Leprosy
Mailing List – February 22nd, 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. 11th,
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.
