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You’re scheduled to anesthetize an NFL quarterback for a shoulder arthroscopy and rotator cuff repair. The patient earns $25 million dollars per year for throwing footballs. Would you feel comfortable inserting a needle into his neck to do a regional anesthetic? Would you feel comfortable doing an interscalene block on an NFL quarterback as part of his anesthetic?
Regional anesthesia is a growing frontier in modern clinical anesthesia, in part because of the availability of ultrasonic imaging to help us direct needle placement. The subspecialty of regional anesthesia has blossomed. Listening to some of its disciples, it would seem that nearly every orthopedic surgery procedure can benefit from an ultrasonic regional block for intraoperative and postoperative pain control.
Anesthesiology News (Hardman D, July 2015, 41:7) recently reviewed the topic of nerve injury after peripheral nerve block. Data shows that the risk for permanent or severe nerve injury after peripheral nerve blocks is low. Per the article, the prevalence of permanent injury rates as defined by a neurologic abnormality present at or beyond 12 months after the procedure, ranges from 0.029% to 0.2%.
Low, but not zero.
There is a high incidence of temporary postoperative neurologic symptoms after arthroscopic shoulder surgery, whether the patient received a regional block or not. The incidence of temporary neurologic symptoms during the first week ranged as high as 16% to 30%. Most of these involved minor sensory symptoms such as paresthesias and dysesthesias.
An incidence of 16% to 30% is a remarkably high number.
Data from a clinical registry at the Mayo Clinic for total shoulder arthroplasty from 1993 to 2007 demonstrated a peripheral nerve injury rate of 3.7% following general anesthesia in contrast to a peripheral nerve injury rate of 1.7% in patients who received an interscalene block (Sviggum HP, et al. Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 2012;37:490-494). It’s striking that the patients with general anesthesia had MORE peripheral nerve injuries than patients who had an interscalene block.
Over 97% of the patients who developed peripheral nerve injury recovered completely or partially at 2.5 years after the procedure. Seventy-one percent experienced full recovery, which means that 29% did not experience full recovery.
Given this information, would you give the NFL quarterback a general anesthetic or would you include an interscalene block?
I submit that no anesthesia provider should feel comfortable inserting a needle in the neck of this $25 million-dollar-a-year man. No anesthesia provider should feel comfortable doing an interscalene block for his shoulder arthroscopy. Why not? Even though the above data show that peripheral nerve injury can occur following shoulder arthroscopy with either general or interscalene anesthesia, the anesthesiologist will likely be sued only if he or she performs the interscalene anesthesia.
A plaintiff lawyer will be quick to link the needle in the patient’s neck to the nerve damage, if the damages are the NFL player’s inability to earn his $25 million per year, and the anesthesiologist will be sued. If there is peripheral nerve injury following a general anesthetic, expect the surgeon to be sued.
With peripheral nerve injury following general anesthesia, the surgeon will incur the medical malpractice risk because shoulder arthroscopy has its own risks for nerve injury. Risks include: 1) traction on the brachial plexus due to positioning during surgery, 2) irrigating fluid extravasation causing tissue edema compressing the brachial plexus and peripheral nerves, or 3) arthroscopic portals damaging nerves.
Ultrasound-guided blocks have many advantages, but there is no sufficient evidence demonstrating a lower neurologic complication rate with this technique.(Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).
If the risk of a limb-harming peripheral nerve injury is prohibitive for an NFL player, why is the risk acceptable for the rest of our patients? Is it because an accountant or a fireman who is a recreational tennis player or golfer is less likely to sue the anesthesiologist if a peripheral nerve injury occurs?
A 2007 survey of academic regional anesthesiologists indicated that nearly 40% of respondents did not disclose the risks of long-term and disabling neurologic injury prior to performing peripheral nerve blocks. (Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11)
It’s more difficult to sell an “optional” peripheral nerve block if you disclose to the patient the risks for long-term nerve damage. However, if you do not disclose the risks of long-term nerve damage, you will be vulnerable to a lawsuit should nerve damage occur.
We’ll need to review the anesthesia closed claims data for peripheral nerve injuries in five or ten years time to see how many successful lawsuits were generated by the current crescendo in the performance peripheral nerve blocks. Until that time, I recommend honest and complete informed consent to all your patients regarding the non-zero risks of permanent nerve damage related to peripheral nerve blocks.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
KIRKUS REVIEW
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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Hi doctor Novak,
I read this article and the NFL player one with a lot of interest thank you for publicising this!
