Perioperative Nerve Injury Research Articles

Surgery of Schwannoma in the upper limb – sensitivity and specificity of preoperative magnetic resonance imaging and relation between tumour size and symptoms

BackgroundBenign peripheral nerve tumours consist of different types, most commonly Schwannomas. Preoperative Magnetic Resonance Imaging (MRI) is commonly performed before surgery and Pathoanatomical Diagnosis (PAD) confirms the diagnosis. Our aims were to study the utility of MRI and the relation between tumour size and symptoms.MethodsRetrospectively, patients, surgically treated for benign nerve tumours between 2008 and 2019, were identified and preoperative MRI, with measurement of tumour size, PAD, symptoms, peroperative details, and symptomatic outcomes of surgery, were analysed.ResultsThe sensitivity and specificity to correctly identify Schwannomas with preoperative MRI were 85% and 50%, respectively, based on 30 Schwannomas and nine neurofibromas that were identified. Tumour size did not affect the presence of preoperative symptoms, but patients with sensory dysfunction at last follow-up had larger Schwannomas (p < 0.05). Symptoms as a palpable tumour, paraesthesia and pain improved by surgical excision (p < 0.001, p < 0.001 and p < 0.012, respectively), but sensory and motor dysfunction were common postoperatively. No malignant peripheral nerve sheath tumours (MPNST) were found. Using a surgical microscope, instead of only loop magnification, lowered the risk of perioperative nerve injuries (p < 0.05), but did not further diminish postoperative symptoms.ConclusionsEarly and accurate diagnosis of Schwannomas is valuable for adequate presurgical preparation and prompt surgical intervention. Preoperative examination with MRI has a high sensitivity, but low specificity; although recent advancement in MRI technology indicates improvement in diagnostic precision. Surgical excision is preferably performed early in conjunction with symptomatic debut to improve outcome.

Clinical Approach to Chronic Pain due to Perioperative Nerve Injury.

Perioperative nerve injuries are common and may be prevented. The estimated incidence of perioperative nerve injury is 10% to 50%. However, most of these injuries are minor and self-recovering. Severe injuries account for up to 10%. Potential mechanisms of injury are nerve stretch, compression, hypoperfusion, direct nerve trauma, or injury during vessel cannulation. Nerve injury pain usually presents as neuropathic pain ranging from mild to severe mononeuropathy and extends to the disabling complex regional pain syndrome. This review provides a clinical approach to subacute and chronic pain secondary to perioperative nerve injury, presentation, and management.

Ultrasonic bone curette in thoracic spinal decompression: a comprehensive systematic review and meta-analysis.

The aim of this study was to compare the efficacy and safety of ultrasonic bone curette (UBC) and conventional surgical instruments in thoracic laminectomy decompression (TLD) for the treatment of thoracic spinal stenosis (TSS) by meta-analysis. Two authors independently searched Medline via PubMed, Embase, Cochrane Library, Web of Science, Wanfang Database, and China National Knowledge Infrastructure for the period from the establishment of the database until January 2023 to identify the studies on the safety and efficacy of UBC vs. conventional instruments for TSS. Data extraction and quality assessment were performed by two researchers independently. We used RevMan 5.4 software (Review Manager Web, The Cochrane Collaboration, Copenhagen, Denmark) to analyze the data. Eight retrospective studies were included in the present work. This meta-analysis revealed that no significant differences in the preoperative JOA scores, the JOA scores at the last follow-up, the improvement rate of JOA scores, and the incidence of cerebrospinal fluid leakage/dura injury were detected between the two groups (p>0.05). However, there were significant differences in the operative time and intraoperative blood loss during single-level TLD [operative time: MD=-1.47, 95% CI (-1.86, -1.09), p<0.001; intraoperative blood loss: MD=-46.62, 95% CI (-53.83, -39.40), p<0.001], total operative time [MD=-56.88, 95% CI (-69.66, -44.10), p<0.001], total intraoperative blood loss [MD=-143.52, 95% CI (-212.49, -74.54), p<0.001], the incidence of neurological deterioration/nerve root injury [RR= 0.29, 95% CI (0.09, 0.91), p=0.03] between the groups. The application of UBC in TLD to treat TSS is safe and effective. UBC can significantly shorten operation time and reduce intraoperative blood loss compared to traditional surgical instruments. Moreover, it has the advantage of reducing perioperative nerve injury.

