|Year : 2016 | Volume
| Issue : 3 | Page : 186-188
One-year outcomes after regional Anesthesia
Shahla Siddiqui1, Sasidar Tangarasu2, Hosanna Lis2, Darren Choo3, Claudia Quek2, Jiexun Wang2
1 Department of Anaesthesia, Khoo Teck Puat Hospital; Department of Anaesthesia, National University of Singapore, Singapore
2 Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
3 Department of Anaesthesia, Yllsom, NUS, Singapore
|Date of Web Publication||10-Jan-2017|
Department of Anaesthesia, Khoo Teck Puat Hospital
Source of Support: None, Conflict of Interest: None
Introduction: Regional anaesthesia (RA) and its accompanying range of central and peripheral nerve blocks (PNB) have fast become a sophisticated and relatively safe mode of sole and adjunct anaesthetic technique in the past decade. Our aims were to retrospectively survey the one year neurological outcomes of regional anaesthesia in our center. We specifically wished to assess the incidence of residual pain as well as sensory and motor loss at one year after receiving regional anaesthesia. Methods: Our design is a telephone survey of all patients included in the study. Usual RA blocks done in our center include central neuraxial blocks as well as all upper limb, lower limb or abdominal wall blocks. Results: When looking at the neurological outcomes, 27% (22 patients) complained of residual pain at the site of the operation; 23% (19 patients) claimed they experienced numbness or paresthesias and 20% (17 patients) reported residual motor weakness. Only 2% of these patients received any further intervention and some stated they have reported their residual pain or sensory/ motor loss to their primary physicians or GPs. Majority of the symptoms was mild in nature (89%). Almost none returned to the chronic pain clinic for assessment. Conclusions: Our study shows a higher than expected incidence of neurological sequelae of this type of anaesthesia. This study highlights the need for careful assessment of RA outcomes and perhaps following these patients more closely at regular intervals during the year, a thorough interval neurological assessment with proper referrals and opening avenues for seeking help or giving feedback for the patients.
Keywords: Complications, outcomes, regional blocks
|How to cite this article:|
Siddiqui S, Tangarasu S, Lis H, Choo D, Quek C, Wang J. One-year outcomes after regional Anesthesia. Indian J Pain 2016;30:186-8
| Introduction|| |
Regional anesthesia (RA) and its accompanying range of central and peripheral nerve blocks (PNBs) have fast become a sophisticated and relatively safe mode of sole and adjunct anesthetic technique in the past decade. The advent of ultrasound guidance has made such interventions relatively safe and cost effective.  Intraoperative and short-term outcomes of such techniques are excellent with the added advantage of quick mobilization and discharge of the patient to home as a result of lack of postoperative complications of other modes of anesthesia and analgesia.  Widespread use of neuraxial and PNBs has advanced rapidly and displays a low morbidity and mortality. Many studies have placed rate of neurological complications after central nerve blockade at 0.04% and the rate of neuropathy after PNB at 3%.  However, permanent neurological injury after RA has been found to be rare in contemporary anesthetic practice. There is a lag in reports of long-term outcomes of RA in literature.  Such reporting is essential in understanding the risks in addition to the benefits of RA to make an informed choice of anesthetic technique. Such neurological complications can be very distressing to patients and their families and difficult to handle clinically. Most reports of long-term outcomes focus on central neuraxial blocks or short-term outcomes and are dated.  Recent reviews establish that permanent complications of peripheral regional anesthetic blocks are rare, but accurate estimates of their incidence are yet to be determined.  Therefore, knowledge of the long-term risks of neurological injury associated with the most common RA techniques is imperative.
Our aims were to retrospectively survey the 1-year neurological outcomes of RA in our center. We specifically wished to assess the incidence of residual pain as well as sensory and motor loss at 1 year after receiving RA.
| Methods|| |
We obtained IRB exemption for the study. From a database maintained at our institution of all patients receiving RA, a list was compiled of patients from 1 year ago in a single month (May 1--31, 2015). Types of block, age, gender, and surgery were recorded. Patients were contacted through telephone. During the interview, patients were asked whether they still experienced residual pain (none, mild, or significant) or any residual sensory or motor loss (none, mild, or significant). Responses were collected in an Excel sheet and subsequently analyzed on SPSS® . Frequencies and cross tabulations were done to study the descriptive results.
