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MIDDLE CHILD SYNDROME: THE NERVE(S) THAT IS COMMONLY OVERLOOKED DURING PLACEMENT OF AN INTERSCALENE NERVE BLOCK
Author(s): ,
Warren, L.*
Affiliations:
Massachusetts General Hospital, Department of Anesthesiology- Critical Care and Pain Medicine, Boston, USA
,
Kamdar, B.
Affiliations:
Massachusetts General Hospital, Department of Anesthesiology- Critical Care and Pain Medicine, Boston, USA
Stefanovich, P.
Affiliations:
Massachusetts General Hospital, Department of Anesthesiology- Critical Care and Pain Medicine, Boston, USA
ESRA Academy. Hasan A. Sep 13, 2017; 190917; 312 Topic: Upper Limb Blocks - Brachial Plexus Block
Dr. Aysha Hasan
Dr. Aysha Hasan

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Abstract
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Background and Aims:

The rising incidence of rotator cuff repair surgery has increased the utilization of interscalene nerve blocks (ISB) for perioperative pain management. Despite early publications indicating the potential for transecting the dorsal scapular nerve (DSN) and long thoracic nerve (LTN) during placement of the ISB, a significant lack of awareness exists amongst regional anesthesia clinicians.  In this paper, we aim to identify and confirm the location of the DSN and LTN. 

Methods:

Five patients were consented for placement of an ISB for shoulder surgeries.
After positioning the patient 30 degrees supine, ultrasound imaging (GE Logiq E, L38 probe, Wauwatosa, WI, USA) was used to identify the interscalene brachial plexus. A 22 g, 8 cm stimulating needle (Pajunk Stimuplex, Geisingen, Germany) was advanced in plane, from a lateral to medial direction through the middle scalene muscle toward the plexus.  Electrical nerve stimulation (Stimuplex RC, B Braun, Melsungen, Germany) was applied with up to 1 mA voltage to elicit twitch responses of the DSN and LTN. 

Results:

Conclusions:

The case series demonstrates that it is common for the needle trajectory to pierce through the DSN (Figures 1, 2). Less commonly, injury to the LTN can occur during placement of this nerve block. (Figure 3).
Discussion: 
Patients with underlying DSN syndrome should be considered relative contraindications to placing an ISB because this may worsen their underlying syndrome. We recommend obtaining a specific history and physical regarding pre-existing pain prior to placement of an ISB.

Figure 1: 


Figure 3: 

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