Management of anesthesia for surgery in prone position for a patient with hereditary neuropathy with liability to pressure palsies. A case report and narrative literature review

The reported case describes a patient with hereditary neuropathy with liability to pressure palsies (HNPP) requiring a neurosurgical laminotomy procedure for an arachnoid cyst with medullary compression. HNPP is a rare pathology requiring meticulous anesthetic and surgical management. We give a detailed overview of the planning, simulation, and performance of the anesthesia procedure in order to minimize all potential risk factors for perioperative nerve injury. During the preparation of this case, where the positioning was extremely challenging, we reviewed the available literature for guidance. A few papers report the use of neuraxial anesthesia in patients previously diagnosed with HNPP. No reports could be found on the management of general anesthesia and positioning for major surgery in those patients.

Progress in the studies of perioperative peripheral nerve injury

Peripheral nerve injury (PNI) is one of the common perioperative complications, which can cause short-term sensory and motor abnormalities in patients, and even permanent sensorimotor disorders. Current studies emphasize that the incidence of perioperative PNI can be reduced through enhancing the awareness of perioperative peripheral nerve protection and implementing effective preventive measures. This paper reviewed the incidence, predisposing factors, injury factors, injury mechanism, preventive measures and treatment regimens of perioperative PNI, so as to provide reference to avoid PNI during clinical anesthesia. Key words: Perioperative; Peripheral nerve injury

A contemporary medicolegal analysis of perioperative vision loss from 2007 to 2016.

Perioperative vision loss (POVL) is a rare but catastrophic event. Closed claim databases are useful for investigating risk factors of POVL to help guide practices in risk mitigation and risk management strategies. We retrospectively analyzed the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System database for perioperative nerve injuries from when claims were closed between 2007 and 2016. We then extracted, deidentified, and analyzed all the POVL cases. Of 53 nerve injury claims closed between 2007 and 2016, we found 9 pertaining to POVL. Of these 9 cases, 100% resulted in permanent injury, 76% were associated with spine surgery, 89% of the patients were positioned prone intraoperatively, 67% were noted to have improper or missing documentation, and 56% of the patients claimed they were not informed of the risk of vision loss during preoperative consenting. Four of the 9 cases were settled, with a mean settlement amount of $906,250 (standard deviation,±$745,647). POVL often results in permanent injury with costly burden on the health care system. Risk reduction strategies need to be instituted on the provider and system level, involving a multidisciplinary health care team to develop and execute clinical protocols and patient communication strategies that will help prevent POVL.

Is It the Surgery or the Block? Incidence, Risk Factors, and Outcome of Nerve Injury following Upper Extremity Surgery.

A total of 297 patients, scheduled for elective distal upper extremity surgery, were prospectively included. At various time points, patients were screened for new onset nerve injury by means of clinical examination and questionnaires (including the Quick Disabilities of the Arm, Shoulder and Hand functionality measure). New nerve injury was diagnosed in 14 patients [4.7% (95% CI, 2.8-7.8)], but no causative risk factors were identified. The exact origin of nerve injury is suspected to be surgical in 11 cases. At 4 years postoperatively, 5 of the 14 patients with nerve injury (36%) were still symptomatic and had reduced functionality relative to preoperative status. This study demonstrates an incidence of all cause nerve injury of 4.7%. No specific patient, anesthetic, or surgical risk factors are identified and, importantly, patients who received regional anesthesia are not at more risk of nerve injury than those who received general anesthesia. The exact origin of nerve injury is very difficult to determine, but is suspected to be caused by direct surgical trauma in most cases. Four years following the nerve injury, approximately 40% of the patients with new onset nerve injury have reduced functionality.

