Download Dorsal scapular nerve injury: a complication of ultrasound

British Journal of Anaesthesia 111 (5): 840–9 (2013)
CORRESPONDENCE
Dorsal scapular nerve injury: a complication
of ultrasound-guided interscalene block
Editor—In-plane ultrasound guidance is often used for interscalene block. This approach shifts the traditional needle insertion point of the Winnie’s approach, that is, in the groove
between the anterior and the middle scalene muscles,1 to a
more distal (either medial or lateral and caudal) puncture
site.2 The increased risk of both vascular and phrenic nerve
lesions, carried by the medial to lateral approach,3 often
makes anaesthetists to choose a lateral to medial needle direction to reach the brachial plexus in the interscalene groove
through the middle scalene muscle. However, this approach
increases the theoretical risk of damage to other branches of
brachial plexus, namely the long thoracic and the dorsal scapular nerves (DSN), which run inside or in close proximity to the
middle scalene muscle.4
DSN originates from the fifth cervical nerve root, with a possible contribution of C6 and after its origin runs in close proximity of the upper trunk of the brachial plexus, before piercing the
middle scalene muscle and passing posteriorly, beneath the
levator scapula muscle. It is responsible for the motor innervation of the levator scapula muscle itself, which elevates the
scapula, and of both the rhomboid major and minor muscles,
which pull the scapula medially.5
DSN injuries can be the origin of a well-defined chronic pain
syndrome, often referred to as DSN syndrome. DSN syndrome is
often characterized by a dull ache along the medial border of
the scapula, eventually radiating to the lateral surface of
the arm and forearm. Patients usually complain of a not
well-defined shoulder pain and dysfunction, with different
degrees of functional impairment. Weakness and hypotrophy
of the rhomboid, the levator scapulae muscles, or both can
be present as well.
The long thoracic nerve (LTN) runs within or next to the
middle scalene muscle, often in close proximity of the DSN
and thus can be injured by the same mechanisms during
performance of an in-plane ultrasound-guided interscalene
block. A lesion of the LTN often results in a chronic pain syndrome of the shoulder, with associated different degree of
serratus anterior muscle palsy, determining impairment of
shoulder elevation and a characteristic scapular winging with
medial translation and rotation of the inferior angle towards
the midline.6
Both DSN syndrome and LTN syndrome symptoms are not
specific and the often poorly defined pain characteristics and
GE
Le
C5
AS
1
MS
C6
LTN
C7
2
Fig 1 Ultrasound image of DSN (arrow) located within the middle scalene muscle. AS, anterior scalene muscle; MS, middle scalene muscle; C5, C6,
C7, fifth, sixth, seventh cervical roots; LTN, long thoracic nerve.
& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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Correspondence
extension are the cause of frequent misdiagnoses, being confused with other shoulder chronic pain syndromes.
DSN lesions have been described in the context of trauma to
the brachial plexus or entrapment syndromes, in which they
are a relatively common cause of shoulder dysfunction.7 8
However, may be because of difficulty in diagnosing if not specifically searched for, DSN injuries have never been described as
a direct complication of an ultrasound-guided interscalene
block. In this context, a lesion, likely due either to direct
needle trauma or to intraneural injection, seems to be not
only possible, but also likely relatively frequent (even if not
reported), if DSN and LTN are not preliminary systematically
identified, in order to choose the safest needle trajectory.
Hanson and Auyong4 demonstrated that DSN and LTN can
be identified by ultrasound in the majority of patients (Fig. 1).
We encourage this practice in all patients undergoing an
ultrasound-guided interscalene block.
Declaration of interest
None declared.
A. Saporito
Bellinzona, Switzerland
E-mail: [email protected]
1 Winnie AP. Interscalene brachial plexus block. Anesth Analg 1970;
49: 455– 66
2 Mariano ER, Loland VJ, Ilfeld BM. Interscalene perineural catheter
placement using an ultrasound-guided posterior approach. Reg
Anesth Pain Med 2009; 34: 60–3
3 Kessler J, Schafhalter-Zoppoth I, Gray AT. An ultrasound study of the
phrenic nerve in the posterior cervical triangle: implications for the
interscalene brachial plexus block. Reg Anesth Pain Med 2008; 33:
545–50
4 Hanson NA, Auyong DB. Systematic ultrasound identification of the
dorsal scapular and long thoracic nerves during interscalene block.
Reg Anesth Pain Med 2013; 38: 54–7
5 Tubbs RS, Tyler-Kabara EC, Aikens AC, et al. Surgical anatomy of the
dorsal scapular nerve. J Nerurosurg 2005; 102: 910–1
6 Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res
1999; 368: 17 –27
7 Sultan HE, Younis El-Tantawi GA. Role of dorsal scapular nerve entrapment in unilateral interscapular pain. Arch Phys Med Rehabil
2013; 94: 1118–25
8 Jerosch J, Castro WH, Geske B. Damage of the long thoracic and
dorsal scapular nerve after traumatic shoulder dislocation: case
report and review of the literature. Acta Orthop Belg 1990; 56: 625– 7
only recently, navigation systems received a CE mark in
Europe. So far the interventional nurses and physicians, in the
field of vascular access in Europe, have been using the ECG
method, fluoroscopy, and/or anthropometric methods in order
to locate the position of the tip in the cavo-atrial junction. This
point is considered to have a certain advantage when it comes
to intravascular therapy.3
We present, for the first time ever in Europe, two instances
where a new navigation system was used for advancing a peripherally inserted central catheter (PICC) (VasoNova, Arrow
International, Reading, PA, USA).
The device uses real-time internal physiological parameters
that are unaffected by the patient’s cardio-pathophysiological
condition as it is designed to achieve optimal placement of the
catheter in the lower third of the superior vena cava and specifically at the cavo-atrial junction.
In both cases, the basilic vein was punctured under ultrasound guidance.
With further advancement of the catheter for about 20 cm, a
red signal came up as the catheter entered the internal jugular
vein which was neither compressed nor observed using the
ultrasound device for identification. After confirming that the
PICC had advanced in the internal jugular, the catheter was
pulled back and re-advanced. In total, the PICC was advanced
46 cm from the entrance point (48 cm had been estimated
using anthropometric methods). As the PICC reached the
optimum point, the maximal P showed up on the navigation
device and the bull’s eye appeared on the screen (Fig. 1).
The procedure in the second patient (an 84-yr-old woman
suffering from osteomyelitis who needed to receive i.v. antibiotics and fluid administration for more than 2 months) was performed by a trainee. The whole procedure lasted about 15 min
and the advancement of the catheter lasted 3.5 min.
At first glance, this navigation system appears to have the
feel of a computer game. There is no need for simultaneous
ultrasonography of the internal jugular vein. In the unlikely
doi:10.1093/bja/aet358
Navigation-assisted peripherally inserted
central catheter’s insertion performed by
university degree nurses: technical report
of two cases
Editor—Although central catheters inserted peripherally under
ultrasound guidance is a common procedure used worldwide,1 2
Fig 1 Bull’s eye appearance, indicating that the tip of the catheter
is at the cavo-atrial junction.
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