Aug-12 Asra News Letter

In This Issue
The 11
th
Annual ASRA Pain Medicine
Meeting and Workshops
- see page 3
A PUBLI CATI ON OF THE AMERI CAN SOCI ETY OF REGIONAL ANESTHESIA AND PAIN MEDICINE
Advancing the Science and Practice of Regional Anesthesia and Pain Medicine
2
Editor
Edward R. Mariano, M.D., M.A.S.
Newsletter Committee
Steven Orebaugh, M.D. (Regional Anesthesia Lead)
David Provenzano, M.D. (Pain Medicine Lead)
Michael Barrington, M.D.
Derek Dillane, M.D.
Jeff Gadsden, M.D.
Elizabeth Huntoon, M.D.
Robert Hurley, M.D., Ph.D.
Sandra Kopp, M.D.
Resident Section
David Webb, M.D.
Foreign Corresponding
Marc Van de Velde, M.D.
Herbert C. Spencer, M.D.
Ofcers
President: Julia E. Pollock, M.D.
President-Elect: Joseph M. Neal, M.D.
Secretary/Treasurer: Oscar A. De Leon Casasola, M.D.
Associate Treasurer: Marc A. Huntoon, M.D.
Past President: Vincent W.S. Chan, M.D.
Executive Director: Julie Kahlfeldt, C.M.P.
Board of Directors
Honorio T. Benzon, M.D.
Asokumar Buvanendran, M.D.
Santhanam Suresh, M.D., F.A.A.P.
William F. Urmey, M.D.
Christopher L. Wu, M.D.
Eugene R. Viscusi, M.D.
Founding Fathers
L. Donald Bridenbaugh, M.D.
Harold Carron, M.D. (Deceased)
Jordan Katz, M.D.
P. Prithvi Raj, M.D.
Alon P. Winnie, M.D.
Presidents Message _______________________________ 2
Upcoming Fall Pain Medicine Meeting in Miami __________ 3
Resident and Fellow Events at the Fall Meeting ___________ 5
Can Ultrasound Guidance Be Harmful? _________________ 6
Editorial _________________________________________ 8
Managing Chronic Pain During Pregnancy ______________ 9
Reconguration of the ASRA Board of Directors _________ 12
Rudolph H. de Jong, MD, 1928-2011 __________________ 13
How I Do It: Ultrasound-Guided Thoracic
Paravertebral Blockade ____________________________ 14
How I Do It: Infraclavicular Block ____________________ 17
Incidence and Etiology of Neurologic Complications
in Regional Anesthesia ____________________________ 20
Table of Contents
American Society of Regional Anesthesia and Pain Medicine
120 West Center Court Schaumburg, IL 60195-3169
phone: (847) 934-7246 fax: (847) 740-2318 www.asra.com
Copyright 2012 American Society of Regional Anesthesia and Pain Medicine. All rights reserved.
Contents may not be reproduced without prior written permission of the publisher.
Article Title
2012
I
hope you are having a wonderful summer. In addition
to following up on the early and very successful ASRA
Spring Meeting that took place March 15-18
th
at
the beautiful Hilton San Diego Bayfront Hotel, I would
like to update you on some other exciting things that
are happening with the American Society of Regional
Anesthesia and Pain Medicine including website
development, E-News, and research grant recipients.
For those of you who have not visited the ASRA Website
recently, you may be surprised to learn that the
information found there is directly applicable to your
anesthesia practice. In addition to the information about
Annual meetings, intensive workshops, and research
grants, there is also information specifically targeting the
clinical anesthesiologist. Major tabs include a direct link
to our journal Regional Anesthesia and Pain Medicine,
a members only image library, practice advisories,
abstracts from the 2012 Spring Meeting, and videos or
recorded refresher courses lectures from the 2011 Fall
Pain Meeting. In particular, I would like to call attention
to the Practice Advisories Section of the Website. Here
you will find 7 different practice advisories including local
anesthetic systemic toxicity, review of ultrasound guided
regional anesthesia, as well as the anticoagulation,
neurologic and infectious complication guidelines.
There is also a downloadable checklist for the treatment
of local anesthetic systemic toxicity. Most of these
practice advisories are the result of consensus guideline
conferences completed during our annual meetings.
The information is thorough, well reviewed, concise and
practical. These guidelines are the most frequent source
of hits to the ASRA website by both ASRA members and
non-members.
Also on the ASRA website you will find links to the ASRA
E-News. Members of ASRA will receive the E-News
directly to their inbox. The E-News carries succinct,
pertinent information including literature reviews, updates
and most recently audio interviews with two authors
of abstracts from the Spring Annual Meeting. Those
interviews feature Karen Boretsky discussing Effects
of a Pain Service on Pain Scores in Selected Orthopedic
Patients and John Braken discussing Outpatient
Management of Continuous
Catheters Following
Orthopedic Surgery. The
E-News team has done a
wonderful job enhancing
communication to all the
members of ASRA. That team
includes Raj Gupta (Editor),
Stephen Choi, Ellen King, Ed
Mariano (Newsletter Editor),
Steven Orebaugh, David
Provenzano, Vanila Singh,
and Chris Wu.
This year at the annual Spring Meeting the winner of
the 2012 Carl Koller Memorial Research Grant was
announced. Details of the research proposal are available
on the ASRA website. The 2012 Grant winner is Caleb
Ing from the Department of Anesthesiology, Division of
Pediatric Anesthesiology, at Columbia University. Dr. Ings
proposal is very timely and applicable: Comparative peri-
operative safety outcomes between regional and general
anesthesia in critically ill infants. Dr. Ing and his co-
investigators are hopeful that information from this study
will provide data for families and their physicians to make
more informed decisions about the choice of anesthetic
techniques for children undergoing anesthesia.
Finally on the website, you will find information about
the upcoming 11
th
Annual ASRA Pain Medicine Meeting
and Workshops to be held November 15-18, 2012, at the
beautifully remodeled Fontainbleu Hotel in Miami, FL.
Program Chair Dan Warren has worked with the Education
Committee chair Terre Horlocker and the Annual Meeting
Oversight Committee to plan a wonderful meeting with
great speakers and outstanding workshops. Full program
information as well as registration materials are available
on the ASRA website. We look forward to seeing you there.
Julia E. Pollock, M.D.
Julia E. Pollock, M.D.
President
Presidents Message
2
2
2012
3
I
t is a great honor to invite
you to the 11
th
Annual ASRA
Pain Medicine Meeting
and Workshops, on behalf
of the American Society of
Regional Anesthesia and
Pain Medicine, and 2012 Fall
Program Committee. Join us
at the beautiful Fontainebleau
Hotel in Miami Beach, Florida,
November 15th through
the 18
th
, 2012. This years
meeting will explore the many
crossroads that we face as
the practice of pain medicine continues to develop. The
changes coming for medicine in general will likely have
substantial impact on the field of pain medicine, and we
must strive to maintain a worthy and sustainable place for
our specialty in this challenging future. We encourage you
to join us as we examine these issues and other hot topics
in a gorgeous setting that is sure to inspire.
The meeting will open on Thursday with Refresher Course
lectures that highlight the intersection of basic science
and clinical applications. We
will have world-renowned
experts addressing core
topics, including neuropathic
pain, cancer pain, and the transition from acute pain to
chronic states. We will also highlight the indications and
implications for lumbar fusion and chronic opioid therapy.
Friday morning, the opening session will address
radiofrequency techniques in pain medicine. The afternoon
plenary session will bring a lively discussion on a therapy
at a crossroads, intrathecal analgesic management. We
will then breakout into parallel sessions to explore topics
suggested by ASRA members: pain physicians in palliative
care, and special considerations for pain syndromes in
women. Further parallel sessions inspired by member
feedback will be held on Sunday, including headache
management and applied pharmacology for the pain
specialist.
A topic that brings a surprising amount of debate is
the finer management points of anticoagulants and
platelet modifying agents in the setting of the spectrum
of interventional pain procedures. Saturday morning
will bring together an expert panel to discuss important
topics surrounding anticoagulant therapy in interventional
pain practice including the implications for implantable
devices and the management of oral anticoagulants and
antiplatelet therapy in the perioperative implantation and
interventional procedural time frame. Audience members
will have a chance to weigh in on this topic, not only
through audience questions for the panel, but also through
the audience response system to survey the current
practice of members participating in the session.
This year we are reaching out to physicians in primary
care with a special parallel session addressing pain
management in the primary care clinic, focusing on
appropriate triage of pain patients. International experts
in pain medicine will also address some of the most
concerning issues in opioid management. We expect
that pain specialists who focus on longitudinal care and
medication management will want to join our primary care
colleagues for this session.
Saturday afternoon heats up with Crossroads and
Controversies as we look to experts in the field to direct
us on sustainability of the specialty, notably, balancing
ethical issues and financial pressures in practice
management. We will also have discussions on newer
interventional techniques, including minimally invasive
lumbar decompression (MILD
), with focus on proper

