The Korean Journal of Pain

The Korean Pain Society (대한통증학회)
권호 표지
DOI QR코드

DOI QR Code

Does subepineural injection damage the nerve integrity? A technical report from four amputated limbs

  • Diwan, Sandeep (Department of Anesthesiology, Sancheti Hospital) ;
  • Nair, Abhijit (Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute) ;
  • Sancheti, Parag (Department of Orthopedics, Sancheti Hospital) ;
  • Van Zundert, Andre (Royal Brisbane and Women's Hospital and The University of Queensland and Queensland University of Technology)
  • Received : 2020.07.30
  • Accepted : 2020.09.16
  • Published : 2021.01.01
Download PDF
⟨ Previous Next ⟩

Abstract

Local anesthetic (LA) injection outside the sheath in epineural or paraneural connective tissue is considered safe practice among regional anesthesiologists. There is limited evidence as to whether neurological complications occur if LA is injected inside the sheath (subepineural - intraneural). We performed ultrasound guided injections at the level of undivided sciatic nerve in four amputated lower limbs. In two specimens, LA was injected in epineural connective tissue (paraneural tissue) and in another two specimens by penetrating the outer nerve sheath (hyperechoic epineurium). Ultrasonography demonstrated an increase in the size of nerve and macroscopic findings revealed fascicular tracings with sub-epineural injections. Limbs were sent for histological analysis in formalin containers. Pathologist performed the analysis which demonstrated an intact perineurium and a breach in the epineurium. We conclude that sub-epineural injections are unsafe and injection should be done in paraneural tissue to ensure safety and avoid unwanted neurological sequelae after the block.

Keywords

Acknowledgement

We acknowledge Dr. Asawari Manjarekar (MD), Pathologist from CareFirst Diagnostics Pvt Ltd Pune, Maharashtra State, India for histopathological analysis of the slides involved in this manuscript.

References

  1. Borgeat A. Regional anesthesia, intraneural injection, and nerve injury: beyond the epineurium. Anesthesiology 2006; 105: 647-8. https://doi.org/10.1097/00000542-200610000-00005
  2. Al-Nasser B. Intraneural injection of local anesthetics during ultrasound-guided peripheral nerve block may lead to nerve injury. Anesthesiology 2007; 106: 1245-6. https://doi.org/10.1097/01.anes.0000265460.54744.6f
  3. Bigeleisen PE. Nerve puncture and apparent intraneural injection during ultrasound-guided axillary block does not invariably result in neurologic injury. Anesthesiology 2006; 105: 779-83. https://doi.org/10.1097/00000542-200610000-00024
  4. Tran DQ, Dugani S, Pham K, Al-Shaafi A, Finlayson RJ. A randomized comparison between subepineural and conventional ultrasound-guided popliteal sciatic nerve block. Reg Anesth Pain Med 2011; 36: 548-52. https://doi.org/10.1097/AAP.0b013e318235f566
  5. Gentili F, Hudson AR, Hunter D, Kline DG. Nerve injection injury with local anesthetic agents: a light and electron microscopic, fluorescent microscopic, and horseradish peroxidase study. Neurosurgery 1980; 6: 263-72.
  6. Westerlund T, Vuorinen V, Kirvela O, Roytta M. The endoneurial response to neurolytic agents is highly dependent on the mode of application. Reg Anesth Pain Med 1999; 24: 294-302. https://doi.org/10.1097/00115550-199924040-00004
  7. Lupu CM, Kiehl TR, Chan VW, El-Beheiry H, Madden M, Brull R. Nerve expansion seen on ultrasound predicts histologic but not functional nerve injury after intraneural injection in pigs. Reg Anesth Pain Med 2010; 35: 132-9. https://doi.org/10.1097/AAP.0b013e3181d25cfe
  8. Brull R, Chan VW, McCartney CJ, Perlas A, Xu D. Ultrasound detects intraneural injection. Anesthesiology 2007; 106: 1244.
  9. Andersen HL, Andersen SL, Tranum-Jensen J. Injection inside the paraneural sheath of the sciatic nerve: direct comparison among ultrasound imaging, macroscopic anatomy, and histologic analysis. Reg Anesth Pain Med 2012; 37: 410-4. https://doi.org/10.1097/AAP.0b013e31825145f3
  10. Sermeus LA, Sala-Blanch X, McDonnell JG, Lobo CA, Nicholls BJ, van Geffen GJ, et al. Ultrasound-guided approach to nerves (direct vs. tangential) and the incidence of intraneural injection: a cadaveric study. Anaesthesia 2017; 72: 461-9. https://doi.org/10.1111/anae.13787
  11. Franco CD, Sala-Blanch X. Functional anatomy of the nerve and optimal placement of the needle for successful (and) safe nerve blocks. Curr Opin Anaesthesiol 2019; 32: 638-42. https://doi.org/10.1097/aco.0000000000000776