Free
Correspondence  |   April 2014
Interscalene Brachial Plexus Blocks and Phrenic Nerve Palsy
Author Affiliations & Notes
  • Boyne Bellew, B.Sc., M.B.B.Ch., D.A.(S.A.), F.R.C.A.
    Imperial College Healthcare Trust, St Mary’s Hospital, London, United Kingdom (B.B.). boyne.bellew@nhs.net
  • William A. Harrop-Griffiths, M.B., B.S., F.R.C.A.
    Imperial College Healthcare Trust, St Mary’s Hospital, London, United Kingdom (B.B.). boyne.bellew@nhs.net
  • Nigel Bedforth, B.M., B.S., B.Med.Sci., F.R.C.A.
    Imperial College Healthcare Trust, St Mary’s Hospital, London, United Kingdom (B.B.). boyne.bellew@nhs.net
  • (Accepted for publication November 25, 2013.)
    (Accepted for publication November 25, 2013.)×
Article Information
Correspondence
Correspondence   |   April 2014
Interscalene Brachial Plexus Blocks and Phrenic Nerve Palsy
Anesthesiology 04 2014, Vol.120, 1056-1057. doi:10.1097/ALN.0000000000000129
Anesthesiology 04 2014, Vol.120, 1056-1057. doi:10.1097/ALN.0000000000000129
To the Editor:
We were interested to read Kaufman et al.’s1  article on the surgical treatment of 14 cases of permanent diaphragm paralysis after shoulder surgery, but dismayed to read the editorial that accompanied it,2  in which it was stated that the diaphragmatic paralysis was “clearly due to phrenic nerve damage after interscalene brachial plexus block.” This assertion is open to question and is not supported by the data presented by Kaufman et al.1 
There is a remarkable similarity between this assertion and that made for many years that the ulnar neuropathy suffered by some patients after surgery was clearly due to errors in on-table positioning that resulted in external nerve compression. The finding that there was a preponderance of obese male patients suffering ulnar nerve neuropathy led to a view that although direct compression may be a factor, other factors such as ulnar nerve stretching and inadequate blood supply to the ulnar nerve were more likely to be of significance.2–8  All Kaufman’s patients were male; all were overweight or obese; their mean age was 58 yr. Phrenic nerve lesions may be associated with degenerative cervical spine disease, trauma, and compression,9–13  and it is possible that these factors played a significant part in the cases described by Kaufman. Rotator cuff repairs are now commonly performed arthroscopically—these are often lengthy procedures performed with the patient in the lateral position and with traction applied to the arm, and in which swelling in the neck commonly results from saline infused under pressure into the joint for prolonged periods. It may well be that the combination of obesity, degenerative spine disease, nerve traction, and nerve compression were therefore significant factors in these cases.
We agree that the performance of an interscalene block may have been a factor (all 14 had blocks), but details of the approach used would have been informative, as a standard lateral, that is, modified Winnie, technique or out-of-plane ultrasound-guided approach brings the needle tip closer to the phrenic nerve compared with the currently popular in-plane ultrasound-guided needle approach through the middle scalene muscle. It may well be that the use of a Tuohy needle and a catheter (the majority of cases) were also factors. However, it is incorrect to assume that the block was the only factor—statistical association does not imply causation. Furthermore, if local anesthetic-induced myotoxicity is implicated as an important cause of nerve damage, why do we not see it more regularly around the many other small nerves that we regularly block?
Hogan’s conclusion that the cause of the phrenic nerve damage is local anesthetic injection is premature, and his suggestion that interscalene block be replaced for these procedures by “peripheral application of local anesthetic” is not supported by the data presented. As ever, we need to know more before we reach conclusions.
Competing Interests
The authors declare no competing interests.