introduction of new therapies. We then will look down the
road to the future of pain medicine, exploring emerging
imaging techniques, and the signposts on the path through
healthcare reform and its implications for pain medicine.
ASRA continues to bring outstanding hands-on workshops
for participants to hone examination and procedural skills,
or to be introduced to techniques that are not yet part
Fall Pain Medicine Meeting in Miami- Pain Medicine at a Crossroads
Daniel T. Warren, MD
Section Head, Pain Clinic Services
Department of Anesthesiology
Virginia Mason Medical Center
Seattle, WA
Audience members will have a chance to weigh in...
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2012
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4
of ones practice. The two-hour workshops are held
Thursday through Saturday and will have instruction on
ultrasound- and fluoroscopic-guided techniques. We will
again offer three Special Session Workshops which
will bring focused didactics together with small group
hands-on training in the following topics: Ultrasound for
Interventional Pain Medicine (back by popular demand),
Advanced Techniques for Spinal Cord Stimulation, and
Radiofrequency Techniques for Pain Medicine.
As always, we will have problem-based learning
discussions during two of the lunch hours. These
sessions give participants a chance to dive deep into
some of the more perplexing issues in the practice of
pain medicine, and not only have guidance from the
expert leading the session, but also share experiences
and concerns with your colleagues in a round table
format.
This years meeting will also have a new system to
support scientific abstract submissions which we
expect to better meet the needs of our valued members
interested in sharing their research with peers. We
look forward to continued outstanding submissions of
basic science and clinical research projects, as well
as medically-challenging cases. There will again be
recognition of the Best of Abstracts as well as a
providing a travel award for residents and fellows with
outstanding submissions. We look forward to receiving
a rich array of abstracts with high scientific merit, but
please note the abstract submission deadline of
August 1, 2012.
The resident program always provides outstanding
opportunities for those in training to interact with
experts and influential pillars of the field of pain
medicine. The resident leadership will again have
programming that will focus on what the residents
really value- hands-on workshop instruction and small
group discussion sessions. A condensed and prioritized
program will allow the residents to attend the main
attractions and maintain the highly valued interactive
sessions. Please see Dr. David Webbs article for further
details.
The glamorous Fontainebleau hotel provides a beachside
backdrop for this exciting meeting, and we will party
on the beach Saturday night with hot Cuban rhythms
and festive fare. Dont forget that South Beach is
just minutes away with steamy night life and endless
attractions. Be sure to come ready for fun in the sun and
to take in some of what this destination location has to
offer. We hope that you are inspired to join hot debates
during the day and let loose afterward for even hotter
nights! We look forward to seeing all of you in Miami.
Saturday afternoon heats up with Crossroads and Controversies
as we look to experts in the eld to direct us on sustainability
of the specialty, notably, balancing ethical issues and nancial
pressures in practice management.
T
he 11
th
annual ASRA Pain
Meeting and Workshops
will be held November
15-18, 2012, in Miami, Florida
at the Fontainebleau Hotel. On
behalf of the ASRA Board of
Directors, this years program
director, Dr. Daniel Warren,
and the ASRA Resident Section
Committee, we welcome and
encourage all residents and
fellows to attend and take part
in the highly regarded resident-
fellow education program.
The program will begin with a resident forum Friday
evening consisting of a panel of pain medicine program
directors and current fellows who will hold a question-
and-answer session about obtaining pain fellowship
positions. The forum will lead into the well-attended wine
and cheese reception, which will provide residents and
fellows with the opportunity to meet and network with
current fellowship directors and pain medicine program
representatives.
The residency-fellow program continues the next day,
beginning with a morning general session consisting
of such lecture topics as anatomy of the spine, basic
fluoroscopy for interventional pain procedures, ultrasound-
guided pain procedures, and introduction to basic surgical
skills for interventional pain. During lunch, you will be
able to sit in on one of three problem-based learning
discussions (PBLDs): the delicate nature of signing your
first contract, how to deal with complications in pain
medicine, or deciding if academic or private pain medicine
is right for you. Then, during the afternoon sessions, you
will apply what was discussed in the morning sessions.
Current staff will moderate discussions regarding
fluoroscopic techniques, basic ultrasound using live
models, and instruction on basic surgical skills.
Dr. Warren and the ASRA Board of Directors have planned
an excellent general conference session. The resident-
fellow education program has been condensed this year so
that you can enjoy the resident program, general sessions,
and the Miami sun. Remember to save the date, and we
look forward to seeing you there.
Resident and Fellow Events at the Fall Meeting
2012
David Webb, M.D.
CA-3, Georgia Health Sciences
University, Augusta, GA
Chair, Resident Section Committee
...sit in on one of three problem-based learning discussions
(PBLDs): the delicate nature of signing your rst contract,
how to deal with complications in pain medicine, or deciding
if academic or private pain medicine is right for you.
5
3
2012
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6
Can Ultrasound Guidance Be Harmful?
Thermal and Mechanical Indices and Their Relevance to Ultrasound Guidance in Anesthesiology
H
armful biological effects of ultrasound in animals have
been recognized for over 6 decades. To enhance image
quality, ultrasound machines are being manufactured
with higher acoustic outputs which increase the potential for
harm. The objective of this report is to provide an overview
of the biological effects of ultrasound, the implications of
indices displayed in most ultrasound machines, and their
clinical relevance.
Can ultrasound cause tissue damage?
Being a form of mechanical energy, ultrasound waves
release thermal and non-thermal energy upon contact with
tissues. Acoustic intensity is a key determinant of biological
effects. Protein content of tissues, which determines
ultrasound energy absorption, is directly proportional to the
absorption coefcient. The absorption coefcients range from
10 dB/MHz
.
cm (bone), to around 1 dB/MHz
.
cm (skin, tendon
and spinal cord). Tissue perfusion, by dissipating heat, plays
a major protective role. Poorly perfused tissues like the lens
and cornea are particularly susceptible to thermal effects
of ultrasound exposure. Factors responsible for an increase
in tissue temperature with ultrasound exposure include
ultrasound frequency, focusing, pulse repetition frequency,
pulse duration, absorption coefcient, and ultrasound
exposure time.
The interaction of ultrasound waves with gas bubbles leads
to rapid changes in bubble size, a phenomenon called
cavitation. Ultrasound wave-induced rapid alterations in
bubble size produce a rapid inux of uid into the collapsing
bubbles. The inertia of in-rushing uid releases free radicals
and produces high temperatures and mechanical injuries to
cellular structures. Non-inertial cavitation follows repetitive
oscillation of the bubbles producing micro-streaming.
Cavitation is linearly related to pulse repetition frequency and
inversely to peak rarefactional pressures. Bubble growth,
and hence cavitation, does not occur with short ultrasound
wavelengths (higher frequencies).
Ultrasound exposure causes alterations in various cellular
elements, including ion channels and tissues, in animals.
Nervous tissue, notably myelin, and bone along with adjacent
tissues are very sensitive to the effects of ultrasound.
Ultrasound exposure causes reversible changes in amplitude
and nerve conduction.
Lung hemorrhage, from
the microvasculature of
visceral pleura, occurs in
various animals including
mice, monkeys, rabbits,
and neonatal pigs following
ultrasound exposure. The
important determinants for
lung hemorrhage are the state
of deation of the lungs
(more prone with deation),
peak rarefactional
pressure, and pulse
repetition frequency. Lung
hemorrhage is not related
to age, animal species or
ultrasound frequency. Of note, lung hemorrhage does not
hinder animal functioning and repairs quickly.
In addition, intestinal petechial hemorrhages with apoptosis
on the mucosal surface can follow exposure to ultrasound
at and above diagnostic ultrasound frequencies. Intestinal
hemorrhage, caused by cavitation, is frequency-dependent.
Is ultrasound exposure of concern in humans?
The majority of data about biological effects in humans are
epidemiological studies of maternal ultrasound exposure
on the fetus with lower intensity machines. Despite the
tremendous increase in the use of obstetrical ultrasound
imaging, fetal malformations have not increased in incidence.
Therapeutic ultrasound, which uses higher intensities, has
been reported to cause prolongation of nerve conduction
in peripheral nerves. Dental hygienists, using hand held
ultrasound cleaning systems, have an increased incidence of
carpal tunnel syndrome. Human beings appear resistant to
lung or intestinal hemorrhage for as yet unknown reasons.
To date, there are no reports of actual damage secondary to
diagnostic ultrasound exposure in human tissues.
What is Output Display Standard?
The Output Display Standard (ODS), was developed by
the American Institute for Ultrasound in Medicine in 1983
to provide safety information. There are FDA regulations
requiring the display of ODS in machines.
ODS consists of 2 major indices: the Thermal index (TI) and
Hariharan Shankar, M.D.
Associate Professor,
Dept. of Anesthesiology
Program Director, Pain Medicine
Fellowship
Medical College of Wisconsin,
Milwaukee, Wisconsin
Section Editor: David Provenzano, M.D.
Can Ultrasound Guidance Be Harmful? continued...
2
2012
7
the Mechanical index (MI). These indices provide conservative,
in-vivo, worst-case scenario output estimates facilitating
clinical decision making. Thermal index is the ratio of acoustic
power of the ultrasound machine to the power required to raise
tissue temperature by 1 degree Celsius (C). Three different
thermal indices were developed based on the type of tissue
predominantly in the ultrasound beam path: soft tissue Thermal
Index (TIS), bone thermal index (TIB), or cranial bone thermal
index (TIC). Thermal indices range from 0-6 and provide an
estimate of maximum temperature increase.
Mechanical Index (MI), ranging from 0-2, is a ratio of the derated
peak rarefactional negative pressure and square root of center
frequency, which provides an estimate of the likelihood of
nonthermal effects including cavitation.
These indices are altered by changes in acoustic output, focal
points, pulse repetition frequency, color Doppler ow and
power Doppler.
How can we limit potential tissue injury?
Many international and national associations have published
guidelines and consensus reports highlighting the need for
concern about ultrasound-related biological effects and have
recommended prudence in the use of ultrasound imaging. FDA
introduced 2 tracks to accommodate manufacturers compliance
with ODS, thereby inuencing the manufacture of higher output
machines for better image quality (Table 1). Track 1, applicable
to machines that do not display the ODS, retain original limits.
Track 3 allows higher limits for machines that display the
ODS. Most of the presently available ultrasound machines
provide information about acoustic intensity, pulse repetition
frequency, and additional features like the power Doppler, which
may be adjusted to limit the indices. Without compromising
image quality, utilization of lower acoustic outputs may limit
indices. Exposure time becomes critical with higher indices.
The British Medical Ultrasound Society has recommended
exposure times for different indices: http://www.bmus.org/
safety_of_ultrasoundNF.htm. Limiting exposure time, especially
in febrile patients and with the use of power Doppler mode, may
be prudent. While incorporating technological advances in the
machines, paying attention to the indices may aid in limiting
potential harm (Figure 1 A & B).
It has been postulated that nerve-related biological effects
secondary to ultrasound exposure are not noticeable or absent
because: 1) the lower temperature of coupling gel limits
temperature rise, 2) the frequent use of B mode along with
constant movement of the transducer during scanning prevents
continuous ultrasound exposure to any particular area, 3) the
needle used during interventions may conduct the heat away
from the focused tissue, 4) the higher frequencies used may
afford protection against mechanical effects and nally, and 5)
the perfusion may lessen potential harmful effects. Although
there is potential for biological effects from ultrasound exposure
in animals, the risk to human tissue appears to be so subtle
that it fails detection both by the patient and the practitioner.
Prudence is still recommended as we continue to advance
ultrasound technology and its use.
Suggested Reading:
1. Barnett SB, Ter Haar GR, Ziskin MC, Rott H, Duck FA, Maeda K. International
recommendations and guidelines for the safe use of diagnostic ultrasound in medicine.
Ultrasound in Medicine & Biology,. 2000 3;26(3):355-66.
2. Barnett SB, Duck F, Ziskin M. WFUMB symposium on safety of ultrasound in medicine:
Conclusions and recommendations on biological effects and safety of ultrasound
contrast agents, 2006. Ultrasound Med Biol. 2007 Feb;33(2):233-4.
3. Church CC, Carstensen EL, Nyborg WL, Carson PL, Frizzell LA, Bailey MR. The risk of
exposure to diagnostic ultrasound in postnatal subjects: Nonthermal mechanisms. J
Ultrasound Med. 2008 Apr;27(4):565,92; quiz 593-6.
Table 1: FDA recommendations for intensity limits based on
compliance with ODS in displaying the indices. Track 3 limits
are for machines displaying the indices. ISPTA.3: Spatial-peak
temporal-average intensity, ISPPA.3: Spatial-peak, pulse-average
intensity, MI: Mechanical Index, TI: Thermal Index, ODS: Output
Display Standard (Table adapted from ref: 8).
Use ISPTA.3(mW/cm2) ISPTA.3(mW/cm2) MI
Track 1 Track 3 Track 1 & 3
Regular 94 720 190 1.9
Eye 17 50 and TI1 28 .023
Figure A & B: Recent introduction of needle visualization
technology causes a small increase in the indices. A: Ultrasound
image of phantom showing the indices (boxed in red); B:
Ultrasound image of phantom showing the needle with the
needle visualization technology software turned on showing an
increase in the mechanical index; MI: Mechanical Index, TIS: Soft
tissue Thermal Index.
continued on bottom of next page
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2012
2012
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Editorial
T
his issue of ASRA News is truly international! Dr.
Michael Barrington has provided us with a fantastic
overview of the incidence and etiology of neurologic
complications associated with regional anesthesia. In
addition, we are very fortunate to have two How I Do It
articles by Drs. Gurkan and Conroy on ultrasound-guided
infraclavicular block and thoracic paravertebral block,
respectively. We appreciate these experts willingness to
share their tips and tricks for performing procedures as well
as their perspectives on the evolution of ultrasound-guided
regional anesthesia.
In recent years, the use of ultrasound guidance for
interventional procedures has increased exponentially
around the world. As anesthesiologists, our rst experiences
using this technology were in the context of vascular access.
Now ultrasound guidance for peripheral nerve blockade has
become mainstream. While we can generally agree that big
ticket outcome benets
such as improvements
in long-term functional
outcomes and decreased
morbidity or mortality
still lack supportive data,
enthusiasm for ultrasound is propelled by the desire to
decrease procedural times, improve block success rates, and
minimize local anesthetic dose. Early successes in applying
ultrasound to regional anesthesia has sparked great interest
in ultrasound for interventional pain procedures.
Program Chair, Dan Warren, M.D., and Resident Section
Chair, David Webb, M.D., provide us with a teaser for
the upcoming Fall Annual Meeting. This looks to be a
progressive program addressing some hot topics affecting
the specialty of pain medicine that shouldnt be missed.
Workshops on ultrasound-guided techniques in interventional
pain medicine are back by popular demand. ASRA has
been a strong proponent is
this eld, establishing the
Special Interest Group (SIG)
in Ultrasonography in Pain
Medicine in 2008. To learn
more about this SIG and for
more information about the
upcoming Fall Annual Meeting,
please visit the ASRA website
http://www.asra.com.
How much do we really know
about ultrasound? Many of us
use it every day. As ultrasound
technology continues to
advance with greater demand from the end-user for
better image quality, we need to be aware of the potential
risks. Hariharan Shankar, M.D., give us an overview of the
biological effects of ultrasound that is sure to be an ongoing
topic of discussion.
Thats not all. We have included even more content covering
educational and informational topics to keep you up to date
on your society ASRA.
Editor
Palo Alto, CA
emariano@stanford.edu
How much do we really know about ultrasound?
Suggested Reading: (cont.)
4. Fowlkes JB, Bioeffects Committee of the American Institute of Ultrasound in
Medicine. American institute of ultrasound in medicine consensus report on
potential bioeffects of diagnostic ultrasound: Executive summary. J Ultrasound
Med. 2008 Apr;27(4):503-15.
5. Nelson TR, Fowlkes JB, Abramowicz JS, Church CC. Ultrasound biosafety
considerations for the practicing sonographer and sonologist. J Ultrasound Med.
2009 Feb;28(2):139-50.
6. OBrien WD,Jr. Ultrasound-biophysics mechanisms.[see comment]. Progress in
Biophysics & Molecular Biology. 2007 Jan-Apr;93(1-3):212-55.
7. OBrien WD,Jr, Deng CX, Harris GR, Herman BA, Merritt CR, Sanghvi N, et al. The
risk of exposure to diagnostic ultrasound in postnatal subjects: Thermal effects. J
Ultrasound Med. 2008 Apr;27(4):517,35; quiz 537-40.
8. Shankar H, Pagel PS. Potential adverse ultrasound-related biological effects: A
critical review. Anesthesiology. 2011 Nov;115(5):1109-24.
A
s physicians we are taught the axiom primum non
nocere rst do no harm. This is never more
important than when treating pregnant patients with
pain medications because one is effectively treating two
patients. The safest pregnancy-related pharmacotherapy is no
therapy. However, as pain physicians we are often challenged
to safely care for the pregnant pain patient who is not only
on opioids but multiple adjuvants as well. This polypharmacy
presents a unique challenge to the physician not only because
of the variability of metabolism for each of these drugs but
also because of the gestational timeline differences for fetal
risk with each exposure. Specic effects of pain medications
and illicit substances on the developing fetus are complex
and depend on many factors including the specic type of
medication, duration of use, and gestational age of the fetus
when rst exposed,
1,2
as well as maternal nutritional status and
the presence of possible polysubstance use.
3
To assist the clinician, the FDA developed a rating system for
the teratogenic effects of drugs (Table 1). General guidelines
for choosing dosages and types of drugs within each class
are lacking in this population, and unfortunately the vast
preponderance of medications in use today fall into the C
category classication (Table 2). Maternal-fetal effects of
chronic opioid use during pregnancy range from no anomalies
to adverse outcomes including intrauterine growth restriction,
placental insufciency, preeclampsia, preterm rupture of
membranes, premature birth, postpartum hemorrhage,
perinatal mortality, prolonged QT interval, low birth weight, and
hypoxic-ischemic brain injury.
4-7
In many cases, it is difcult
if not impossible to ascribe certain cause and effect to these
exposures. Intrauterine fetal withdrawal from opioids in animal
models is associated with increased morbidity and mortality
possible due to reduced intrauterine and placental blood ow
and diminished availability of oxygen to the fetus.
8

