantilla CB, Sviggum HP et al. Perioperative nerve injury after total knee arthroplasty: regional anesthesia risk during a 20-year cohort study. Anesthesiology 2011; 114: 311-317
• 3 Claudio R, Hadzic A, Shih H et al. Injection pressures by anesthesiologists during simulated peripheral nerve block. Reg Anesth Pain Med 2004; 29: 201-205
• 4 Hadzic A, Dilberovic F, Shah S et al. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med 2004; 29: 417-423
• 5 Steinfeldt T, Werner T, Nimphius W et al. Histological analysis after peripheral nerve puncture with pencil-point or Tuohy needletip. Anesth Analg 2011; 112: 465-470
• 6 Steinfeldt T, Nimphius W, Wurps M et al. Nerve perforation with pencil point or short bevelled needles: histological outcome. Acta Anaesthesiol Scand 2010; 54: 993-999
• 7 Kapur E, Vuckovic I, Dilberovic F et al. Neurologic and histologic outcome after intraneural injections of lidocaine in canine sciatic nerves. Acta Anaesthesiol Scand 2007; 51: 101-107
• 8 Rice AS, McMahon SB. Peripheral nerve injury caused by injection needles used in regional anaesthesia: influence of bevel configuration, studied in a rat model. Br J Anaesth 1992; 69: 433-438
• 9 Steinfeldt T, Nimphius W, Werner T et al. Nerve injury by needle nerve perforation in regional anaesthesia: does size matter?. Br J Anaesth 2010; 104: 245-253
• 10 Fredrickson MJ. Case report: Neurological deficit associated with intraneural needle placement without injection. Can J Anaesth 2009; 56: 935-938
• 11 Kaufman BR, Nystrom E, Nath S et al. Debilitating chronic pain syndromes after presumed intraneural injections. Pain 2000; 85: 283-286
• 12 Shah S, Hadzic A, Vloka JD et al. Neurologic complication after anterior sciatic nerve block. Anesth Analg 2005; 100: 1515-1517
• 13 Funk W, Angerer M, Sauer K, Altmeppen J. Brachial plexus. Long lasting neurological deficit following interscalene blockade of the brachial plexus. Anaesthesist 2000; 49: 625-628
• 14 Cohen JM, Gray AT. Functional deficits after intraneural injection during interscalene block. Reg Anesth Pain Med 2010; 35: 397-399
• 15 Bonner SM, Pridie AK. Sciatic nerve palsy following uneventful sciatic nerve block. Anaesthesia 1997; 52: 1205-1207
• 16 Lee LA, Posner KL, Cheney FW et al. Complications associated with eye blocks and peripheral nerve blocks: an american society of anesthesiologists closed claims analysis. Reg Anesth Pain Med 2008; 33: 416-422
• 17 Szypula K, Ashpole KJ, Bogod D et al. Litigation related to regional anaesthesia: an analysis of claims against the NHS in England 1995–2007. Anaesthesia 2010; 65: 443-452
• 18 Staender S, Schaer H, Clergue F et al. A Swiss anaesthesiology closed claims analysis: report of events in the years 1987-2008. Eur J Anaesthesiol 2011; 28: 85-91
• 19 Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Study Group on Regional Anesthesia. Anesth Analg 1999; 88: 847-852
• 20 Auroy Y, Benhamou D, Bargues L et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002; 97: 1274-1280
• 21 Brull R, McCartney CJ, Chan VW, El Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007; 104: 965-974
• 22 Fredrickson MJ, Ball CM, Dalgleish AJ. A prospective randomized comparison of ultrasound guidance versus neurostimulation for interscalene catheter placement. Reg Anesth Pain Med 2009; 34: 590-594
• 23 Liu SS, Zayas VM, Gordon MA et al. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg 2009; 109: 265-271
• 24 Orebaugh SL, Williams BA, Vallejo M, Kentor ML. Adverse outcomes associated with stimulator-based peripheral nerve blocks with versus without ultrasound visualization. Reg Anesth Pain Med 2009; 34: 251-255
• 25 Gorthi V, Moon YL, Kang JH. The effectiveness of ultrasonography-guided suprascapular nerve block for perishoulder pain. Orthopedics 2010; 238-241
