May 9, 2008
Ultrasound-Guided Brachial Plexus Block in a Patient With Multiple Glomangiomatosis
By Duggan, Edel Brull, Richard; Lai, Jacob; Abbas, Sherif
Background and Objectives: Glomangiomas are rare, vascular tumors consisting of an afferent artery, arteriovenous canal, neuro- reticular elements, collagen, and efferent veins, and are most often located in the soft tissue of the upper extremities. We describe how the use of ultrasound-guided nerve blockade altered the anesthetic management of a patient with multiple glomangiomatosis undergoing elective forearm surgery. Ultrasound Findings: A 32-year-old man was scheduled for excision of painful glomangiomas from the ulnar aspect of his right wrist, with exploration of his ulnar nerve. The anesthetic concerns included (1) morbid obesity, (2) chronic pain syndrome and opioid intolerance, (3) a potentially difficult airway, and (4) obstructive sleep apnea. Ultrasound-guided supraclavicular blockade was the proposed anesthetic of choice. Ultrasound scan of the supraclavicular fossa revealed numerous vascular lesions surrounding the divisions of the brachial plexus. Color Doppler imaging confirmed these pulsatile lesions to be vascular in origin. Even under two-dimensional ultrasound guidance, we believed that the risk of vascular puncture and unintentional intravascular injection of local anesthetic was high, and therefore we abandoned the supraclavicular approach. A successful ultrasound-guided axillary brachial plexus blockade was performed uneventfully.Conclusions: Although multiple glomangiomatosis is a rare disease, this case illustrates the invaluable contribution that ultrasound has made to modern, regional anesthetic practice, especially for patients with aberrant anatomy in whom traditional nerve-localization techniques could result in serious complications. Reg Anesth Pain Med 2008;33:70-73.
Key Words: Brachial plexus, Glomangioma, Regional anesthesia, Ultrasound.
Ultrasound (US) for nerve localization has gained popularity worldwide, because US guidance affords real-time visualization of the needle, target nerve, and surrounding structures. Ultrasound guidance can improve blockade success and reduce the potential likelihood of vascular puncture, and may avoid traumatic nerve injury.1-4 Traditional "blind" nerve-localization techniques, based on surface anatomical landmarks and surrogate endpoints such as peripheral nerve stimulation or the mechanical elicitation of paresthesias, can be hazardous in patients with aberrant anatomy or unsuspected pathology. We report on a patient with multiple glomangiomatosis in whom peripheral nerve blockade would have been precarious in the pre-US era. This report underscores the pitfalls of performing "blind" regional anesthetic techniques in patients with altered anatomy or vascular anomalies that can be visualized with US technology.
A 32-year-old man was scheduled for the excision of a painful glomangioma from the ulnar aspect of his right wrist, with exploration of his ulnar nerve. He had been diagnosed with multiple glomangiomatosis as a child, and had similar resections of these painful lesions in the past. Although his previous operations under general anesthesia had been uneventful, he now presented with numerous anesthetic concerns. The patient's daily opioid requirement exceeded 700 mg of morphine sulfate for the treatment of chronic pain associated with his vascular neoplastic disease. He was obese (body mass index = 41 kg/m^sup 2^), having gained considerable weight in the previous year. Based on clinical symptoms, he was recently diagnosed with obstructive sleep apnea. A preoperative physical examination of the patient revealed multiple, tender lesions on his right forearm. Of note, he had no symptoms in his shoulder area and no palpable lesions proximal to his right elbow. In addition, no bruits were present on auscultation of his neck. He was found to have sensory loss in the distribution of his right ulnar nerve, with associated muscle weakness. An airway assessment revealed a short neck with limited mouth opening, and a modified Mallampati score of III. A magnetic resonance image of the right wrist revealed vascular lesions infiltrating the flexor carpi ulnaris and extensor digiti minimi muscles. Magnetic resonance imaging of his shoulder was not performed.
