To the Editor:—
In the past few years, Dr. Alain Borgeat and his colleagues have acquired a justified reputation by publishing several pivotal studies on interscalene brachial plexus blockade (ISB). We read with great interest the article recently published by Borgeat et al. 1evaluating the incidence of acute and nonacute complications associated with interscalene brachial plexus block for shoulder surgery. In this study, 14% of patients with ISB showed neurologic complications “apparently not related to surgery” on the 10th day after the block. These symptoms were still present in 7.8% of the cases at the 1-month follow-up. This represents an unprecedented high rate of neurologic complications related by “default” to ISB (since no other factors were discussed by the authors). Fanelli et al. 2published a multicenter study (not cited by the authors) evaluating the incidence of neurologic complications following 4,000 peripheral nerve blocks performed with the multiple injection technique. In this study, the incidence of neurologic complications observed after ISB at the 1-month follow-up visit was 4%, and all symptoms completely resolved within 3 months after surgery.
There is no doubt that minor neurologic complications most likely remain undiagnosed if a proper follow-up is not planned and performed; nonetheless, the definition of neurologic complications “apparently not related to surgery” deserves more consideration. Mitterschiffthaler et al. 3reported two cases of brachial plexus injury caused by wrong positioning during surgery. Postoperative nerve injuries unrelated to regional anesthesia techniques have been reported following shoulder surgery even by our orthopedic colleagues. 4The lack of details concerning the patient's rehabilitation protocols also make it difficult to eliminate the role played by physical therapy. Thus, there are great differences in the duration of immobilization and the duration and intensity of the physical therapy protocols according to the type of surgery and for a given type of shoulder surgery among centers, and even more between the United States and Europe.
The unprecedented high number of electroneuromyographic examinations performed by the authors and the associated lack of any significant findings confirmed that these studies are mostly unrevealing in this situation. Furthermore, it is unlikely that the use of sensory criteria would be clinically acceptable to justify performing such examinations.
The authors should be congratulated for their efforts. However, the article by Borgeat et al. 1further stresses the need for performing a multicenter and multinational prospective study specifically looking at peripheral nerve blocks and postoperative neurologic complications, taking into consideration the consequences of positioning, surgery, and physical therapy.