A recently published study by Broussard et al.
9
using data
from the National Birth Defects Prevention Study 1997-
2005, found children born to mothers who used opioids in
the rst trimester had statistically signicant higher risk for
congenital heart abnormalities including: 1) conoventricular
septal defects, 2) atrioventricular septal defects, 3) atrial
septal defects, 4) hypoplastic left heart syndrome, 5) tetralogy
of Fallot, and 6) pulmonary valve stenosis. The author also
reported a statistically-signicant association between infants
who were exposed to early pregnancy opioid treatment and
the occurrence of spina bida.
9
The authors postulated that
one of the mechanisms mediating these negative effects may
be the opioids ability to inuence growth regulation during
embryologic development. Exogenous opioids may act on
opioid growth factor receptors during embryogenesis, resulting
in delayed cell growth and migration at critical times in
development thus resulting in an increased risk for certain birth
defects.
9
Adjuvant medication use is also associated with teratogenic
effects. For example, in utero antiepileptic drug (AED) exposure
is associated with cardiac malformations, hypospadias,
and facial clefts. Treatment with certain AEDs (e.g., valproic
acid and carbamazepine) was found to be associated with a
Managing Chronic Pain During Pregnancy
2
2012
9
Elizabeth Huntoon, M.D.
Assistant Professor of Clinical Orthopaedic
Surgery and Rehabilitation
Vanderbilt University School of Medicine
Nashville, TN
Section Editor: David Provenzano, M.D.
Table 1: FDA Pregnancy Categories
24
Category A
Adequate and well-controlled studies have failed to demonstrate a risk to the
fetus in the rst trimester of pregnancy (and there is no evidence of risk in
later trimesters).
Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and
there are no adequate and well-controlled studies in pregnant women.
Category C
Animal reproduction studies have shown an adverse effect on the fetus
and there are no adequate and well-controlled studies in humans, but
potential benets may warrant use of the drug in pregnant women despite
potential risks.
Category D
There is positive evidence of human fetal risk based on adverse reaction
data from investigational or marketing experience or studies in humans, but
potential benets may warrant use of the drug in pregnant women despite
potential risks.
Category X
Studies in animals or humans have demonstrated fetal abnormalities and/or
there is positive evidence of human fetal risk based on adverse reaction data
from investigational or marketing experience, and the risks involved in use of
the drug in pregnant women clearly outweigh potential benets.
3
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10
greater risk of specic malformations including neural tube
defects. Exposure to certain AEDs, most notably valproic
acid, may result in altered cognitive function later in life.
Unfortunately there is no evidence that additional folic acid
supplementation ameliorates the increased risk of congenital
malformations associated with the use of AEDs.
10

Risks to the unborn fetus range in presentation as well as
severity. In addition to the teratogenic effects of opioids
and adjuvants, infants born to mothers who consume
opioids chronically during pregnancy may develop neonatal
abstinence syndrome (NAS). NAS is an array of signs and
symptoms including central nervous system, metabolic,
vasomotor, and respiratory, and GI dysfunction.
11
NAS usually
begins within 72 hours of birth and can last for several
weeks depending on the half-life of the drug used. Other
substances including alcohol,
12,13
benzodiazepines,
14,15

antidepressants,
16
and SSRIs,
17
may also produce
neurobehavioral dysregulation similar to that seen with
NAS.
11
When the benets of maintaining the pregnant patient on
chronic opioid therapy outweigh the risks, there are several
options available to the clinician. A complete discussion
of opioid maintenance in pregnancy for both chronic pain
management and opioid dependence is beyond the scope of
this newsletter; however, several options are presented here.
Methadone has been used for many years as a standard
for maintenance therapy and currently is the only
opioid medication approved by the U.S. Food and Drug
Administration (FDA) for medication-assisted treatment
of opioid addiction in pregnant patients.
18
Due to DEA
restrictions, pain physicians are currently able to prescribe
methadone only for pain management but not for addiction
purposes. An alternative to methadone is buprenorphine
which requires special DEA identication in order to
prescribe for opioid addiction. Buprenorphine, a partial
mu-opioid agonist, has not been extensively studied in
pregnancy. Despite the lack of FDA approval for use in
pregnant women in the United States, the Center for
Substance Abuse Treatment (CSAT) recommends the use
of buprenorphine under certain clinical circumstances.
19

