Spinal Complication?

[Noyac]

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Locums does a spinal and FNB for a TKA. The following day the pt has a complete foot drop. Surgeon tells pt it is most likely residual spinal effects.😱 2 months later foot drop still there.

Can spinal or FNB cause a foot drop?
How do you pursue this?

 

[Bertelman]

Locums does a spinal and FNB for a TKA. The following day the pt has a complete foot drop. Surgeon tells pt it is most likely residual spinal effects.😱 2 months later foot drop still there.

Can spinal or FNB cause a foot drop?
How do you pursue this?

TKA can cause foot drop, fo sheezy.

"Foot drop has an estimated prevalence of 0.3-4% after total knee arthroplasty" courtesy of eMedicine.

That sounds like a much higher incidence than spinal, FNB or both.

This article suggests epidural anesthesia (or FNB) could have contributed to unfavorable limb positioning which may have allowed further nerve damage.

Cohen DE, Van Duker B, Siegel S. Common peroneal nerve palsy associated with epidural analgesia. Anesth Analg. Feb 1993;76(2):429-31

 

[dfk]

i'm thinking more of nerve compression (specifically peroneal) or perhaps extended plantar flexion and tibial n. injury. all r/t surgery/surgeon or lack of vigilance on positioning. IMO anyway.

 

[Tenesma]

get EMG to figure out if this is a peroneal neuropathy - you don't get foot drop w/ Femoral block and you don't get persistent foot drop without any other symptoms from a spinal..

 

[dhb]

Locums does a spinal and FNB for a TKA. The following day the pt has a complete foot drop. Surgeon tells pt it is most likely residual spinal effects.😱 2 months later foot drop still there.

Can spinal or FNB cause a foot drop?
How do you pursue this?

A spinal giving just a unilateral foot drop 😕 no
FNB giving a foot drop i think not

EMG will tell you that the damage was done at the popliteal level

 

[huktonfonix]

Wow, that surgeon should know better. ortho guys know very well that peroneal nerve damage is a known complication of surgery, especially in those patients with excessive valgus angulation since straightening out the knee into a neutral position causes stretch to the peroneal nerve. Since this a#$hole surgeon already decided to blame you, then I would spend some time with the patient explaining the nature of the potential injury along with the pattern that would have resulted from any spinal/FNB injury. Then a consult to a neurologist would be in order with EMG/NCV studies and see if its a nerve root distribution or a peripheral (peroneal) distribution. Then I would have a talk with the surgeon.

Sure, I guess a spinal can cause foot drop if by some very strange incident you happened to either directly hit multiple nerve roots with your needle or concentrate all your local along one side on those nerve roots with a spinal microcatheter, but cmon.

 

[militarymd]

this is one time where I can't blame the complication on the locum...the ortho dude screwed up....

the emg will prove it.

 

[Planktonmd]

Can spinal or FNB cause a foot drop?
How do you pursue this?

No for FNB.
And Unlikely for the spinal.
Get nerve studies.

 

[Noyac]

Very good everyone is on the right tract. We all know that a foot drop (peroneal n injury) can't be the result of a FNB since the peroneal n comes from the sciatic.

And I'm not blaming the locums for this at all, he's pretty good (for a locums). It's just my job to follow up on this pt as I am the director and the locums guy is, well a locums.

So I got an EMG and sent the pt to our local neurologist. It's been about a month so when I get to work tomorrow I will post the results of the EMG since I don't remember the details verbatum.

As far as the surgeon, well he's an idiot. He take s forever to do a TKA (4-5 hrs) and has 2 tourniquet times of 90 and 60 minutes. My partners and I don't do regional on his cases b/4 surgery at all. Maybe post-op after we can evaluate neural fxn. It really sucks for his pts.

 

[Bertelman]

As far as the surgeon, well he's an idiot. He take s forever to do a TKA (4-5 hrs) and has 2 tourniquet times of 90 and 60 minutes. My partners and I don't do regional on his cases b/4 surgery at all. Maybe post-op after we can evaluate neural fxn. It really sucks for his pts.

Maybe that's why he chose to blame anesthesia for this one. Saw something new (spinal and FNB), and thought it was the unique case occurrence that led to his [surgical] complication.

 

[Noyac]

Maybe that's why he chose to blame anesthesia for this one. Saw something new (spinal and FNB), and thought it was the unique case occurrence that led to his [surgical] complication.

No, all his partners pts get FNB, +/- ScNB, and spinal. No GA. He knows we treat his pts differently and why. He is very aware of his inabilities.😉

 

[mille125]

This is likely a complication of surgery and the EMG will prove it. There is a good chance that it will resolve spontaneously in a six month period. I have seen five cases like this (from different surgeons). It is a known complication of TKA. A more appropriate action would have been to reassure the patient instead of blaming anesthesiology. Possible but less likely cause is positioning injury. This was not caused by the FNB or spinal.

 

[periopdoc]

No, all his partners pts get FNB, +/- ScNB, and spinal. No GA. He knows we treat his pts differently and why. He is very aware of his inabilities.😉

What approach do you favor for the sciatic block when doing a combined FNB, SCI, SAB? I have been doing primarily FNB and SAB for my knees, but I am thinking about trying to add in a subgluteal approached sciatic block with the patient in the same lateral decubitus position that I use to place the SAB. That way I could do a quick FNB supine, up into decubitus, sciatic block, SAB, to OR.

-pod

 

[huktonfonix]

thats the way we do it. Or you could do femoral/anterior sciatic approach, lateral for spinal. whichever approach youre more familiar with for the sciatic. I personally do a posterior approach because I think if you come in lower than the classical approach (below the gluteus) than you go through less muscle and its less painful.

 

[Noyac]

What approach do you favor for the sciatic block when doing a combined FNB, SCI, SAB? I have been doing primarily FNB and SAB for my knees, but I am thinking about trying to add in a subgluteal approached sciatic block with the patient in the same lateral decubitus position that I use to place the SAB. That way I could do a quick FNB supine, up into decubitus, sciatic block, SAB, to OR.

-pod

I do the anterior approach to the sciatic nerve. My routine is, in the block room I prep the groin for both FNB and ant. Sc block. I place the FNB with the short 2" B bevel NS needle and then change to the longer (i think its a 5") needle. A line connecting the anterior-superior iliac spine (ASIS) and the medial pubic tubercle represents the inguinal ligament. This line is divided into thirds. Another line parallel to the inguinal ligament and passing through the greater trochanter is identified. A third line is drawn perpendicular to these two lines and passing through where the medial third of the inguinal ligament meets the middle third. The intersection of this third line with the transtrochanteric line (second line drawn) is the needle insertion point. More than likely, the femur will be contacted with the needle. The needle is then "walked off" the femur's medial edge. Once off the bone, another 3-5 centimeters is usually required for maximal stimulation. Twitches of the hamstring should not be accepted. The endpoint is twitches in the foot. Once I start the FNB i am finished with both in 5-10 minutes. This avoids the repositioning of the pt which takes longer than the block itself.

 

[lobelsteve]

Surgery vs positioning.

Bashar Katirji has an excellent case study on this in his text.
The EMG/NCV will determine the extent of injury as well as the prognosis.
The patient needs to be referred to PM&R for appropriate rehab and ankle foot orthosis to best augment recovery chances.

http://www.amazon.com/Electromyography-Clinical-Practice-Study-Approach/dp/0815149719