New trends in regional anesthesia for shoulder surgery: Avoiding devastating complications

Abstract

Surgeons and patients are often reluctant to support regional anesthesia (RA) for shoulder and other orthopedic surgeries. This is because of the sometimes true but usually incorrectly perceived "slowing down" of operating room turnover time and the perceived potential for added morbidity. Recently, severe devastating and permanent nerve injury complications have surfaced, and this article attempts to clarify the modern place of RA for shoulder surgery and the prevention of these complications. A philosophical approach to anesthesiology and regional anesthesiology is offered, while a fresh appreciation for the well-described and often forgotten microanatomy of the brachial plexus is revisited to explain and avoid some of the devastating complications of RA for shoulder surgery.

Keywords: Acute pain management; complications; continuous peripheral nerve block; permanent nerve damage; regional anesthesia; shoulder surgery; upper limb surgery.

Figure 1

Microanatomy of a peripheral nerve

Figure 2

Microanatomy at the brachial plexus trunk level

Figure 3

Microanatomy at the brachial plexus root level

Figure 4

Ultrasound picture at the brachial plexus root level. Note root appears hypo-echoic

Figure 5

Ultrasound appearance of the femoral nerve – a peripheral nerve. Note the nerve appears hyper-echoic