Boyne Bellew, B.Sc., M.B.B.Ch., D.A.(S.A.), F.R.C.A., William A. Harrop-Griffiths, M.B., B.S., F.R.C.A., Nigel Bedforth, B.M., B.S., B.Med.Sci., F.R.C.A. Imperial College Healthcare Trust, St Mary’s Hospital, London, United Kingdom (B.B.). boyne.bellew@nhs.net
References
1.Kaufman, MR, Elkwood, AI, Rose, MI, Patel, T, Ashinoff, R, Fields, R, Brown, D Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery.. Anesthesiology. (2013). 119 484–7 [Article] [PubMed]
1.Kaufman, MR, Elkwood, AI, Rose, MI, Patel, T, Ashinoff, R, Fields, R, Brown, D Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery.. Anesthesiology. (2013). 119 484–7 [Article] [PubMed]×
2.Hogan, QH Phrenic nerve function after interscalene block revisited: Now, the long view.. Anesthesiology. (2013). 119 250–2 [Article] [PubMed]
2.Hogan, QH Phrenic nerve function after interscalene block revisited: Now, the long view.. Anesthesiology. (2013). 119 250–2 [Article] [PubMed]×
3.Warner, MA, Warner, DO, Harper, CM, Schroeder, DR, Maxson, PM Lower extremity neuropathies associated with lithotomy positions.. Anesthesiology. (2000). 93 938–42 [Article] [PubMed]
3.Warner, MA, Warner, DO, Harper, CM, Schroeder, DR, Maxson, PM Lower extremity neuropathies associated with lithotomy positions.. Anesthesiology. (2000). 93 938–42 [Article] [PubMed]×
4.Warner, MA Perioperative neuropathies.. Mayo Clin Proc. (1998). 73 567–74 [Article] [PubMed]
4.Warner, MA Perioperative neuropathies.. Mayo Clin Proc. (1998). 73 567–74 [Article] [PubMed]×
5.Contreras, MG, Warner, MA, Charboneau, WJ, Cahill, DR Anatomy of the ulnar nerve at the elbow: Potential relationship of acute ulnar neuropathy to gender differences.. Clin Anat. (1998). 11 372–8 [Article] [PubMed]
5.Contreras, MG, Warner, MA, Charboneau, WJ, Cahill, DR Anatomy of the ulnar nerve at the elbow: Potential relationship of acute ulnar neuropathy to gender differences.. Clin Anat. (1998). 11 372–8 [Article] [PubMed]×
6.Warner, MA, Warner, ME, Martin, JT Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients.. Anesthesiology. (1994). 81 1332–40 [Article] [PubMed]
6.Warner, MA, Warner, ME, Martin, JT Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients.. Anesthesiology. (1994). 81 1332–40 [Article] [PubMed]×
7.Warner, MA Perioperative neuropathies, blindness, and positioning problems.. ASA Refresher Courses Anesthesiol. (2006). 34 195–205 [Article]
7.Warner, MA Perioperative neuropathies, blindness, and positioning problems.. ASA Refresher Courses Anesthesiol. (2006). 34 195–205 [Article]×
8.Barner, KC, Landau, ME, Campbell, WW A review of perioperative nerve injury to the upper extremities.. J Clin Neuromuscul Dis. (2003). 4 117–23 [Article] [PubMed]
8.Barner, KC, Landau, ME, Campbell, WW A review of perioperative nerve injury to the upper extremities.. J Clin Neuromuscul Dis. (2003). 4 117–23 [Article] [PubMed]×
9.Pakala, SR, Beckman, JD, Lyman, S, Zayas, VM Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block.. Reg Anesth Pain Med. (2013). 38 239–42 [Article] [PubMed]
9.Pakala, SR, Beckman, JD, Lyman, S, Zayas, VM Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block.. Reg Anesth Pain Med. (2013). 38 239–42 [Article] [PubMed]×
10.Finsterer, J, Topakian, R, Wanschitz, J, Quasthoff, S, Bodner, G, Grisold, W, Löscher, WN Brachial plexopathies.. Br J Med Med Res. (2013). 3 928–52 [Article]
10.Finsterer, J, Topakian, R, Wanschitz, J, Quasthoff, S, Bodner, G, Grisold, W, Löscher, WN Brachial plexopathies.. Br J Med Med Res. (2013). 3 928–52 [Article]×
11.Ferrante, MA Brachial plexopathies: Classification, causes, and consequences.. Muscle Nerve. (2004). 30 547–68 [Article] [PubMed]
11.Ferrante, MA Brachial plexopathies: Classification, causes, and consequences.. Muscle Nerve. (2004). 30 547–68 [Article] [PubMed]×
12.Marecek, GS, Saltzman, MD Complications in shoulder arthroscopy.. Orthopedics. (2010). 33 492–7 [Article] [PubMed]
12.Marecek, GS, Saltzman, MD Complications in shoulder arthroscopy.. Orthopedics. (2010). 33 492–7 [Article] [PubMed]×
13.Rains, DD, Rooke, GA, Wahl, CJ Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy.. Arthroscopy. (2011). 27 532–41 [Article] [PubMed]
13.Rains, DD, Rooke, GA, Wahl, CJ Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy.. Arthroscopy. (2011). 27 532–41 [Article] [PubMed]×