• 26 Liu SS, YaDeau JT, Shaw PM et al. Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anaesthesia 2011; 66: 168-174
• 27 O'Neill T, Cuignet-Royer E, Lambert M et al. Perioperative ulnar neuropathy following shoulder surgery under combined interscalene brachial plexus block and general anaesthesia. Eur J Anaesthesiol 2008; 25: 1033-1036
• 28 Dullenkopf A, Zingg P, Curt A, Borgeat A. Persistent neurological deficit of the upper extremity after a shoulder operation under general anesthesia combined with a preoperatively placed interscalene catheter. Anaesthesist 2002; 51: 547-551
• 29 Ehrenberg R, Bucher M, Graf B. Neurological complication after a vertical infra-clavicular brachial plexus block. Case report of possible differential diagnoses of a neurological deficit. Anaesthesist 2009; 58: 800-804
• 30 Bhardwaj D, Peng P. An uncommon mechanism of brachial plexus injury. A case report. Can J Anaesth 1999; 46: 173-175
• 31 Shankar S, Vansonnenberg E, Silverman SG et al. Brachial plexus injury from CT-guided RF ablation under general anesthesia. Cardiovasc Intervent Radiol 2005; 28: 646-648
• 32 Staff NP, Engelstad J, Klein CJ et al. Post-surgical inflammatory neuropathy. Brain 2010; 133: 2866-2880
• 33 Koff MD, Cohen JA, McIntyre JJ et al. Severe brachial plexopathy after an ultrasound-guided single-injection nerve block for total shoulder arthroplasty in a patient with multiple sclerosis. Anesthesiology 2008; 108: 325-328
• 34 Neal JM, Bernards CM, Hadzic A et al. ASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med 2008; 33: 404-415
• 35 Candido KD, Sukhani R, Doty Jr. R et al. 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. Anesth Analg 2005; 100: 1489-1495
• 36 Hebl JR, Horlocker TT, Kopp SL, Schroeder DR. Neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spine surgery: efficacy and neurologic complications. Anesth Analg 2010; 111: 1511-1519
• 37 Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973; 2: 359-362
• 38 Osterman AL. The double crush syndrome. Orthop Clin North Am 1988; 19: 147-155
• 39 Hebl JR, Horlocker TT, Pritchard DJ. Diffuse brachial plexopathy after interscalene blockade in a patient receiving cisplatin chemotherapy: the pharmacologic double crush syndrome. Anesth Analg 2001; 92: 249-251
• 40 Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive continuous axillary catheters. Anesth Analg 2003; 96: 247-252
• 41 Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae? Nerve lesions after axillary blocks. Acta Anaesthesiol Scand 1979; 23: 27-33
• 42 Hartung HJ, Rupprecht A. The axillary brachial plexus block. A study of 178 patients. Reg Anaesth 1989; 12: 21-24
• 43 Urban MK, Urquhart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth 1994; 19: 175-182
• 44 Cooper K, Kelley H, Carrithers J. Perceptions of side effects following axillary block used for outpatient surgery. Reg Anesth 1995; 20: 212-216
• 45 Stan TC, Krantz MA, Solomon DL et al. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach. A prospective study of 1000 consecutive patients. Reg Anesth 1995; 20: 486-492
• 46 Pearce H, Lindsay D, Leslie K. Axillary brachial plexus block in two hundred consecutive patients. Anaesth Intensive Care 1996; 24: 453-458
• 47 Schroeder LE, Horlocker TT, Schroeder DR. The efficacy of axillary block for surgical procedures about the elbow. Anesth Analg 1996; 83: 747-751
• 48 Horlocker TT, Kufner RP, Bishop AT et al. The risk of persistent paresthesia is not increased with repeated axillary block. Anesth Analg 1999; 88: 382-387
• 49 Carles M, Pulcini A, Macchi P et al. An evaluation of the brachial plexus block at the humeral canal using a neurostimulator (1417 patients): the efficacy, safety, and predictive criteria of failure. Anesth Analg 2001; 92: 194-198
