Korean J Pain.  2014 Jul;27(3):210-218. 10.3344/kjp.2014.27.3.210.

Brachial Plexus Injury as a Complication after Nerve Block or Vessel Puncture

• Kim HJ
• Park SH
• Shin HY
• Choi YS

• KMID: 2278224
• DOI: http://doi.org/10.3344/kjp.2014.27.3.210

Abstract

Brachial plexus injury is a potential complication of a brachial plexus block or vessel puncture. It results from direct needle trauma, neurotoxicity of injection agents and hematoma formation. The neurological presentation may range from minor transient pain to severe sensory disturbance or motor loss with poor recovery. The management includes conservative treatment and surgical exploration. Especially if a hematoma forms, it should be removed promptly. Comprehensive knowledge of anatomy and adept skills are crucial to avoid nerve injuries. Whenever possible, the patient should not be heavily sedated and should be encouraged to immediately inform the doctor of any experience of numbness/paresthesia during the nerve block or vessel puncture.

Keyword

brachial plexus; brachial plexus neuropathies; nerve block; subclavian vein

MeSH Terms

Brachial Plexus Neuropathies
Brachial Plexus*
Hematoma
Humans
Needles
Nerve Block*
Punctures*
Subclavian Vein

Figure

• 

  Fig. 1 Flowchart for the treatment of brachial plexus injury caused by a nerve block or vessel puncture.

Reference

1. Iwata T, Mitoro M, Kuzumoto N. Feasibility of early and repeated low-dose interscalene brachial plexus block for residual pain in acute cervical radiculopathy treated with NSAIDS. Korean J Pain. 2014; 27:125–132. PMID: 24748940.

2. Johnson PS, Greifenstein FE. Brachial plexus block anesthesia. J Mich State Med Soc. 1955; 54:1329–1331. PMID: 13271992.

3. Woolley EJ, Vandam LD. Neurological sequelae of brachial plexus nerve block. Ann Surg. 1959; 149:53–60. PMID: 13617908.

4. Karakaya D, Baris S, Güldogus F, Incesu L, Sarihasan B, Tür A. Brachial plexus injury during subclavian vein catheterization for hemodialysis. J Clin Anesth. 2000; 12:220–223. PMID: 10869922.

5. Trentman TL, Rome JD, Messick JM Jr. Brachial plexus neuropathy following attempt at subclavian vein catheterization. Case report. Reg Anesth. 1996; 21:163–165. PMID: 8829409.

6. Urban MK, Urquhart B. Evaluation of brachial plexus anesthesia for upper extremity surgery. Reg Anesth. 1994; 19:175–182. PMID: 7999652.

7. Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Study Group on Regional Anesthesia. Anesth Analg. 1999; 88:847–852. PMID: 10195536.

8. Porzionato A, Montisci M, Manani G. Brachial plexus injury following subclavian vein catheterization: a case report. J Clin Anesth. 2003; 15:582–586. PMID: 14724079.

9. Jernigan WR, Gardner WC, Mahr MM, Milburn JL. Use of the internal jugular vein for placement of central venous catheter. Surg Gynecol Obstet. 1970; 130:520–524. PMID: 5413435.

10. Chitwood RW, Shepard AD, Shetty PC, Burke MW, Reddy DJ, Nypaver TJ, et al. Surgical complications of transaxillary arteriography: a case-control study. J Vasc Surg. 1996; 23:844–849. PMID: 8667506.

11. Tsao BE, Wilbourn AJ. Infraclavicular brachial plexus injury following axillary regional block. Muscle Nerve. 2004; 30:44–48. PMID: 15221877.

12. Madison SJ, Ilfeld BM. Peripheral nerve blocks. In : Butterworth JF, Mackey DC, Wasnick JD, editors. Morgan & Mikhail's clinical anesthesiology. 5th ed. New York (NY): McGraw-Hill;2013. p. 981–983.

13. Jenkins GW, Kemnitz CP, Tortora GJ. Anatomy and physiology from science to life. Hoboken (NJ): John Wiley & Sons, Inc;2007.

14. Mian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M. Brachial plexus anesthesia: a review of the relevant anatomy, complications, and anatomical variations. Clin Anat. 2014; 27:210–221. PMID: 23959836.