Buprenorphine is classied as a category C drug by the
FDA (i.e., one lacking adequate, well-controlled studies
in pregnant women), although several studies have found
it safe and effective in this group.
20,21
Infants with NAS
born to mothers maintained on buprenorphine required
signicantly less morphine (mean dose, 1.1 mg vs. 10.4
mg; P<0.0091), had a signicantly shorter hospital stay
(10.0 days vs. 17.5 days, P<0.0091), and shorter duration
of treatment for neonatal abstinence syndrome (4.1 days vs.
9.9 days, P<0.003125) compared to methadone.
22
A more
Table 2: FDA Categories of commonly used drugs in
chronic pain management
24

Medication Pregnancy
Category
Comments
Propionic Acids (Ibuprofen) B Contraindicated in 3rd
trimester of pregnancy
Salicylates-acetylated (Aspirin)
Salicylates non-acetylated
(Diunisal)
D
C
In the last trimester
Contraindicated in 3rd
trimester
Oxicams (Meloxicam) C
D
Prior to 30 weeks gestation
Starting at 30 weeks gestation
Cox-2 inhibitors (Celecoxib) C Contraindicated in 3rd
trimester
Acetaminophen B IV acetaminophen category C
Gabapentin
Pregabalin
C
C
Duloxetine
Milnacipran
C
C
Caution in 3rd trimester
Caution in 3rd trimester
Nortriptyline D
Amitriptyline
Bupropion
C
C
Cyclobenzaprine B
Carisoprodol
Metaxalone
C
C
Paroxetine D
Tizanidine
Baclofen
C
C
Capsaicin Topical N/A No data available
Diclofenac Epolamine Topical C Contraindicated in 3rd
trimester
Trolamine Salicylate C
Lidocaine Patch 5% B
Methadone B
Tramadol C
Codeine/Hydrocodone C
Morphine C Caution in 3rd trimester
Oxycodone B Contraindicated in labor
and delivery; caution in 3rd
trimester
Fentanyl C
Tapentadol C Not recommended for
use in women during and
immediately prior to labor and
delivery.
2
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11
detailed discussion on buprenorphine use in the treatment
and management of pregnant patients and its effects in
newborns can be found in TIP 40, Clinical Guidelines for the
Use of Buprenorphine in the Treatment of Opioid Addiction.
19

