Axillary blocks. Better to be sure than sorry!

Leprosy Mailing List – February 22^nd, 2010

Ref.: Axillary blocks. Better to be sure than sorry!

From: Grace Warren, Sydney , Australia

---

Dear Dr Noto,

I appreciate the letter from Dr Wim Theuvenet (LML Feb. 11^th, 2010) regarding axillary blocks and all he says is very true! Careful anaesthesia and duration of torniquet should not produce a neural deficit. But it is easy for accidents to happen. As we have heard in Angelika’s case reports. Thanks Wim.

The tourniquet pressure and time is very true and can in theory cause problems. Yes, I have seen such occasionally but I must state that in 50 years of doing arm surgery in third world countries for leprosy and other disabilities I have never had one of my patients develop a neural deficit from the tourniquet. Yes, I must confess some of the patients had the tourniquet on for longer that I really wanted. But I have seen residual deficits in leprosy and in non neuropathic conditions from anaesthesia into the nerve directly as via axillary or brachial or cervical block and even from spinal anaesthesia. Devastating - especially in third world countries - especially when preventable by use of anaesthesia that does not require injecting into the nerve. Hence I have avoided such blocks since the 1960s.

Never forget that a nerve may appear to be functioning normally when up to 10% of the fibres for any one modality can be already non functioning and in many patients there is no way of telling clinically which nerves are partially damaged and which are not. Electrical tests are useful but cannot tell the whole story! So, a normal EMG or electrical sensory tests may not show how much damage is present. I would prefer not to risk causing more damage in a nerve that may already been affected.

I rarely if ever use the major nerve blocks, certainly not in neuropathy patients. Better to be sure than sorry! We want to improve the patients function. Not increase his disability.

Thanks Wim for the details.

Grace Warren

MD., MS., FRCS, Rehabilitation surgery, especially in Leprosy.