Any neurologic test to prove source of brachial plexus injury?

[Surfer]

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Will a nerve conduction study or EMG show with enough precision where the nerve injury is to rule out injury from interscalene nerve block? What do you guys do when a shoulder surgeon is blaming nerve injury on your block?

 

[nimbus]

Yes a nerve conduction study would help pinpoint the site of injury.

 

[deleted171991]

And then sue the surgeon's ass for defamation.

 

[urge]

MRI also.

The patient should see a neurologist who would order all the required test.

I doubt they would be able to say it was the surgery vs the block but they might.

If I had to say which is the most likely cause of injury I would say the block.

What is the patient complaining of?

What was the surgery? Rotator cuff? Does that put the patient at risk of any particular nerve injury?

 

[Mman]

EMG can differentiate if the nerve injury is at the level of the individual nerve or the cords or the divisions or trunks or roots or whatever.

 

[Mman]

I doubt they would be able to say it was the surgery vs the block but they might.

If I had to say which is the most likely cause of injury I would say the block.

shoulder surgery itself has a higher incidence of permanent nerve injury than a brachial plexus block

 

[pjl]

shoulder surgery itself has a higher incidence of permanent nerve injury than a brachial plexus block

~4 percent for at least transient nerve injury last I read.

 

[urge]

shoulder surgery itself has a higher incidence of permanent nerve injury than a brachial plexus block

What nerve injury specifically? Suprascapular? Does that even count?

 

[deleted126335]

And then sue the surgeon's ass for defamation.

Damages?

 

[DM27]

From my understanding you can somewhat localize the lesion via EMG/NCV studies with some adjunct role from imaging, however, the etiology of the injury can't really be declared from any of these tests unless the block is fairly remote from the surgical site.

A fictitious example would be someone who had a femoral block for a knee procedure and the testing was able to move proximal enough to delineate a lesion that is distant from the surgical site. However, I am not sure of the level of granularity of these tests and if this can be routinely done with this much precision.

 

[deleted171991]

Damages?

To professional reputation. It's a classical case of defamation. One can't just go around badmouthing somebody's competence without proof.

 

[Mman]

From my understanding you can somewhat localize the lesion via EMG/NCV studies with some adjunct role from imaging, however, the etiology of the injury can't really be declared from any of these tests unless the block is fairly remote from the surgical site.

A fictitious example would be someone who had a femoral block for a knee procedure and the testing was able to move proximal enough to delineate a lesion that is distant from the surgical site. However, I am not sure of the level of granularity of these tests and if this can be routinely done with this much precision.

Injury from a shoulder surgery would basically be at the individual nerve level as opposed to a nerve block which would cause issues at the roots or divisions (assuming it was an interscalene block).

 

[Timeoutofmind]

EMG/NCV is basically a sophisticated physical exam, and quite subjective. You can often tell which neurologist did it just from reading the report once you are familiar with your local guys.

Nevertheless, it would be useful here. Would want a baseline one ASAP (within 6 weeks of injury) and then one at >6 weeks out, as these injuries typically take that amount of time to show up. This would be helpful to rule out any pre-existing injury or issues.

But really you just need to get them in with a good neurologist ASAP who is comfortable with peripheral nerve injuries. A good physical exam is probably the most important thing (r/o cervical radicular pain etc). Maybe ask around, considering this may well end up in litigation and you want someone thoughtful to give a good assessment.

 

[Tman507]

Get a neurologist to perform a Neve conduction study and doppler ultrasound for completeness(the neurologist will probably do the pns and/cns examination appropriately-they're cool like that and love localization which is good for you too). If you want, you could get a radiologist (preferably an MSK radiologist bcos orthopods respect those guys) to give a report on a detailed ultrasound/mri as well.

 

[Monterosso]

ASRA has a recommended flowchart for management for nerve injury (middle of their guidelines article): The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary 2015. - PubMed - NCBI

Of note, often it is not the block causing the injury but other more common factors (i.e. the surgery itself, positioning, etc)

 

[PieOHmy]

To professional reputation. It's a classical case of defamation. One can't just go around badmouthing somebody's competence without proof.

Why not?

 

[PieOHmy]

This is why they have to twist my arm to do a block... I ask the surgeon do you really want a block? in a tone that reveals a major pain in the ass on my part.

 

[Planktonmd]

To professional reputation. It's a classical case of defamation. One can't just go around badmouthing somebody's competence without proof.

Physicians do exactly that to other physicians everyday, everywhere!
It's likely caused by the narcissistic personality disorder many physicians acquire during medical school and residency that makes them gradually believe that they are better than other physicians. It's likely caused by incomplete maturity.