For a comprehensive review of buprenorphine use in pregnant
patients and its effects on the neonate, see the article by
Johnson and colleagues.
23
In addition to medications for controlling chronic pain during
pregnancy, non-pharmacological alternatives are readily
available. Physical therapy for low back pain, massage,
complementary alternative medicine (acupuncture,
aromatherapy), and other modalities are often effective in
decreasing pain. It is also important to consider counseling
and enrollment in a substance abuse program for the pregnant
opioid-dependent patient.
The pregnant chronic pain patient presents a unique set of
challenges to the pain physician. Avoidance of usual pain
medications would be ideal, however difcult, in many
circumstances. If opioids are indicated in this population,
methadone or buprenorphine combined with non-
pharmacologic therapies may serve as possible treatments
for chronic pain management and opioid dependence during
pregnancy. Primum non nocere.
References:
1. Zagon IS, Wu Y, McLaughlin PJ. Opioid growth factor and organ development in rat
and human embryos. Brain Res. 1999; 839:313322.
2. de Graaf-Peters VB, Hadders Algra M. Ontogeny of the human central nervous
system: What is happening when. Early Hum Dev 2006; 82(4):257-66.
3. Bandstra ES, Morrow CE, Mansoor E, Accornero, VH. Prenatal drug exposure: infant
and toddler outcomes. J Addict Dis 2010; 29(2): 245-58.
4. Bolnick JM, Rayburn WF. Substance use disorders in women: special considerations
during pregnancy. Obstet Gynecol Clin North Am 2003; 30:545-58.
5. Kaltenbach K, Berghella V, Finnegan L. Opioid dependence during pregnancy. Obstet
Gynecol Clin North Am 1998; 25:139-51.
6. Barr GA, Jones K. Opiate Withdrawl in the infant. Neurotoxicol Teratol 1994; 16:219-
25.
7. Chou R, Fanciullo G, Fine P, et al; Clinical Guidelines for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain. The Journal of Pain 2009; 10(2):113-130.
8. Barr GA, Jones K. Opiate Withdrawl in the infant. Neurotoxicol Teratol 1994; 16:219-
25.
9. Broussard CS, Rasmussen SA, Reefhuis J, et al: Maternal treatment with opioid
analgesics and risk for birth defects. Am J of Obstet & Gyn 2011; 204(4): 314.e1-
314.e11.
10. Hill DS, Wlodarczyk BJ, Palacios AM,, Finnell RH. Teratogenic effects of antiepileptic
drugs. Expert Rev Neurother 2010 June; 10(6): 943959.
11. Jansson LM, Velez M. Neonatal abstinence syndrome. Therapeutics and toxicology.
Current Opinion in Pediatrics 2012; 24(2):252-258.
12. Pierog S, Chandavasu O, Wexler I. Withdrawal symptoms in infants with the fetal
alcohol syndrome. J Pediatr 1977; 90:630633.
13. Robe LB, Gromisch DS, Iosub S. Symptoms of neonatal ethanol withdrawal. Curr
Alcohol 1981; 8:485493.
14. Wikner BN, Stiller C, Bergman U, et al. Use of benzodiazepines and benzodiazepine
agonists during pregnancy: neonatal outcome and congenital malformations.
Pharmacoepidemiol Drug Saf 2007; 16:12031210.
15. Iqbal MM, Sobhan T, Ryals T. Effects of commonly used benzodiazepines on the
fetus, the neonate and the nursing infant. Psychiatr Serv 2002; 53:3949
16. Gentile S. On categorizing gestational, birth and neonatal complications following
late pregnancy exposure to antidepressants: the prenatal antidepressant exposure
syndrome. CNS Spectr 2010; 15:167185.
17. Sanz EJ, De-las-Cuevas C, Kiuru A, Bate A, et al: Selective serotonin reuptake
inhibitors in pregnant women and neonatal withdrawal syndrome: a database
analysis. The Lancet 2005 365(9458): 482-487.
18. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus
no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev
2009; (3):CD002209.
19. Center for Substance Abuse Treatment. Chapter 13. Medication-assisted treatment
for opioid addiction during pregnancy. In: SAMHSA/CSAT treatment improvement
protocols. Available from: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hss
amhsatip&part=A83488. Accessed April 19, 2012.
20. Fischer G, Johnson R E, Eder H, Jagsch R, Peternell A, Wehinger M, Langer M,
Aschauer H N. Treatment of opioid-dependent pregnant women with buprenorphine.
Addiction 2000; 95(2):239244.
21. Lacroix I, Berrebi A, Chaumerliac C, Lapeyre-Mestre M, Montastruc J L, Damase-
Michel C. Buprenorphine in pregnant opioid-dependent women: First results of a
prospective study. Addiction 2004; 99(2):209214.
22. Jones HE, Kaltenbach K, Heil SH, Stine SM, et al. Neonatal Abstinence Syndrome
after Methadone or Buprenorphine Exposure. N Engl J Med 2010; 363:2320-2331.
23. Johnson R E, Jones H E, Fischer G. Use of buprenorphine in pregnancy: Patient
management and effects on the neonate. Drug and Alcohol Dependence.
2003a;70(Suppl. 2):S87S101.
24. Epocrates. Drug Safety/Monitoring. Available at: http://online.epocrates.com.
Accessed June 15, 2012.
Managing Chronic Pain During Pregnancy continued...
Reconguration of the ASRA Board of Directors
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I
n 2010, the American Society of Regional Anesthesia and
Pain Medicine (ASRA) entered into a strategic planning
process. Part of that process entailed a member survey
in 2011. One of the clear messages from the membership,
both as reected in the survey results and through personal
conversations between individual members and directors
of the Society, is that the governance structure of ASRA is
often seen as less than transparent and overly exclusive.
From the directors view, the Boards membership structure
is also problematic in that it can require up to a 16 year
commitment to complete the ofcer track. Indeed, over the
past decade some outstanding directors have had to resign
from the Board because of their advancing age or expanding
obligations with other professional organizations. In response
to these concerns, the ASRA Board of Directors approved at
their spring 2011 meeting a reconguration of the Boards
structure. This new conguration will affect those elected to
the Board of Directors at the September 2012 interim Board
meeting and will take effect at the end of the spring 2013
annual meeting. In essence, the reconguration involves
the addition of one Director-at-Large and the elimination of
the Associate Treasurer position, both of which combine to
increase access to the Board by over 20% and to reduce the
maximum time on the Board from 16 to 13 years.
The essential elements of the Board of Directors
reconguration are:
The number of ofcers is reduced from 5 to 4 by
eliminating the Associate Treasurer position, which
decreases time spent as an ofcer from 10 to 8 years.
Ofcers will continue to serve 2-year terms. The Treasurer
is elected by vote of the Board of Directors and will
automatically ascend through the ranks of President-
Elect, President, and Immediate Past President. Current or
past Board members who have not served the Society as
President are eligible for election to the ofce of Treasurer.
Currently ASRA has 6 Directors-at-Large who are elected
for 2-year terms and may enter the ofcer track or serve a
maximum of 6 years before moving off the Board. The new
conguration includes 7 Directors-at-Large 6 of these
positions are for two years and 1 is for one year. Directors
may now serve a maximum of 5 years unless they ascend
onto the ofcer track.
These combined changes
a reduction of 1 ofcer, an
increase of 1 director, and
a shorter term as director -
will afford more members
the opportunity of being
elected to the Board of
Directors.
The nal change involves
member nomination for
directors. Prior to each
election, ASRA members will
be asked by the Nominations
Committee to submit names of individuals who they
believe should be considered for an open director position.
The Committee will consider these nominations when
they present a slate of candidates to the sitting Board of
Directors. However, election of new directors, re-election
of existing directors (up to the 5-year limit), and election of
the treasurer will remain the duty of the Board of Directors,
as stipulated by the Societys Bylaws.
The ASRA Board of Directors believes that the new
conguration will both address membership concerns
related to access to Director-at-Large positions and will
make the potential time commitment for board service more
palatable to those who are elected. For the new conguration
to become possible, a current ofcer of the Society will
step down and not become President. Some of the current
Directors-at-Large will see their terms reduced from 6 to 5
years, and will less likely ascend to the ofcer track.
If you have any questions regarding these changes, please
feel free to address them to Joe Neal (anejmn@vmmc.org).
Joseph M. Neal, MD
Virginia Mason Medical Center
Seattle, WA
Rudolph H. de Jong, MD, 1928-2011
2
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Rudolph H. de Jongscholar par excellencepassed
away May 27, 2011. Rudy, as he was known by friends
and colleagues, was a quiet, unassuming man with a
passionate quest for knowledge. His contributions to
anesthesiology include publications of original research
in peer-reviewed journals, regular scientic and refresher
course presentations at ASA, IARS and ASRA meetings,
book chapters, letters-to-the-editor and 3 monographs.
He served on the FDA Committee that had oversight of
anesthetic drugs and various committees of professional
societies. He challenged himself and those he mentored to
present scientic information in a form easily understood
by clinical anesthesiologists. He embraced and encouraged
collaborative research both among anesthesiologists as well
as between basic scientists and anesthesiologists. Perhaps
best known for his studies of local anesthetic toxicity, Rudy
also contributed to knowledge about neuromuscular blocking
drugs, various aspects of regional anesthesia and pain, as
well as mechanisms of action of general anesthetics.
Born in Amsterdam, the Netherlands he immigrated with his
family to the United States when he was 17 yo. He earned
his B.A. and his M.D. degree at Stanford University School
of Medicine and obtained training in regional anesthesia at
the Virginia Mason Hospital under the tutelage of Dr. Daniel
Moore.
His rst of many major contributions to the anesthesia
literature was an article published in Anesthesiology in
1961 entitled Axillary Block of the Brachial Plexus. In
this landmark article, Rudy reported the importance of the
anatomy of the axillary sheath. He applied the measurements
he obtained from careful cadaver dissections to the formula
for the volume of a cylinder and concluded 42 ml should be
sufcient to completely bathe all branches of the brachial
plexus distal to the cords.
A review article entitled Physiological Mechanisms of
Peripheral Nerve Block by Local Anesthetics was perhaps
Rudys most important single publication. This publication
ultimately affected the clinical practice of many hundreds
if not thousands of anesthesiologists. This article published
in 1963 with his friend and mentor Irv Wagman formed the
basis for Rudys textbook Physiology and Pharmacology of
Local Anesthesia.
In 1965, Rudy moved to Seattle, where he spent
the next decade doing research at the University of
Washington involving neuropharmacology and particularly
local anesthetic toxicity. Rudy seized on the fact that
local anesthetics selectively stimulate amygdala and
demonstrated conclusively that diazepam, which specically
suppresses the electrical activity of the amygdaloid, provides
improved and much more specic local anesthetic seizure
prophylaxis and management than that provided by the then
used barbiturates.
Later Rudy served as a senior editor of the Journal of the
American Medical Association and corresponding editor of
Archives of Surgery, during which time he was research
professor of anesthesiology at the University of Illinois
Medical Center. Other appointments included Eleanor Brooks
Saltonsall Professor for Research in Anesthesiology and
the Control of Pain at Tufts University School of Medicine
in Boston and at the University of Cincinnati in the Pain
Control Center with Dr. Raj. He served as director of the
Interdisciplinary Pain Management Center at the Medical
College of Georgia, then director of the Jefferson Pain
Institute Thomas Jefferson University in Philadelphia. He next
became director of the Carolina Pain Center at the University
of South Carolina School of Medicine He retired from this
position in 1998.
It is rare that an individual can make major contributions
in all three aspects of academic anesthesia, namely,
teaching, research, and patient care. Rudy has provided
us with the classic textbook on the pharmacology of local
anesthetics, with much of the information obtained from
his own laboratory; he gave us an entirely new therapeutic
approach to the management of systemic reactions to local
anesthetics; and directed a pain service at several major
universities, and in so doing he not only provided patients
with his expertise in pain management but also provided his
residents and fellows with invaluable teaching in this rapidly
expanding subspecialty of anesthesiology.
* Much of the material for this was extracted from Dr Alon Winnies
introduction of Dr. de Jong as the Gaston Labat Lecturer at the 1995
ASRA annual meeting.
Written by: James E Heavner, DVM, PhD, DACVA
Fellow of Interventional Pain Management (HON)
Professor Emeritus, Anesthesiology and Cell Physiology
and Molecular Biophysics
Clinical Professor of Anesthesiology, TTUHSC
Lubbock, TX
3
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How I Do It: Ultrasound-guided Thoracic Paravertebral Blockade
P
aravertebral block involves the use of local anaesthetic
lateral to the vertebral column to produce ipsilateral
anaesthesia and analgesia by blockade of the thoracic
segmental nerves. The key advantages over intercostal
blocks are broader coverage (can cover multiple dermatomes
and include blockade of the posterior primary ramus) and the
ability to insert a catheter.
Single-level injection with catheter insertion constitutes
my usual approach for analgesia as part of a multimodal
regimen for unilateral incisions in thoracic dermatomes, such
as thoracotomy and nephrectomy. I have found it particularly
useful for management of analgesia for fractured ribs in
difcult cases. A bolus dose of 15 ml 0.5% bupivacaine can
cover a mean of 4 (1-11) thoracic dermatomes.
1
Single-
injection blocks performed at multiple spinal levels has been
described as an anaesthetic technique for breast surgery.
There are case reports and prospective studies of bilateral
paravertebral blocks being used for obstetric analgesia, and
even as an alternative to general anaesthesia for abdominal
surgery.
2
Block failure occurs in approximately 12% cases,
1,3
and
various patterns of spread have been observed in contrast
studies.
4
It is plausible that the use of ultrasound to
accurately locate the paravertebral space and observe
patterns of spread in real time may reduce the failure rate
and improve local anaesthetic coverage.
Problems associated with epidural blockade, such as
lower limb motor blockade, urinary retention, hypotension,
and concerns about neuraxial nerve damage related
to haematoma or abscess formation may explain the
resurgence in use of the paravertebaral block. Recent reports
suggest improved long term outcomes, with reduced chronic
pain
5
and cancer recurrence
6
after breast surgery, which is
now the subject of prospective study.
7
Anatomy
The thoracic paravertebral space is a wedge-shaped
potential space. Medially it is bound by the vertebral
body, intervertebral disc, and intervertebral foramen.
Its anterolateral border is the parietal pleura, and it
communicates with the intercostal space laterally beyond the
tip of the transverse process. The posterior border is formed
by the transverse process and the superior costotransverse
ligament, which forms the
most important structure
to be traversed by the
needle. This ligament joins
the inferior aspect of the
transverse process above
with the superior aspect of
the neck of the rib below
and may be appreciated by a
click (loss of resistance)
on advancement
of the needle. The
contents include fat
and extrapleural fascia,
the segmental nerve
branching into anterior
and posterior primary
rami, the sympathetic chain and rami communicantes, and
radicular vessels. The nerve at this point may consist of
rootlets, devoid of a sheath, allowing good local anaesthetic
penetration. The nerve should lie deep to the transverse
process, protecting it from the needle. The endothoracic
fascia, the deep fascia of the thorax, is a broelastic
structure dividing the paravertebral space into anterior and
posterior compartments. It is closely applied to the anterior
vertebral body; laterally it contains the sympathetic chain
anterior to it and the segmental nerve posterior to it. Catheter
placement relative to this layer may determine the different
patterns of spread observed with this block.
Myles Conroy, MBBS,
DRANZCOG, FANZCA
Staff Anaesthetist
Department of Anaesthesia, Perioperative
and Pain Medicine
Geelong Hospital, Barwon Health
Geelong, Australia
Section Editor: Steven Orebaugh, M.D.
Fig 1:
Anatomy of paravertebral space(*).
*
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How I Do It: Ultrasound-guided Thoracic Paravertebral Blockade continued...
Surface anatomy
In the thoracic spine, the superior aspect of the spinous
process relates laterally to the transverse process of the
vertebra below it, due to its steep downwards angulation.
The tip of the transverse process is located ~2.5 cm from the
spinous process. This is the insertion point for the traditional
approach to paravertebral blockade.
Sonoanatomy
I usually start imaging with a high-frequency linear probe
and change to a low-frequency curvilinear probe if imaging is
difcult. The curved probe provides a wider eld of view which
can help identify the midline and pleura during transverse
scanning but at lower resolution. The transverse process
projects posteriorly, and the costotransverse articulation
is on its anterior aspect, forming a step in bony depth and
angle to allow identication of the transverse process tip with
ultrasound. With a transverse probe orientation, the acoustic
shadow of these bony margins becomes deeper at the
point where the transverse process joins the rib (Fig. 2). It is
important to distinguish the pleura from the acoustic shadow
of bone pleura moves with inspiration, and some penetration
of ultrasound occurs. The pleura can be distinguished from
bone more easily in the sagittal plane it is the deeper
hyperechoic structure (Fig. 3). Local anaesthetic injected into
the paravertebral space should increase the depth between
transverse process and parietal pleura. Identication of the
radicular vessels using colour ow Doppler while scanning the
paravertebral space is difcult because of the depth and size of
the vessels, and the presence of acoustic shadow.
Ultrasound-guided techniques
A number of US-guided approaches to the paravertebral space
have been advocated, and no particular approach has been
proven superior.
8
Proximity to the neuraxis and lung require a
good orientation to the anatomy, and steep angles of insertion
may make needle visibility difcult. Orientation to the transverse
and spinous processes during needle insertion is greatly helped
by creating surface markings during your survey scan.
For novice sonographers, in obese patients, or if there
is subcutaneous emphysema making imaging difcult, I
recommend an ultrasound-assisted approach. A survey scan
denes the location and depth of the transverse process tip
for marking and the depth to lung. When measuring distance,
only light probe pressure should be used. Proceed with
paravertebral blockade in the traditional way, ensuring the
angle of needle insertion matches the angle of the ultrasound
beam during the survey. The non-ultrasound technique has a
good success rate and low risk of complications.
3