A medicolegal analysis of positioning-related perioperative peripheral nerve injuries occurring between 1996 and 2015

Study objectiveTo provide an analysis of closed malpractice claims brought against anesthesiologists for positioning-related perioperative nerve injury (PRPNI). DesignIn this retrospective study, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database. SettingClosed claims involving nerve injuries that occurred between January 1, 1996 and December 31, 2015 in all surgical settings, provided the alleged damaging event occurred under general anesthesia. PatientsPatient ages ranged from 23 to 94. Patients underwent a variety of surgical procedures. Severity of nerve injury ranged from “Insignificant” to “Grave” according to the NAIC Severity of Injury Code. InterventionsNone. MeasurementsPatient age and gender, alleged nerve injury type and severity, operating surgical specialty, contributing factors to the alleged nerve injury, and case outcome. Some of these data were drawn directly from coded variables in the CBS database, and some were gathered by the authors from CRICO-encoded narrative case summaries. Main resultsSeventy-five claims were determined to represent PRPNI. Ninety-two percent of all PRPNI claims involved practitioner technical knowledge/performance. Of all the recorded nerve injuries in this series, 56% involved brachial plexus injuries, and supine patient positioning represented 55% of brachial plexus claims. Settlement payments were made in 33% of claims, and the average payment for all cases was $46,269. Twenty-four percent of PRPNI claims were found to be temporary, while 76% were permanent. ConclusionsPRPNI is multifactorial, and stems both from practitioner errors as well as from patient comorbidities and pre-existing neuropathies. Supine positioning can increase PRPNI risk. There are likely still causes of PRPNI of which we are not yet aware, given that despite concerted efforts towards positioning and padding interventions, injuries such as those described in this study still occur.

Complications After Continuous Posterior Lumbar Plexus Blockade for Total Hip Arthroplasty: A Retrospective Cohort Study.

While benefits of regional anesthesia in total hip arthroplasty (THA) are well documented, data describing the incidence of complications related to the use of posterior lumbar plexus blockade for THA remain limited. Our primary aim was to evaluate the incidence of infectious, bleeding, and neurological complications related specifically to the use of continuous posterior lumbar plexus block for elective THA. We reviewed the electronic medical records of all adult patients who underwent elective THA with continuous posterior lumbar plexus blockade between December 1, 2004, and April 30, 2015, using the Mayo Clinic Total Joint Registry. All complications were verified via manual chart review by 2 reviewers. Patient demographics, type of surgery, and complications were analyzed. A total of 9649 patients who underwent 11,395 THA procedures met the inclusion criteria. There were 8686 (76.2%) primary and 2709 (23.8%) revision THAs. There were no block-related infections (0.00%; 95% confidence interval [CI], 0.00%-0.03%) and only 1 block-related hematoma (0.01%; 95% CI, 0.00%-0.05%) in a patient with multiple risk factors for bleeding. There were 60 (0.53%; 95% CI, 0.40%-0.68%) perioperative nerve injuries. Forty-three were in the sciatic distribution (71.67%; incidence, 0.38%). Although there were no documented overt iatrogenic nerve injuries, the posterior lumbar plexus blockade could not be excluded as the potential cause in 9 cases (incidence, 0.08%) based on clinical distribution or electromyographic findings. In our large, single-center cohort study, we report no catheter-related infections, whereas catheter-related hemorrhagic and neurological complications also appear to be rare.

Local Anesthetic-Induced Neurotoxicity.

This review summarizes current knowledge concerning incidence, risk factors, and mechanisms of perioperative nerve injury, with focus on local anesthetic-induced neurotoxicity. Perioperative nerve injury is a complex phenomenon and can be caused by a number of clinical factors. Anesthetic risk factors for perioperative nerve injury include regional block technique, patient risk factors, and local anesthetic-induced neurotoxicity. Surgery can lead to nerve damage by use of tourniquets or by direct mechanical stress on nerves, such as traction, transection, compression, contusion, ischemia, and stretching. Current literature suggests that the majority of perioperative nerve injuries are unrelated to regional anesthesia. Besides the blockade of sodium channels which is responsible for the anesthetic effect, systemic local anesthetics can have a positive influence on the inflammatory response and the hemostatic system in the perioperative period. However, next to these beneficial effects, local anesthetics exhibit time and dose-dependent toxicity to a variety of tissues, including nerves. There is equivocal experimental evidence that the toxicity varies among local anesthetics. Even though the precise order of events during local anesthetic-induced neurotoxicity is not clear, possible cellular mechanisms have been identified. These include the intrinsic caspase-pathway, PI3K-pathway, and MAPK-pathways. Further research will need to determine whether these pathways are non-specifically activated by local anesthetics, or whether there is a single common precipitating factor.

