Koogler Andrew T, Kushelev Michael
Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W. 10th Ave., Columbus, OH 43210, USA.
Case Rep Anesthesiol. 2018 Jan 3;2018:9873621. doi: 10.1155/2018/9873621. eCollection 2018.
A 76-year-old male presented for reverse total shoulder arthroplasty (TSA) in the beach chair position. A preoperative interscalene nerve catheter was placed under direct ultrasound-guidance utilizing a posterior in-plane approach. On POD 2, the catheter was removed. Three weeks postoperatively, the patient reported worsening dyspnea with a subsequent chest X-ray demonstrating an elevated right hemidiaphragm. Pulmonary function testing revealed worsening deficit from presurgical values consistent with phrenic nerve palsy. The patient decided to continue conservative management and declined further invasive testing or treatment. He was followed for one year postoperatively with moderate improvement of his exertional dyspnea over that period of time. The close proximity of the phrenic nerve to the brachial plexus in combination with its frequent anatomical variation can lead to unintentional mechanical trauma, intraneural injection, or chemical injury during performance of ISB. The only previously identified risk factor for PPNP is cervical degenerative disc disease. Although PPNP has been reported following TSA in the beach chair position without the presence of a nerve block, it is typically presumed as a complication of the interscalene block. Previously published case reports and case series of PPNP complicating ISBs all describe nerve blocks performed with either paresthesia technique or localization with nerve stimulation. We report a case of a patient experiencing PPNP following an ultrasound-guided placement of an interscalene nerve catheter.
一名76岁男性在沙滩椅位接受反式全肩关节置换术（TSA）。术前在直接超声引导下采用后侧平面内入路放置了肌间沟神经导管。术后第2天，导管被拔除。术后3周，患者报告呼吸困难加重，随后胸部X线显示右半膈肌抬高。肺功能测试显示与术前相比功能缺损恶化，符合膈神经麻痹。患者决定继续保守治疗，拒绝进一步的侵入性检查或治疗。术后对其进行了一年的随访，在此期间其运动性呼吸困难有中度改善。膈神经与臂丛神经位置接近，且其解剖结构常有变异，这可能导致在实施肌间沟阻滞（ISB）时意外造成机械性创伤、神经内注射或化学损伤。此前唯一确定的膈神经麻痹后麻痹（PPNP）风险因素是颈椎退行性椎间盘疾病。虽然在沙滩椅位进行TSA后且未进行神经阻滞时也有PPNP的报道，但通常认为这是肌间沟阻滞的并发症。此前发表的关于PPNP使ISB复杂化的病例报告和病例系列均描述了采用异感技术或神经刺激定位进行的神经阻滞。我们报告一例患者在超声引导下放置肌间沟神经导管后发生PPNP的病例。
