This author conducted a retrospective review of 211 shoulder arthroplasties in 202 patients. All patients received interscalene regional anesthesia. In 56 patients, this involved the use of a continuous ambulatory interscalene catheter; in the remainder, a singleshot nerve block was administered.
44 patients were identified as having sustained a nerve complication. Reverse shoulder arthroplasty was associated with the highest number of nerve complications. The median nerve (25 patients) and musculocutaneous nerve (8 patients) were most commonly involved.
Most nerve complications were transient and resolved within 6 months.
Comment: It is not clear how each patient was examined for a nerve injury or when the examination was carried out: "In all patients, a comprehensive analysis of all postoperative neurologic complications had been undertaken, including onset, duration, investigation, treatment, and resolution of neurologic symptoms. The diagnosis was established at the time by subjective complaints of the patient and careful clinical assessment of the upper extremity. " "In many of these cases, the patient was not aware of biceps weakness in the postoperative period and tended to complain only of altered sensation in the distribution of the lateral antebrachial cutaneous nerve. " Thus, it is possible that the rate of neurologic complications may be substantially higher than reported here.
This report highlights the difficulty in establishing the etiology of a nerve deficit after surgery: related to the interscalene block, to carpal tunnel syndrome, to compression of the ulnar were at the elbow, to cervical radiculopathy, or to retraction or positioning at the time of shoulder arthroplasty. This differential diagnosis may be quite difficult to sort out.
To minimize the risk of neurologic problems, we are careful in positioning of the neck, avoiding traction on the arm, limiting the number of minutes the coracoid muscles are retracted during glenoid exposure, and limiting the number of minutes during which the arm is held in extension and external rotation for humeral preparation. We also avoid any form of brachial plexus block.
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