We are a 600 bedded regional hospital with surgery provided for all specialties except obstetrics and pediatrics. All adult patients coming to the operation theater for surgery requiring regional blocks as a primary or secondary anesthetic technique 1 year prior in the study period were included in the study. Our design is a telephone survey of all patients included in the study. Usual RA blocks done in our center include central neuraxial blocks as well as all upper limb, lower limb, or abdominal wall blocks.
| Results|| |
Of 93 patients who received RA in our hospital in the month of May 2015, 13 were uncontactable by phone. Our total number of patients who received RA, therefore, was 80. Of these, 68% were male, and the majority were of Chinese descent. Our median age was 56 years. Most common blocks performed upper limb (45%) followed by lower limb PNBs (43%) and abdominal wall blocks (8%) [Figure 1]. Forty-five percent received general anesthesia in combination with a PNB while others received a PNB alone.
When looking at the neurological outcomes, 27% (22 patients) complained of residual pain at the site of the operation; 23% (19 patients) claimed they experienced numbness or paresthesias, and 20% (17 patients) reported residual motor weakness [Figure 2]. Only 2% of these patients received any further intervention, and some stated they have reported their residual pain or sensory/motor loss to their primary physicians or general practitioners. Majority of the symptoms were mild in nature (89%). Almost none returned to the chronic pain clinic for assessment. Majority of the adverse symptoms were reported after upper limb blocks (54% of patients with residual pain, 47% of the patients with residual sensory loss, and 64% of the patients with residual motor loss).
Many patients were lost to follow-up. Of those reporting pain or neurological symptoms related to RA, some could be confusing the sources of these such as the initial injury, the surgery itself, or new confounding sources of neurological complaints such as neuropathies.  Recollection bias could also be present and considering our high rates of residual symptoms, yet a low rate of interventions sought brings up the validity of these complaints.
| Conclusion|| |
The rates of neurologically adverse outcomes of RA remain low in literature. However, these reviews have noted the marked lack of long-term neurological outcome results of RA. Our study shows a higher than expected incidence of neurological sequelae of this type of anesthesia. Of interest, in our departmental monthly RA audit, when 1-week post-RA outcomes are assessed the rate of residual pain, sensory or motor loss is reportedly <1%. It seems surprising that after 1 year, the incidence of such outcomes increased so dramatically; nevertheless, this study highlights the need for careful assessment of RA outcomes and perhaps following these patients more closely at regular intervals during the year, a thorough interval neurological assessment with proper referrals and opening avenues for seeking help or giving feedback for the patients.
Finally, our patients deserve the safest interventions and as with any invasive technique, there is a dire need for rigorous assessment and focus on functional outcomes before we can reasonably claim for a procedure to be absolutely "risk free." As many other institutions where such studies are conducted, our center is a teaching one and therefore further studies are needed to look at the long-term complication rates of novice versus experts performing such techniques. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anaesthesia and outcome: Lessons learned from the last 10 years. Br J Anaesth 2015;114:728-45.
Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al.
Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ 2000;321:1493.
Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: Contemporary estimates of risk. Anesth Analg 2007;104:965-74.
Phillips OC, Ebner H, Nelson AT, Black MH. Neurologic complications following spinal anesthesia with lidocaine: A prospective review of 10,440 cases. Anesthesiology 1969;30:284-9.
Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW. Injuries associated with regional anesthesia in the 1980s and 1990s: A closed claims analysis. Anesthesiology 2004;101:143-52.
Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: A meta-analysis of randomized trials. Br J Anaesth 2000;84:450-5.
Candido KD, Sukhani R, Doty R Jr., Nader A, Kendall MC, Yaghmour E, et al.
Neurologic sequelae after interscalene brachial plexus block for shoulder/upper arm surgery: The association of patient, anesthetic, and surgical factors to the incidence and clinical course. Anesth Analg 2005;100:1489-95.
Hargett MJ, Beckman JD, Liguori GA, Neal JM; Education Committee in the Department of Anesthesiology at Hospital for Special Surgery. Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med 2005;30:218-25.
[Figure 1], [Figure 2]