Neurologic Evaluation and Management of Perioperative Nerve Injury

Neurologic Evaluation and Management of Perioperative Nerve Injury

Roles of Inflammatory Reaction and Cytokines in Chronic Postsurgical Pain

Chronic postsurgical pain (CPSP) is characterized by high incidence,prolonged duration,multiple risk factors,and complicated pathogenesis. It seriously impairs patients' quality of life,especially after thoracotomy. Perioperative nerve injury is a major cause of CPSP. Meanwhile,the excessive neuroinflammation and inflammatory cytokines caused by surgery also accelerate the formation of CPSP. This review aims to provide an overview of the recent advances in the roles of inflammatory reaction and cytokines in the development of CPSP.

Assessment of perioperative, early, and late postoperative complications of the inside-out transobturator tape procedure in the treatment of stress urinary incontinence

Objective: To evaluate the complications of urinary incontinence surgery with transobturator tape (TVT-O) system and to describe itsdiagnosis and management. Materials and Methods: A total of 156 patients who were diagnosed as having stress incontinence and mixedincontinence with stress predominance underwent a TOT operation under spinal anesthesia by one surgeon or two surgeons (MB, AEY) from the team. TVT-obturator inside out material was used in the operation. Urodynamic tests and pad tests were done on all the patients. This is a prospective and retrospective study of the complications of TVT- O. The operation was performed under regional anesthesia, asdescribed by Deval et al. Patients were excluded from the study if they had been operated under general or local anesthesia, had undergoneany vaginal operations except for anterior repair (cystocele), wanted to have a baby, had severe systemic diseases or had been diagnosedas having urge incontinence in urodynamic tests. These situations may affect the rate of complications, the authors also excluded slings thathad materials other than monofilament polypropylene, and patients who were suspected of having neurologic bladder conditions. The bladderand urethra were evaluated using cystoscopy. The durations of the TOT procedure, cystoscopy, and if performed, the cystocele operation,were recorded. Perioperative, early, and late postoperative complications were analyzed by follow-up visits (after two months to fouryears). Results: Of the 156 patients included in the study, 100 (64.1%) had pure stress urinary incontinence and 56 (35.9%) had mixed incontinence,20 (12.8%) had previous incontinence surgery. The mean duration of follow up was 30.3 &#x00B1; 7.4 (range 17-42) months. Themean age of the patients was found to be 48.43 &#x00B1; 6.24 years (range 42-68). The mean parity of the patients was 5.24 &#x00B1; 2.86 (range 2-13), and mean body mass index was found to be 23.7 &#x00B1; 4.8. Mean maximum detrusor pressure was 10.30 &#x00B1; 4.08 and the mean ALP value was80.80 &#x00B1; 25.57. Mean operative time was found to be 13.8 &#x00B1; 5.16 min in patients who underwent only TOT and TOT-anterior repair. Vaginalinjury including to the lateral fornix (4.4%), hemorrhaging of more than 200 ml (3.2%), vascular damage (1.9%), hematoma on the leg(1.9%), hemorrhaging of more than 500 ml (0.064%), and bladder perforation (1.2%) were detected as perioperative complications. Urethralinjury and perioperative nerve and intestinal injury did not occur. The most common complication in early postoperative period wasinguinal pain extending the legs (30.7%), followed by headaches (23.7%), fever (12.8%), urinary tract infection (5.7%), and urinary retention(3.2%), respectively. Late postoperative complications included vaginal erosion (4.4%), de novo urge incontinence (8.9%), de novo dyspareunia(7.1%), perineal pain (4.4%), and worsening urgency (8.9%). Conclusion: Although the TVT-O technique is a minimal invasivesurgery method applied to treat the urinary incontinence surgically, it does not imply that it is a complication-free surgical procedure. Despitethe low incidence of intraoperative complications, there is a mild risk of early and late postoperative complications. Fortunately thesecomplications can be taken under control by either conservative and simple medical treatments or surgical procedures.