• 50 Hebl JR, Horlocker TT, Sorenson EJ, Schroeder DR. Regional anesthesia does not increase the risk of postoperative neuropathy in patients undergoing ulnar nerve transposition. Anesth Analg 2001; 93: 1606-1611
• 51 Grant SA, Nielsen KC, Greengrass RA et al. Continuous peripheral nerve block for ambulatory surgery. Reg Anesth Pain Med 2001; 26: 209-214
• 52 Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology 2001; 95: 875-880
• 53 Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for continuous interscalene block after shoulder surgery. Anesthesiology 2003; 99: 436-442
• 54 Cuvillon P, Ripart J, Lalourcey L et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001; 93: 1045-1049
• 55 Weber SC, Jain R. Scalene regional anesthesia for shoulder surgery in a community setting: an assessment of risk. J Bone Joint Surg Am 2002; 84: 775-779
• 56 Provenzano DA, Viscusi ER, Adams Jr. SB et al. Safety and efficacy of the popliteal fossa nerve block when utilized for foot and ankle surgery. Foot Ankle Int 2002; 23: 394-399
• 57 Boezaart AP, De Beer JF, Nell ML. Early experience with continuous cervical paravertebral block using a stimulating catheter. Reg Anesth Pain Med 2003; 28: 406-413
• 58 McCartney CJ, Brull R, Chan VW et al. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology 2004; 101: 461-467
• 59 Borgeat A, Blumenthal S, Karovic D et al. Clinical evaluation of a modified posterior anatomical approach to performing the popliteal block. Reg Anesth Pain Med 2004; 29: 290-296
• 60 Capdevila X, Pirat P, Bringuier S et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1416 patients. Anesthesiology 2005; 103: 1035-1045
• 61 Bogdanov A, Loveland R. Is there a place for interscalene block performed after induction of general anaesthesia?. Eur J Anaesthesiol 2005; 22: 107-110
• 62 Devera HV, Furukawa KT, Matson MD et al. Regional techniques as an adjunct to general anesthesia for pediatric extremity and spine surgery. J Pediatr Orthop 2006; 26: 801-804
• 63 Liguori GA, Zayas VM, YaDeau JT et al. Nerve localization techniques for interscalene brachial plexus blockade: a prospective, randomized comparison of mechanical paresthesia versus electrical stimulation. Anesth Analg 2006; 103: 761-767
• 64 Faryniarz D, Morelli C, Coleman S et al. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg 2006; 15: 686-690
• 65 Watts SA, Sharma DJ. Long-term neurological complications associated with surgery and peripheral nerve blockade: outcomes after 1065 consecutive blocks. Anaesth Intensive Care 2007; 35: 24-31
• 66 Fredrickson MJ, Ball CM, Dalgleish AJ. Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private practice setting. Reg Anesth Pain Med 2008; 33: 122-128
• 67 Orebaugh SL, Williams BA, Vallejo M, Kentor ML. Adverse outcomes associated with stimulator-based peripheral nerve blocks with versus without ultrasound visualization. Reg Anesth Pain Med 2009; 34: 251-255
• 68 Liu SS, Gordon MA, Shaw PM et al. A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg 2010; 111: 617-623
• 69 Compere V, Legrand JF, Guitard PG et al. Bacterial colonization after tunneling in 402 perineural catheters: a prospective study. Anesth Analg 2009; 108: 1326-1330
• 70 Barrington MJ, Watts SA, Gledhill SR et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med 2009; 34: 534-541
• 71 Christ S, Rindfleisch F, Friederich P. Superficial cervical plexus neuropathy after single-injection interscalene brachial plexus block. Anesth Analg 2009; 109: 2008-2011
• 72 Misamore G, Webb B, McMurray S, Sallay P. A prospective analysis of interscalene brachial plexus blocks performed under general anesthesia. J Shoulder Elbow Surg 2011; 20: 308-314