Transverse in-plane approach. Identication of the key
landmarks is as described above. When performing a survey
scan, mark the tip of the transverse process and spinous
process. It is usually possible to visualize the transverse
process and pleura without the rib obscuring it. Position the
tip of the transverse process in the middle of the image and
then rotate the probe slightly. The heel of the hand holding the
probe should be resting rmly against the patient to hold this
position. The needle insertion point should be at least 2 cm
lateral to the tip of the transverse process to allow an insertion
angle suitable for needle visualization. The needle is directed
in between the transverse process and pleura, and injection is
Fig 3:
Sagittal paramedian scan at tip of transverse process. Note the rib
shadow deep and cephalad to the transverse process in this example.
Lateral angulation of probe helps imaging of the pleura as it reects
medially towards the mediastinum.
Fig 2A: Fig 2B:
Note correlation of bone topography of posterior thorax in a spine model
(A) with the acoustic shadow of the transverse ultrasound image (B).
C
E
P
H
A
L
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How I Do It: Ultrasound-guided Thoracic Paravertebral Blockade continued...
performed under vision (by an assistant with extension tubing)
to observe pleural displacement and conrm correct position.
Care should be taken not to advance the needle more than 1
cm once it is in the acoustic shadow of the transverse process,
as it is pointing in the direction of the intervertebral foramen.
It is also possible the catheter fed beyond the needle may
enter the neuraxis, although this has not been reported in the
published case series.
9
Sagittal in-plane approach. Positioning the probe in a sagittal
orientation 2-3 cm lateral to the midline to obtain an image as
in Figure 3 clearly distinguishes bone and pleura. Angulating
the probe slightly laterally may improve visibility of the pleura
which reects anteriorly toward the mediastinum at this site
(Fig 1). Between the transverse processes are the superior
costotransverse and intertransverse ligaments and, deep to
these, the paravertebral space. The difculty I nd with this
approach is that the angle of insertion becomes relatively steep
to map a course between the bony landmarks and nish close
to pleura, making needle visibility difcult (Fig 5). This may be
helped by exing the patient as much as possible, making the
target slightly more shallow and the bones further apart, and/or
using a more echogenic needle. Potential advantages include
observation of spread in the adjacent acoustic windows and
catheter insertion is not pointing toward the neuraxis.
Conclusion
Paravertebral blockade is experiencing a resurgence in
interest and use. As regional anaesthetists become more
experienced with the use of ultrasound, its application to guide
routine paravertebral insertion is inevitable. Although this
is challenging, it can be achieved. Further study is required
to dene the optimal approach and demonstrate improved
outcomes with ultrasound guidance.
References
1. Cheema S, Richardson J, McGurgan P: Factors affecting the spread of bupivacaine in
the adult thoracic paravertebral space. Anaesthesia 2003; 58: 684-7
2. Richardson J, Lonnqvist PA, Naja Z: Bilateral thoracic paravertebral block: potential
and practice. Br J Anaesth 2011; 106: 164-71
3. Lonnqvist PA, MacKenzie J, Soni AK, Conacher ID: Paravertebral blockade. Failure
rate and complications. Anaesthesia 1995; 50: 813-5
4. Lonnqvist PA, Hesser U. Radiological and clinical distribution of thoracic paravertebral
blockade in infants and children. Paediatric Anesthesia 1993; 3: 83-7.
5. Kairaluoma PM, Bachmann MS, Rosenberg PH, Pere PJ: Preincisional paravertebral
block reduces the prevalence of chronic pain after breast surgery. Anesth Analg
2006; 103: 703-8
6. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI: Can anesthetic
technique for primary breast cancer surgery affect recurrence or metastasis?
Anesthesiology 2006; 105: 660-4
7. Trial registry data. http://clinicaltrials.gov/ct2/show/NCT00418457.
8. Karmakar M. Ultrasound-guided thoracic paravertebral block. Techniques Reg Anes
Pain Med 2009; 13: 142-9
9. Renes SH, Bruhn J, Gielen MJ, Scheffer GJ, van Geffen GJ: In-plane ultrasound-
guided thoracic paravertebral block: a preliminary report of 36 cases with radiologic
conrmation of catheter position. Reg Anesth Pain Med 2010; 35: 212-6
Fig 4:
Transverse-in plane approach. Probe has been rotated from the image
obtained in Figure 2 to visualize pleura rather than rib. Needle tip is
just deep to transverse process and is obscured by its acoustic shadow.
Note local anaesthetic (LA) distending the lateral paravertebral and
intercostal space.
Fig 5:
Sagittal in-plane needle insertion. Note the small distance between
the transverse processes determines the steep angle of insertion. Local
anaesthetic can be seen in the paravertebral space at the levels adjacent
to the insertion point when a curved probe is used. A small haemothorax
from fractured ribs is also present separating the pleura.
L
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L
C
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D
A
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Infraclavicular block (ICB) is
an upper extremity block that
provides complete anesthesia
below the shoulder.
Refinement in techniques and
ultrasound (US) guidance have
increased the interest in ICB,
and it is probably one of the
most commonly-performed
upper extremity blocks today.
Anatomy
This block is performed
below the clavicle at the cord
level of brachial plexus. The
axillary (subclavian) artery is
surrounded by three cords. The axillary vein lies adjacent
to the artery and is positioned caudally. These three cords
- lateral, posterior and medial - are named according to
their relative position to the artery. The anatomy of the
plexus varies widely among individuals. The MRI study
of Sauter
1
revealed that the cords are found within 2 cm
from the center of the artery, approximately within 2/3 of
a circle. With reference to a clock face with the axillary
artery at the center, the cords are distributed between 3
and 11 oclock. Considering all volunteers, an average
point with shortest distances to all cords was found at 8
oclock, close to the artery, in the cranioposterior quadrant.
History
ICB was first described by Bazy
2
in 1914. Although the
technique has a long history, Raj
3
modified the technique
and reported a high success rate using a nerve stimulator
in 1973. Failure to obtain similar success rates reported
by Raj has led to a search for an approach that has
consistently-high success rates in different hands. Since
that time, many approaches, which differ in the site of
needle entry and/or needle direction, have been described.
Following MRI studies, Klaastad
4
has suggested that ICB
can be accomplished by the lateral sagittal route [lateral
sagittal infraclavicular block (LSIB)] with ease and low
risk of complications, such as pneumothorax or vascular
puncture. LSIB is the infraclavicular approach used in
our clinic. With this technique, it is easy to palpate the
bony landmarks -clavicle and coracoid process- even in
obese patients. Using LSIB, the single injection technique
is well-accepted by patients with fewer adverse effects
than an axillary block by multiple-injection technique
5

and more complete anesthesia with a block onset time
of 20 minutes. Large-scale studies have reported similar
success rates that range between 89.5% and 91%.
6-8

This dependably-high success rate seems to be a major
advantage of the LSIB technique.
Ultrasound-Guided LSIB Technique
Although LSIB was first performed using nerve stimulation
(NS), it is a technique very suitable for US guidance.
Important sonoanatomic structures include the axillary
artery and three cords of the brachial plexus posterior to
the pectoralis minor muscle.
9
Using a linear probe, the
prominent pulsatile axillary artery can be easily identified.
Brachial plexus cords that surround the artery look
hyperechoic and can be identified with high resolution US
machines. Yet, sometimes difficulty can be encountered
seeing the posterior cord, which lies behind the artery
and can be confused with the acoustic enhancement
beyond the blood vessel (Fig. 1). Comparative studies
have revealed that US guidance further increases the
block success rate up to 95%.
10-11
Currently in our
clinic, where more than 1000 US guided LSIB has been
performed during recent years, our success rate is over
95% (unpublished data). US guidance has also reduced
How I Do It: Infraclavicular Block
Yavuz Grkan, M.D.
Associate Professor of Anesthesiology
and Reanimation
Kocaeli University Hospital
Kocaeli, Turkey
yavuzgurkanmd@gmail.com
Fig 1:
AA: Axillary (subclavian) artery, AV: Axillary vein. Cords of the brachial
plexus appear hyperechoic. Arrows indicate lateral, posterior and
medial cords. The axillary vein can be compressed to some extent.
3
2012
2012
18
vascular puncture incidence from 20% to almost nil.
6,10,11

In addition to high success rates, improved patient
safety, and comfort, US guidance has provided certain
advantages that allow the technique to be used in many
instances where it would not be clinically feasible with
NS alone.
12-14