Neurologic Evaluation and Management of Perioperative Nerve Injury.

Studies pertinent to the recognition, evaluation, and treatment of neurologic assessment of perioperative nerve injury and published since the last advisory on the topic are reviewed and a new structured algorithmic approach is proposed. The evolving literature on postoperative inflammatory neuropathies is reviewed to help define the clinical criteria and to identify patients who would benefit from early neurological evaluation. New sections review potential acute interventions to improve neurologic outcome and long-term management of neuropathic pain resulting from perioperative nerve injury.

What is the frequency of nerve injuries associated with acetabular fractures?

Acetabular fractures and surgical interventions used to treat them can result in nerve injuries. To date, only small case studies have tried to explore the frequency of nerve injuries and their association with patient and treatment characteristics. High-quality data on the risk of traumatic and iatrogenic nerve lesions and their epidemiology in relation to different fracture types and surgical approaches are lacking. The purpose of this study was to determine (1) the proportion of patients who develop nerve injuries after acetabular fracture; (2) which fracture type(s) are associated with increased nerve injury risk; and (3) which surgical approach was associated with the highest proportion of patients developing nerve injuries using data from the German Pelvic Trauma Registry. Two secondary aims were (4) to assess hospital volume-nerve-injury relationship; and (5) internal data validity. Between March 2001 and June 2012, 2236 patients with acetabular fractures were entered into a prospectively maintained registry from 29 hospitals; of those, 2073 (92.7%) had complete records on the endpoints of interest in this retrospective study and were analyzed. The neurological status in these patients was captured at their admission and at the discharge. A total of 1395 of 2073 (67%) patients underwent surgery, and the proportions of intervention-related and other hospital-acquired nerve injuries were obtained. Overall proportions of patients developing nerve injuries, risk based on fracture type, and risk of surgical approach type were analyzed. The proportion of patients being diagnosed with nerve injuries at hospital admission was 4% (76 of 2073) and at discharge 7% (134 or 2073). Patients with fractures of the "posterior wall" (relative risk [RR], 2.0; 95% confidence interval [CI], 1.4-2.8; p=0.001), "posterior column and posterior wall" (RR, 2.9; CI, 1.6-5.0; p=0.002), and "transverse+posterior wall" fracture (RR, 2.1; CI, 1.3-3.5; p=0.010) were more likely to have nerve injuries at hospital discharge. The proportion of patients with intervention-related nerve injuries and that of patients with other hospital-acquired nerve injuries was 2% (24 of 1395 and 46 of 2073, respectively). They both were associated with the Kocher-Langenbeck approach (RR, 3.0; CI, 1.4-6.2; p=0.006; and RR, 2.4; CI, 1.4-4.3; p=0.004, respectively). Acetabular fractures with the involvement of posterior wall were most commonly accompanied with nerve injuries. The data suggest also that Kocher-Langenbeck approach to the pelvic ring is associated with a higher risk of perioperative nerve injuries. Trauma surgeons should be aware of common nerve injuries, particularly in posterior wall fractures. The results of the study should help provide patients with more exact information on the risk of perioperative nerve injuries in acetabular fractures. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Femoral nerve injury following a lumbar plexus blockade.

Lumbar plexus blockade (LPB) combined with sciatic nerve block (SNB) is frequently used for lower extremity surgery. Perioperative nerve injury is a rarely encountered complication of peripheral nerve blocks (PNB). Here we report a 44-year-old male patient who developed a partial femoral nerve injury (FNI) following a LPB which was performed before the surgery of a patellar fracture. The clinical and electroneuromyographic findings of the patient were recovered almost completely within the following six months. The presented case demonstrated a FNI despite the absence of any pain or paresthesia sensation, with the disappearance of motor response under 0.3 mA of neurostimulation in the experienced hands.