15. Selander D, Edshage S, Wolff T. Paresthesiae or no paresthesiae? Nerve lesions after axillary blocks. Acta Anaesthesiol Scand. 1979; 23:27–33. PMID: 425811.

16. Kapral S, Greher M, Huber G, Willschke H, Kettner S, Kdolsky R, et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Reg Anesth Pain Med. 2008; 33:253–258. PMID: 18433677.

17. Orebaugh SL, Williams BA, Vallejo M, Kentor ML. Adverse outcomes associated with stimulator-based peripheral nerve blocks with versus without ultrasound visualization. Reg Anesth Pain Med. 2009; 34:251–255. PMID: 19587625.

18. Ben-David B, Barak M, Katz Y, Stahl S. A retrospective study of the incidence of neurological injury after axillary brachial plexus block. Pain Pract. 2006; 6:119–123. PMID: 17309720.

19. Bernard RW, Stahl WM. Subclavian vein catheterizations: a prospective study. I. Non-infectious complications. Ann Surg. 1971; 173:184–190. PMID: 5100094.

20. Ryan JA Jr, Abel RM, Abbott WM, Hopkins CC, Chesney TM, Colley R, et al. Catheter complications in total parenteral nutrition. A prospective study of 200 consecutive patients. N Engl J Med. 1974; 290:757–761. PMID: 4205578.

21. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986; 146:259–261. PMID: 3947185.

22. Fuller GN, Dick JP, Colquhoun IR. Brachial plexus compression by hematoma following jugular puncture. Neurology. 1994; 44:775–776. PMID: 8164848.

23. Paschall RM, Mandel S. Brachial plexus injury from percutaneous cannulation of the internal jugular vein. Ann Emerg Med. 1983; 12:58–60. PMID: 6849530.

24. Jackson L, Keats AS. Mechanism of brachial plexus palsy following anesthesia. Anesthesiology. 1965; 26:190–194. PMID: 14261054.

25. García-Fages LC, Castillo J, Gomar C, Villalonga A, Nalda MA. Transient block of the brachial plexus after catheterization of the subclavian vein. Ann Fr Anesth Reanim. 1990; 9:93–94. PMID: 2331089.

26. Govenko FS, Rogulov VA. Injury of the brachial plexus after catheterization of the subclavian vein in a 6-month-old child. Vestn Khir Im I I Grek. 1983; 130:121–122.

27. Defalque RJ. Percutaneous catheterization of the internal jugular vein. Anesth Analg. 1974; 53:116–121. PMID: 4589503.

28. Daily PO, Griepp RB, Shumway NE. Percutaneous internal jugular vein cannulation. Arch Surg. 1970; 101:534–536. PMID: 5457256.

29. Matz R. Complications of determining the central venous pressure. N Engl J Med. 1965; 273:703. PMID: 5827035.

30. 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; 111:214–220. PMID: 20442258.

31. Gentili F, Hudson AR, Hunter D. Clinical and experimental aspects of injection injuries of peripheral nerves. Can J Neurol Sci. 1980; 7:143–151. PMID: 7407720.

32. Nowill WK, Hall H, Stephen CR. Neurological complications following the use of efocaine. AMA Arch Surg. 1953; 67:738–740. PMID: 13103940.

33. Yamashita A, Matsumoto M, Matsumoto S, Itoh M, Kawai K, Sakabe T. A comparison of the neurotoxic effects on the spinal cord of tetracaine, lidocaine, bupivacaine, and ropivacaine administered intrathecally in rabbits. Anesth Analg. 2003; 97:512–519. PMID: 12873946.

34. Radwan IA, Saito S, Goto F. The neurotoxicity of local anesthetics on growing neurons: a comparative study of lidocaine, bupivacaine, mepivacaine, and ropivacaine. Anesth Analg. 2002; 94:319–324. PMID: 11812691.

35. Selander D. Neurotoxicity of local anesthetics: animal data. Reg Anesth. 1993; 18:461–468. PMID: 8110648.

36. Neal JM. Effects of epinephrine in local anesthetics on the central and peripheral nervous systems: neurotoxicity and neural blood flow. Reg Anesth Pain Med. 2003; 28:124–134. PMID: 12677623.