I had minor shoulder surgery recently to releive a suprascapular nerve entrapment and arthroscopic subacromial impingement.
I was unaware that a ultrasonic nerve block would be used, and it was not even mentioned in the post operation notes.
For a few days post operation my hand was very numb, that then cleared up.
But then 2-3 weeks later my thumb and index fingers are hypersensitive, and index finger has lost most function, plus forearm issues, its debilitating.
Ive now been diagnosed with Parsonage Turner syndrome(PTS) with a 12-24 month recovery time.
The doctors say the operation is totally unrelated to the PTS issue, but i have doubts.
Are you aware of PTS being related to nerve blocks or shoulder operations?
Again, many thanks!
Tony,
PTS is a possibility.
PTS is rare. See this reference:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2926354/
However, if you had surgery on that shoulder, and now you have post-operative complications in that limb, there are other questions.
If the post-operative notes do not mention a nerve block, you may not have had a nerve block. A subacromial decompression surgery does not require a nerve block.
Surgical complications or positioning complications can cause nerve damage, and can cause your symptoms.
It may be prudent to have a neurologist go over your case. An EMG (electromyogram) could identify the site of any nerve damage if there is any.
It would also be important to know if you indeed had a nerve block, and whether you consented to a nerve block if it was performed.
Hi.
I asked my doc if i has a ultrasound guided nerve block and he said yes, i feel like that really should be in the post op notes, and I’m suspicious that it was not but seems like its not mandatory? I did not consent to a nerve block.
Overall it sounds like long term nerve injuries related to nerve block’s are overall low and proving that or improper arm postioning/padding or other surgery related issues would be tough(as per page 4 of the link below) as there are other potential causes like virus’s, vaccines etc.
I really don’t want to take legal action but I would if I though guidelines had been breached given that fact i cant even sign my name or cut with a knife at dinner nearly 2 months after the operation.
https://edus.ucsf.edu/sites/edus.ucsf.edu/files/wysiwyg/Hardman_NerveInjury_AN0715_WM.pdf
Thanks again for your good work educating people on this site.
Doc, I disagree with the take. It’s difficulty to make the comparison of a professional athlete to the average individual. I mean on the same note should we not just remove ourselves from any general anesthetic case where we think the risk of a lawsuit is possible; GETA carries many risks at a similar profile of <1%, based on the argument presented maybe no one should get it. I do present GETA as an option, but when the only other option is to not have surgery do patients really appreciate the risk? Additionally, not all patients are the health of professional athletes; co morbidities carry risk especially within the first 24h when opioids will be used more heavily, further do surgeons counsel their patients about the increased risk of chronic pain and long term narcotic use with poorly managed acute pain? Now if this is simply about informed consent, no problem I present nerve damage as a risk for nerve blocks. However, when patients refuse them I don't often counsel about the risk of chronic pain, opioid use or complications such as CRPS.
Adlei,
Thanks for your email. GETA has risks, of course, but you need general anesthesia for most surgery, so we do it. GA is not optional for most surgery.
Regional nerve blocks are almost always optional. I’ve represented numerous patients with permanent nerve damage from their (optional) nerve blocks, and they’re all angry and irate. A lifetime with a weakened or numb extremity is a tragedy.
I’m an athletic person, and personally I would not consent to a nerve block. I’d rather take my chances on taking the pain pills after the surgery, expecting I will not become a lifelong narcotic addict.
The issue is informed consent. If a patient is OK with the small (about 1/3000) risk of permanent nerve damage, then the nerve block is part of your anesthetic plan. For some particularly painful surgeries, i.e. total knees and shoulders, the risk of severe post-op pain (probably) makes a nerve block indicated.
Thanks for the reply. I agree with informed consent, people have a right to know. However, there is a lot more nuance involved that you seemingly glossed over in your post. Sounds like you are in great health and the opioid trial is likely appropriate, but we both know that is not the case for many of our patients. I am equally active, but I would not instinctually rule out a PNB, it would be situational. Each case should be a discussion tailored to the patient. Now if I had a block with a bad outcome would I be upset, yes! But I have yet to find any patient not upset with a complication even though they may find themselves in the group of rare occurrences. I also think your risk of 1/3000 is slightly higher than what I have come across, due to the difficulty of controlling for the many confounders. Furthermore, in my experience many providers gloss over the inherent risks of GA because it’s not presented as optional, if so then is it truly “informed consent”?