Nerve injuries associated with gynaecological surgery

Key content Nerve injuries are a common complication of gynaecological surgery, occurring in 1.1–1.9% of cases. Patient mal‐positioning, incorrect placement of self‐retaining retractors, haematoma formation and direct nerve entrapment or transection are the primary causative factors in perioperative nerve injury. Nerves most commonly injured during surgery include the femoral, ilioinguinal, pudendal, obturator, lateral cutaneous, iliohypogastric and genitofemoral nerves. The majority of neuropathies resolve with conservative management and physiotherapy. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and gamma‐aminobutyric acid (GABA) antagonists are of significant benefit in managing painful neuropathies. Learning objectives To gain an overview of the spectrum of different neuropathies that may occur following pelvic surgery. To learn about safe surgical techniques in the prevention of postoperative neuropathies. To review the clinical anatomy of the lumbo‐sacral and brachial plexuses. Ethical issues Neuropathies can cause considerable postoperative morbidity. Should neuropathies following gynaecology surgery be discussed routinely during consent taking? Neuropathies following surgery may have considerable medico‐legal implications.

Perioperative Nerve Injury After Total Hip Arthroplasty

Jacob, Adam K.*; Mantilla, Carlos B.*; Sviggum, Hans P.*; Schroeder, Darrell R.†; Pagnono, Mark W.‡; Hebl, James R.* Author Information

Misdiagnosis of an early postoperative upper limb deficit

Transient left upper limb deficit was diagnosed on the first postoperative day following a long surgery procedure and was assumed to have been caused by a positioning injury. Three months after the operation, multiple sclerosis was diagnosed. Importantly, this Case Report emphasizes the importance of carefully considering a differential diagnosis of perioperative nerve injury when observed in the early postoperative period. Also, the question arises as to whether the onset of multiple sclerosis was directly related to anesthesia and/or surgery and whether the early postoperative upper limb deficit was the initial sign of malignant sclerosis.

THIS MONTH IN Anesthesiology

The concept that the μ-opioid receptor may be involved in tumor progression is discussed.This lecture promotes pursuing a redesign of perioperative healthcare.This study suggests that exploration of the μ-opioid receptor in non-small cell lung carcinoma merits further study both as a diagnostic and therapeutic option.Anesthetic- or surgical-related etiologies of perioperative nerve injury are reviewed.Unbundling of consciousness, connectedness, and responsiveness is critical for the future development of anesthesia.Previous studies have suggested interactions between opioid genetics, tumor growth, and clinical effects of morphine. In this long term study, 2,039 patients with breast cancer were genotyped and followed for clinical outcomes. Patients genotyped with the A118G μ-opioid receptor polymorphism had less breast cancer–specific mortality at 10 yr. Breast cancer–specific mortality was significantly reduced in patients with one or more copies of the G allele (P &lt; 0.001) for invasive cases. Mortality was significantly decreased in patients with A/G and G/G phenotypes compared with A/A (P = 0.006). This study supports further investigation between opioid genetics, pain management, and cancer survival.There is conflicting literature regarding a patient's need for preoperative blood typing and screening. This study reviewed anesthesia information management system data from 160,207 scheduled noncardiac adult cases at a single hospital. Procedures could be defined to have minimal estimated blood loss (&lt; 50 ml) based on low incidence of transfusion and low incidence of hemoglobin being checked preoperatively. Type and screen was unnecessary when the confidence intervals for erythrocyte transfusion were less than 5%. These data may allow development of a new method for determining which patients require preoperative type and screen. See the accompanying Editorial View on page 749 Use of perioperative epidural anesthesia and analgesia during cancer resections may avoid immunosuppressive recurrence triggers. Using the Medicare-Surveillance, Epidemiology, and End Results database, the authors compared survival and cancer recurrence rates for resection of colorectal cancer in patients who received perioperative epidural anesthesia and analgesia to those who did not. Of 42,151 patients, 5-yr survival was similar between groups (61% and 55% in the epidural group and the nonepidural groups, respectively). Although there was a significant association between epidural use and improved survival (hazard ratio = 0.91), after adjustment for covariates there was no significant reduction of recurrence in this group (odds ratio = 1.05). This study does not support an association between perioperative epidural use and decreased cancer recurrence in patients with nonmetastatic colorectal cancer undergoing resection.