37. O'Keefe DM. Brachial plexus injury following axillary arteriography. Case report and review of the literature. J Neurosurg. 1980; 53:853–857. PMID: 7441349.

38. Reiss W, Kurapati S, Shariat A, Hadzic A. Nerve injury complicating ultrasound/electrostimulation-guided supraclavicular brachial plexus block. Reg Anesth Pain Med. 2010; 35:400–401. PMID: 20607905.

39. Spinner RJ, Kline DG. Surgery for peripheral nerve and brachial plexus injuries or other nerve lesions. Muscle Nerve. 2000; 23:680–695. PMID: 10797390.

40. Gentili F, Hudson AR, Kline D, Hunter D. Early changes following injection injury of peripheral nerves. Can J Surg. 1980; 23:177–182. PMID: 7363181.

41. Yoshikawa T, Hayashi N, Yamamoto S, Tajiri Y, Yoshioka N, Masumoto T, et al. Brachial plexus injury: clinical manifestations, conventional imaging findings, and the latest imaging techniques. Radiographics. 2006; 26(Suppl 1):S133–S143. PMID: 17050511.

42. Shafighi M, Gurunluoglu R, Ninkovic M, Mallouhi A, Bodner G. Ultrasonography for depiction of brachial plexus injury. J Ultrasound Med. 2003; 22:631–634. PMID: 12795559.

43. Gray P. Acute neuropathic pain: diagnosis and treatment. Curr Opin Anaesthesiol. 2008; 21:590–595. PMID: 18784484.

44. Dhir S, Tureanu L, Stewart SA. Axillary brachial plexus block complicated by cervical disc protrusion and radial nerve injury. Acta Anaesthesiol Scand. 2009; 53:411. PMID: 19243339.

45. Kim DH, Murovic JA, Kline DG. Brachial plexus injury: mechanisms, surgical treatment and outcomes. J Korean Neurosurg Soc. 2004; 36:177–185.

46. Po BT, Hansen HR. Iatrogenic brachial plexus injury: a survey of the literature and of pertinent cases. Anesth Analg. 1969; 48:915–922. PMID: 5391386.

47. Hems T. Nerve transfers for traumatic brachial plexus injury: advantages and problems. J Hand Microsurg. 2011; 3:6–10. PMID: 22654410.

48. Wilkinson MC, Birch R, Bonney G. Brachial plexus injury: when to amputate? Injury. 1993; 24:603–605. PMID: 8288380.

49. Pearce H, Lindsay D, Leslie K. Axillary brachial plexus block in two hundred consecutive patients. Anaesth Intensive Care. 1996; 24:453–458. PMID: 8862642.

50. Gelfand HJ, Ouanes JP, Lesley MR, Ko PS, Murphy JD, Sumida SM, et al. Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis. J Clin Anesth. 2011; 23:90–96. PMID: 21377070.

51. Klaastad O, Sauter AR, Dodgson MS. Brachial plexus block with or without ultrasound guidance. Curr Opin Anaesthesiol. 2009; 22:655–660. PMID: 19550303.

52. Hirasawa Y, Katsumi Y, Küsswetter W, Sprotte G. Experimental studies on peripheral nerve injuries caused by injection needles. Reg Anaesth. 1990; 13:11–15. PMID: 2305114.

53. Dooley J, Fingerman M, Melton S, Klein SM. Contralateral local anesthetic spread from an outpatient interscalene catheter. Can J Anaesth. 2010; 57:936–939. PMID: 20652841.

54. Moberg E, Dhuner KG. Brachial plexus block analgesia with xylocaine. J Bone Joint Surg Am. 1951; 33-A:884–888. PMID: 14880542.

55. Liu SS, YaDeau JT, Shaw PM, Wilfred S, Shetty T, Gordon M. Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anaesthesia. 2011; 66:168–174. PMID: 21320084.

56. Stan TC, Krantz MA, Solomon DL, Poulos JG, Chaouki K. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach. A prospective study of 1,000 consecutive patients. Reg Anesth. 1995; 20:486–492. PMID: 8608066.