The patient is placed in supine position with relaxed
shoulders. Typically the arm to be blocked is adducted
and the hand is on the abdomen but special arm
positioning is not necessary, which is an advantage,
especially in the case of painful, traumatized
extremities. However, abduction of the arm will further
bring cords to a more superficial position, which may be
an advantage during deep blocks.
15
The head is rotated
slightly to the opposite direction. The anesthesiologist
works from behind the shoulder. The point of needle
insertion is at the intersection between the clavicle and
the coracoid process. The US probe is placed just below
the clavicle, in para-sagittal orientation, about 0.51
cm inferior to the site of needle entry (Fig. 2). Any US
machine with a variable frequency linear probe can be
used for performing the block. In very obese patients,
convex or microconvex probes should be considered.
A 22 gauge, 80 mm block needle is used during block
performance. The needle is directed in-plane with
the US probe, and aimed towards the cranioposterior
part of the axillary artery. The needle tip is positioned
close to the recognizable cords around the 8 oclock
position based on a previous-published MRI study.
1
The
visualized local anesthetic (LA) distribution should be
considered sufficient when it reaches all identified cords
or surrounds the artery in a U shape covering 311
oclock of the clock face. If spread is judged insufficient,
the needle should be redirected to provide a U-shaped
LA distribution around the axillary artery. In adult
patients, we typically administer 30 ml of LA mixture (20
ml of levobupivacaine 0.5% and 10 ml of lidocaine 2%).
If bilateral block is planned, we administer only 20 ml of
LA for each side.
Single- versus Dual-Control during US-Guided ICB
Some clinicians choose to use both localization
modalities, NS and US guidance, simultaneously for
the performance of this block. However, avoidance of
NS may result in a greater degree of patient comfort,
especially in trauma cases, where motor stimulation
may be quite painful. In a randomized study, it was
shown that during LSIB performance, US guidance
alone produces a block success rate identical to the
combination of both US and NS guidance, yet provides
a shorter block performance time.
16
Block onset time
was similar in both groups. The axillary artery is a large,
pulsatile landmark that can be easily identified during
US scanning (Fig. 1). For these reasons, we recommend
using US guidance alone.
ICB in Children
LSIB is easy to perform in children due to distinct
anatomical landmarks. Using NS in our study that
Fig 2:
The point of needle insertion is at the intersection between the clavicle
and the coracoid process. A linear probe is placed just below the
clavicle inferior to the site of needle entry. Needle is directed using
in-plane technique.
The visualized local anesthetic (LA) distribution should be considered
sufcient when it reaches all identied cords or surrounds the artery in
a U shape covering 311 oclock of the clock face.
2
2012
19
included 80 children, all patients received 0.5 ml/kg
of bupivacaine 0.25% with adrenaline 5 mcg/ml. All of
the patients were pain-free at awakening from general
anesthesia with a mean duration of analgesia of 13 8 h
and a mean duration of motor block of 6 2 h. Vascular
puncture was detected in six patients.
17
Currently in our
clinic, all ICB blocks in children are performed using US
guidance alone and 0.25% levobupivacaine 0.5 ml.kg.
Possible complications
Vascular puncture with or without inadvertent LA toxicity
is the most frequent complication described, although US
guidance has dramatically reduced the incidence of this
occurrence. Because ICB block is a relatively deep block in
a noncompressible area, coagulopathy can be considered
as a relative contraindication. Pneumothorax is probably
the most feared complication; attention should be paid to
stay strictly lateral and sagittal to avoid meeting
the pleura.
18

Catheter Technique
The infraclavicular area is the best site of the brachial
plexus for catheter placement. Pectoral muscles keep
the catheter in place, and therefore catheter dislodgment
is not a major problem. Catheters are most useful for
repeated surgery, daily debridement and painful complex
surgeries like elbow surgery. During catheter placement
we administer 20 ml of LA as described before. The needle
tip is placed around 8 oclock, and the catheter is further
threaded about 2-3 cm beyond the tip of the needle.
Different regimens (LA administration on demand, and/
or continuous infusion via patient-controlled analgesia
pumps) using dilute LA concentration can be used for pain
treatment. We typically administer levobupivacaine 0.125-
0.25% either 5 ml/h continuous infusion or 5 ml bolus
doses on demand. All patients with catheters are followed
at regular intervals and necessary adjustments should be
made to optimize pain therapy and also to assess possible
complications like infection, migration of the catheter,
failure, and persistent motor or sensory block.
References
1. Sauter AR, Smith HJ, Stubhaug A, et al. Use of magnetic resonance imaging to
define the anatomical location closest to all three cords of the infraclavicular
brachial plexus. Anesth Analg 2006; 103: 1574-1576.
2. Bazy L. LAnesthesie du plexus brachial. In: Pauchet V, Sourdat P, Laboure J,
eds. LAnesthesie regionale. Paris: Doin et Cie, 1917: 2225.
3. Raj PP, Montgomery SJ, Nettles D, Jenkins MT. Infraclavicular brachial plexus
block A new approach. Anesth Analg 1973; 52: 897-904.
4. Klaastad , Smith HJ, Smedby O, et al. A novel infraclavicular brachial plexus
block: The lateral and sagittal technique, developed by Magnetic Resonance
Imaging studies. Anesth Analg 2004; 98: 252-256.
5. Koscielniak-Nielsen ZJ, Rasmussen H, Hesselbjerg L, et al. Infraclavicular
block causes less discomfort than axillary block in ambulatory patients. Acta
Anaesthesiol Scand. 2005; 49: 1030-1034.
6. Klaastad O, Dodgson MS, Stubhaug A, Sauter AR. Lateral sagittal
infraclavicular block (LSIB). Reg Anesth Pain Med. 2006; 31:86.
7. Grkan Y, Hosten T, Solak M, Toker K. Lateral sagittal infraclavicular block:
clinical experience in 380 patients. Acta Anaesthesiol Scand. 2008; 52: 262-
266.
8. Koscielniak-Nielsen ZJ, Rasmussen H, Hesselbjerg L, et al. Clinical evaluation
of the lateral sagittal infraclavicular block developed by MRI studies. Reg
Anesth Pain Med. 2005; 30: 329-334.
9. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus
block. BJA 2002; 89: 254-259.
10. Sauter AR, Dodgson MS, Stubhaug A, et al. Electrical nerve stimulation or
ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized,
controlled, observer-blinded, comparative study. Anesth Analg. 2008; 106:
1910-1915.
11. Grkan Y, Acar S, Solak M, Toker K. Comparison of nerve stimulation vs.
ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol
Scand. 2008; 52: 851-855.
12. Kus A, Grkan Y, Gk CN, Solak M, Toker K. Infraclavicular block with
ultrasound at amputated upper extremity. Agri. 2010; 22: 134-6.
13. Tekin M, Grkan Y, Ceylan DB, Solak M, Toker K. Ultrasound- guided bilateral
infraclavicular block: case report Agri. 2010; 22: 41-3.
14. Grkan Y, Ozdamar D, Hosten T, Solak M, Toker K. Ultrasound guided lateral
sagittal infraclavicular block for pectoral flap release. Agri. 2009; 21: 39-42.
15. Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided
infraclavicular block. British Journal of Anaesthesia 2006; 96: 5027.
16. Grkan Y, Tekin M, Acar S, Solak M, Toker K. Is nerve stimulation needed
during an ultrasound-guided lateral sagittal infraclavicular block? Acta
Anaesthesiol Scand. 2010; 54: 403-7.
17. Grkan Y, Ozdamar D, Solak M, Toker K. Lateral sagittal infraclavicular block
is a clinically effective block in children. Eur J Anaesthesiol. 2008; 25: 949-
951.
18. Koscielniak-Nielsen ZJ, Rasmussen H, Hesselbjerg L. Pneumothorax after
an ultrasound-guided lateral sagittal infraclavicular block. Acta Anaesthesiol
Scand 2008; 52: 1176-7.
How I Do It: Infraclavicular Block continued...
3
2012
2012
20
in Regional Anesthesia
N
eurologic complications associated with regional
anesthesia often have a diverse and complex etiology.
Following peripheral nerve blockade (PNB), presenting
features of potential nerve injury include paresthesia,
dysesthesia, neuropathic pain, and weakness. Devastating
complications of neuraxial anesthesia such as epidural
hematoma and abscess have been subject to large series
and its risk-benet ratio examined. In recent years, regional
anesthesia, and in particular PNB, has been increasingly
utilized and has evolved signicantly with the use of new
procedures, technology, and equipment.
Neuraxial anesthesia
Moen et al performed a comprehensive retrospective study
on severe complications following central neuraxial block
(CNB) in Sweden.
1
The denominator was estimated from a
postal survey to all anesthetic departments, then modied
according to commercial records of local anesthetics. To
validate the number of CNBs performed relevant registers
were consulted - the Swedish birth registry; the hip and knee
arthroplasty registers and a national audit of hip fractures.
From a denominator of 1,260,000 spinal and 450,000
epidural nerve blocks, there were 127 complications and
permanent neurologic damage in 85 patients. Complications
occurred more frequently in orthopedic patients (47/127)
and in patients who had received epidural anesthesia
(EA). To illustrate how infrequently major complications
are published, only 17 from 127 complications were the
subject of case reports. Hematoma in obstetric cases only
occurred with coexisting severe coagulopathy, for example
the HELLP (Hemolysis, Elevated Liver enzymes and Low
Platelets) syndrome. This resulted in a risk of hematoma
following obstetric epidural blockade of 1:200,000. The
incidence of epidural hematoma following total knee
arthroplasty in female patients was 1:3,600. In the Moen
study, in addition to coagulopathy (often pharmacologically-
induced) osteoporosis was proposed as an important risk
factor (more common in females) and part of a degenerative
process contributing to spinal canal stenosis. Spinal canal
stenosis combined with continuous epidural blockade is a
particular concern and requires a high level of vigilance and
postoperative neurologic surveillance. The study detected
iatrogenic meningitis (1:44,000) and abscess rarely. In a
1-year nationwide survey in Denmark, Wang et al estimated
the incidence of spinal-
epidural abscess after EA
to be 1:1930.
2
Risk factors
were immunosuppression,
prolonged duration of
catheterization (> 5 days)
and delayed diagnosis. The
most common organism
identied was Staphloccocus
aureus. The incidence of
abscess in this study was
signicantly higher than
previously appreciated.
In a review of neuraxial
morbidity at a single
hospital, Cameron et al
published experience
of over 8000 cases.
3

Epidural site infection
and pyrexia were triggers
for investigation with 20 MRIs performed to diagnose 6
abscesses. The combined risk of abscess or hematoma
was 1:1026 patients (95% CI 0.04 019%); however only
one laminectomy was required, and there were no cases
of permanent neurological decits. Epidural abscess was
associated with epidural site infection and fever in 5 out of 6
cases. The low rate of surgical intervention and lack of long-
term sequelae were a distinguishing feature of this series.
For a comprehensive review of infectious complications of
regional anesthesia refer to a recent article by Horlocker.
4

