Abstract ID: A14
Abstract Title: Persistant Horner's Syndrome Following Single Interscalene Nerve Block
Authors: Alshab A
Case Western Reserve University / University Hospitals of Cleveland Cleveland OH
Poster Type: Poster
ABSTRACT BODY
Introduction:
The interscalene approach to the brachial plexus block is a useful anesthetic technique for shoulder surgery. A single block provides intra-operative anesthesia and post-operative analgesia. Transient Horner's Syndrome is common immediately following placement of the block. This following is a case report of prolonged partial Horner's Syndrome lasting for one year following an interscalene block and the ensuing diagnostic and therapeutic patient care.
Case Report: A 57 year-old male with right shoulder instability and hyperlipidemia was scheduled for a right rotator cuff repair. The patient had been previously educated about a nerve block by the orthopedic surgeon and requested that block be performed as part of the anesthetic plan. He weighed 90.7 kg and was 165 cm tall. His neck anatomy was well defined.
After placement of a peripheral IV, consent for the block, and routine monitor placement, the block was performed. Premedication for the block consisted of 2 mg of midazolam and 100 mcg of fentanyl IV. After sterile betadine prep and drape, 1% lidocaine was injected to form a skin weal. An insulated 22 G insulated nerve finder needle was utilized to locate the brachial plexus. Two attempts at needle insertion were required to achieve appropriate motor twitch (0.32 ma). After negative aspiration, 45 mL of 0.5% marcaine with 1:200K epinephrine and 40 mg of depomedrol was slowly injected. No parasthesias occurred at any point during the entire procedure.
The patient had sensory and motor loss to the right arm after 3 minutes and developed a Horner's Syndrome preoperatively. The anesthetic plan was a general endotrachial anesthetic with isoflorane for maintenance. The block provided excellent intra-operative and post-operative analgesia as the patient tolerated the procedure with only 100 mcg of fentanyl. In the recovery room the Horner's Syndrome was present and the patient was informed that would normally take 24-48 hours to resolve.
The patient was noted to have a persistent Horner's Syndrome at the three month orthopedic follow up visit, with no sensory or motor deficits of the left shoulder or upper extremity. The patient was most concerned about the partial ptosis of the left eyelid.
A follow up neuro-opthamology appointment tested the level of the Horner's Syndrome with 1% hydroxymethamine. The patient was advised by neuro-opthamologists that the partial ptosis was present despite good levator tone and recommended the deferment for any additional intervention until at least six months after the block was placed.
On follow up appointments at six and twelve months the patient continued to have continued improvement of the partial ptosis of his left eyelid and has deferred surgery at this point.
Discussion:
Transient Horner's Syndrome is common immediately following placement of the block. Prolonged partial ptosis of the same side that an interscalene block has been performed has been reported in literature. Whether this is related to local anesthetic toxicity, nerve injury, epinephrine, or depomedrol injection is unknown. The management of this rare but reported complication of the interscalene block requires close follow-up by anesthesia personnel with appropriate expert consultants.
ATTACHED FILES
Reg Anesth Pain Med 2005; 30(3):A14