A collaborative effort involving all hospitals in the United
Kingdom (UK) National Health Service, recently reported on
serious complications of CNB.
5
The article and especially
the accompanying report contain substantial detail. The
pessimistic and optimistic incidences of paraplegia or death
were 1.8 (1.0 3.1) and 0.7 (0 1.6), n/100,000, 95%
Condence Interval (CI) respectively. The risk of permanent
injury following adult perioperative EA was 1:5,800 and
1:12,200 using pessimistic and optimistic incidences
respectively. In a large population-based cohort study,
propensity scoring was used to remove important baseline
differences between two groups of 44,094 patients who
received either EA or GA. The incidence of decompressive
Michael Barrington, MBBS
Senior Staff Specialist Anaesthesiologist
Department of Anaesthesia, St.
Vincents Hospital
Senior Lecturer, St. Vincents Hospital
Clinical School, University of Melbourne
Senior Lecturer, Melbourne Clinical
School, The University of Notre Dame
Senior Fellow, Department of Anatomy
and Cell Biology, University of
Melbourne
Melbourne, Australia
in Regional Anesthesia continued...
2
2012
21
laminectomy at 30 days was unchanged if patients received
EA (8:44,094) compared to those who had received GA
(7:44,094).
6
This incidence of laminectomy is similar to the
above-mentioned UK (1:8,100)
5
and single-center study
(1:8,000).
3
It is the authors opinion that neuraxial anesthesia has been
subject to more intense scrutiny than any other anesthesia
procedure. This scrutiny is understandable given the potential
devastating nature of neurologic complications following
neuraxial anesthesia. The incidence of serious complications is
consistently rare and clearly inuenced by patient morbidities
with outcome inuenced by practice location. A good patient
outcome following abscess and hematoma depends on a
high level of vigilance, early diagnosis, and prompt treatment.
Neuraxial catastrophes may be associated with organizational
and professional failures. The obstetric population is the safest,
while the aged, comorbid orthopedic surgical population
appears to represent a higher risk group.
Peripheral nerve blockade
Borgeat et al documented the incidence, etiology and evolution
of paresthesia, dysesthesia or pain not related to surgery
following interscalene block (ISB) and shoulder surgery. The
proportion of patients with symptoms reduced over time
(14% at 10 days, 7.9% at one month, 3.9% at 3 months,
0.9% at 6 months, and 0.2% at 9 months postoperatively).
Important diagnoses were sulcus ulnaris syndrome, carpal
tunnel syndrome and complex regional pain syndrome.
7
Liu
et al compared nerve stimulator with ultrasound guided ISB
in a randomized controlled trial and found a similar incidence
of postoperative neurological symptoms.
8
Auroy et al used
voluntary reporting and a telephone hotline service offering
expert advice to estimate the incidence of major complications
of regional anesthesia in France.
9
The incidences of block
related neuropathy were 2.9 (0 14.5), ISB; 1.8 (0 6.3),
axillary block; 2.9 (0 7.8), femoral block and 2.4 (0 8.2),
sciatic block [n/10,000, 95% CI]. From a total of 50,000 PNB
there were 12 neurologic complications and 7 had sequelae at
6 months. The Australasian Regional Anaesthesia Collaboration
collected data on a total of 6950 patients who received 8189
PNB.
10
Of the 6950 patients, 6069 patients were successfully
followed up. In these 6069 patients, there were a total of 7156
PNB forming the denominator for late neurologic complications.
Thirty patients (0.5%) had clinical features (paresthesia 22,
pain 4, motor 3 and none 1) meeting the criteria for neurologic
assessment. Three of the 30 patients had a block-related
nerve injury, giving an incidence of 0.4 per 1000 blocks
(95% condence interval, 0.08-1.1:1000). The remainder of
the 30 patients had patient-related etiologies (cervical spine
degeneration, ulnar entrapment, carpal tunnel syndrome,
lumbar canal stenosis, diabetic and peripheral neuropathies,
n = 9), surgical etiologies (swelling, direct trauma, peroneal
injury, n = 7), or anesthesia was excluded as the cause (n = 9).
Anatomical, patient, surgical and anesthetic factors
The attachments of the brachial plexus together with the high
ratio of neural to connective tissue in its proximal components
may place it at risk of stretch or compression injuries.
11
It is
therefore not surprising that neurological sequelae after ISB
and shoulder surgery are not uncommon, but fortunately most
neurologic features resolve with time.
7,12
Surgical patients
may have a preoperative subclinical neuropathy that becomes
clinically-evident in the postoperative period. Entrapment
neuropathies may involve the ulnar, median, lateral femoral
cutaneous nerves, or proximal nerve roots. The ulnar nerve
is particularly vulnerable at the elbow, and its course through
the supercial postcondylar groove and cubital tunnel place it
at risk of compression. Flexion of the elbow and pronation of
the forearm places the nerve at increased risk.
13
Risk factors
for ulnar neuropathy include male gender, extremes of body
habitus and prolonged admission.
14
Postoperative forearm and
wrist swelling may induce an acute median nerve neuropathy
or exacerbate existing carpal tunnel syndrome. Spinal canal
stenosis is relevant to peripheral nerve injury (PNI) in that
its severity may be asymmetrical and may exaggerate what
may have otherwise been a mild decit. Intrinsic peripheral
neuropathies have many causes including diabetes, vascular
disease, chemotherapy and other metabolic etiologies.
15

Smoking and medical conditions such as diabetes and
hypertension adversely impact the caliber and function of the
small blood vessels that supply nerves. An editorial written by
Hebl
16
that accompanied a case report of brachial plexopathy
after ultrasound-guided ISB in a patient with multiple
sclerosis highlighted important factors relating to neurologic
complications associated with PNB. The main message was
that PNI often originates from multiple sources and that patient,
3
2012
2012
22
surgical, and anesthetic factors may all be contributory in
determining outcome. In addition, distinguishing between
these factors may be difcult if not impossible for a given
case.
Surgical procedures have a native risk of nerve injury and
this has been highlighted in recent studies. During major
orthopedic surgery, patients are placed in positions they
would not normally tolerate if not anesthetized. Further,
tourniquet neuropathy can cause nerve damage either by
ischemia or mechanical deformation with damage greatest
at the edge of the tourniquet and the fast conducting
myelinated bers the most vulnerable. The risk of regional
anesthesia has been examined recently in the context of
total knee arthroplasty in 20-year cohort study.
17
During the
time period of the study, there was a substantial increase
in utilization of PNB; however there was no change in
the incidence of PNI. PNI within 3 months of TKA was
not associated with PNB or anesthesia type. PNI risk was
increased with age and tourniquet time.
Mechanisms of nerve injury related to regional anesthesia
include direct toxicity of local anesthetics (concentration
and time dependent) and mechanical trauma from the
needle and/or injectate.
18
A cadaver sciatic nerve model
has indicated that as few as 3% of fascicles may be
injured during deliberate intraneural injection.
19
The clinical
implications of this and other experimental models (e.g.,
animal) are unknown and of note no deliberate human
intraneural model incorporating histological analysis will
be possible. Peripheral nerve injection injury has been
studied recently in a rodent model and demonstrated
that even extrafascicular injection of ropivacaine caused
marked histologic abnormalities, although not as severe as
intrafascicular injection.
20
In summary, postoperative neurologic sequelae following
PNB are not infrequent and most resolve. The incidence of
serious neurologic complications related to PNB is infrequent
or rare. Distinguishing and determining the relative
contribution of each of those factors is challenging. PNI
frequently have patient, anesthetic and surgical etiologies
with evidence mounting that support its complex and
multifactorial etiology.
References
1. Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central
neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004; 101: 950-9
2. Wang LP, Hauerberg J, Schmidt JF: Incidence of spinal epidural abscess after
epidural analgesia: a national 1-year survey. Anesthesiology 1999; 91: 1928-36
3. Cameron CM, Scott DA, McDonald WM, Davies MJ: A review of neuraxial epidural
morbidity: experience of more than 8,000 cases at a single teaching hospital.
4. Horlocker TT, Wedel DJ: Infectious complications of regional anesthesia. Best
Pract Res Clin Anaesthesiol 2008; 22: 451-75
5. Cook TM, Counsell D, Wildsmith JA: Major complications of central neuraxial
block: report on the Third National Audit Project of the Royal College of
Anaesthetists. Br J Anaesth 2009; 102: 179-90
6. Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A: Epidural anaesthesia
and survival after intermediate-to-high risk non-cardiac surgery: a population-
based cohort study. Lancet 2008; 372: 562-9
7. Borgeat A, Ekatodramis G, Kalberer F, Benz C: Acute and nonacute complications
associated with interscalene block and shoulder surgery: a prospective study.
8. Liu SS, Zayas VM, Gordon MA, Beathe JC, Maalouf DB, Paroli L, Liguori GA, Ortiz
J, Buschiazzo V, Ngeow J, Shetty T, Ya Deau JT: 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: 265-71
9. Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ, Bouaziz H,
Samii K: Major complications of regional anesthesia in France: The SOS Regional
Anesthesia Hotline Service. Anesthesiology 2002; 97: 1274-80
10. Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay
VS, Jamrozik K: 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: 534-41
11. Moayeri N, Bigeleisen PE, Groen GJ: Quantitative architecture of the brachial
plexus and surrounding compartments, and their possible signicance for plexus
blocks. Anesthesiology 2008; 108: 299-304
12. Candido KD, Sukhani R, Doty R, Jr., Nader A, Kendall MC, Yaghmour E, Kataria
TC, McCarthy R: 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: 1489-95,
table of contents
13. Barner KC, Landau ME, Campbell WW: A review of perioperative nerve injury to
the upper extremities. J Clin Neuromuscul Dis 2003; 4: 117-23
14. Prielipp RC, Warner MA: Perioperative nerve injury: a silent scream?
15. 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: 249-51
16. Hebl JR: Ultrasound-guided regional anesthesia and the prevention of neurologic
injury: fact or ction? Anesthesiology 2008; 108: 186-8
17. Jacob AK, Mantilla CB, Sviggum HP, Schroeder DR, Pagnano MW, Hebl JR:
Perioperative nerve injury after total knee arthroplasty: regional anesthesia risk
during a 20-year cohort study. Anesthesiology 2011; 114: 311-7
18. Hogan QH: Pathophysiology of peripheral nerve injury during regional
anesthesia. Reg Anesth Pain Med 2008; 33: 435-41
19. Sala-Blanch X, Ribalta T, Rivas E, Carrera A, Gaspa A, Reina MA, Hadzic A:
Structural injury to the human sciatic nerve after intraneural needle insertion.
Reg Anesth Pain Med 2009; 34: 201-5
20. Whitlock EL, Brenner MJ, Fox IK, Moradzadeh A, Hunter DA, Mackinnon SE:
Ropivacaine-induced peripheral nerve injection injury in the rodent model.
Anesth Analg 2010; 111: 214-20
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