Fig 1. Transverse sonogram of right supraclavicular region. Arrowheads indicate first rib. A, subclavian artery; N, divisions of the brachial plexus; X, abnormal hypoechoic structures. B: Color Doppler imaging to demonstrate position of the subclavian artery. C: Color Doppler imaging confirms that hypoechoic pulsatile structures lateral to the subclavian artery are vascular lesions with turbulent flow.
Ultrasound-guided supraclavicular blockade was proposed as the most appropriate anesthetic option for this patient. An L12 5-MHz linear transducer US probe (ATL HDI 5000 unit, Philips Medical Systems, Bothell, WA) was placed in the supraclavicular fossa, and revealed numerous vascular lesions surrounding the divisions of the brachial plexus and subclavian artery (Fig 1A, B). Color Doppler imaging confirmed that these pulsatile lesions were vascular in origin (Fig 1C). Because of the high likelihood of vascular puncture and possible unintentional intravascular injertion of local anesthetic, we abandoned the supraclavicular approach to the brachial plexus. Ultrasound scan distally into the ipsilateral axillary region revealed remarkably normal vasculature and discrete nerve targets. No aberrant vascular structures were visualized (Fig 2). Using a combined US and peripheral nerve-stimulator technique to ensure correct needle placement, the radial, medial, ulnar, and musculocutaneous nerves were stimulated, using a minimum current of 0.4 mA. After negative aspiration, 10 mL of local anesthetic (a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 1:200,000 epinephrine) was deposited around each of the four nerves. The spread of local anesthetic was visualized surrounding each of the nerves, using US. Surgical anesthesia was successful; the patient underwent an uneventful surgery, and was discharged home later that day.
Multiple glomangiomatosis presents a unique challenge to the regional anesthesiologist. Glomangiomata are vascular lesions that consist of an afferent artery, arteriovenous canal, neuro-reticular elements, collagen, and efferent veins.5 They are usually found in the extremities, head, and neck, but can also be located in the trachea, lung, bowel, and stomach.6 Given that 1% to 2% of all soft- tissue tumors are glomus in origin, the incidence of multiple glomangiomatosis is estimated at 2 in 1,000,000.7 Clinically, these lesions closely resemble hemangiomas, arteriovenous malformations, and lymphangiomas. Forty-two percent of all patients with glomangiomatosis complain of pain.8 Treatment is aimed at symptomatic relief, and consists of analgesics, surgical excision of the glomangiomata, and recently, laser and sclerotherapy.9
The anesthetic implications of multiple glomangiomatosis include an increased risk of complications when performing regional techniques, difficulty in managing postoperative pain, substance dependence, and potential airway complications because of tracheal lesions.10 Important risks of peripheral nerve blockade in a patient with multiple glomangiomatosis include (1) a failed blockade secondary to abnormal anatomy, (2) unintentional vascular puncture and potential local anesthetic toxicity, and (3) hematoma formation, with an increased risk of neural ischemia. Indeed, previous studies showed that the increased pressure generated by a localized hematoma or pseudoaneurysms can compromise the neural microcirculation, leading to neurologic deficits.11 These potential drawbacks notwithstanding, regional anesthesia was selected for this patient, given his multiple comorbidities. General anesthesia would have been challenging because of the patient's morbid obesity and potentially difficult airway. The patient's diagnosis of sleep apnea, combined with his chronic, high-dose opioid use, would likely have confounded postoperative pain management. Moreover, general anesthesia combined with chronic opioid use and a diagnosis of sleep apnea is contraindicated for day-case surgery.12 At our institution, we perform more US-guided supraclavicular blockades than any other brachial plexus blockade. We find this blockade easy to perform, with a reliable and quick onset of anesthesia of the entire forearm, wrist, and hand. An interscalene blockade would have spared the site of surgery (i.e., the ulnar aspect of his right wrist, with exploration of the ulnar nerve). The supraclavicular approach is especially useful for obese patients, because the divisions of the brachial plexus are relatively superficial beneath the skin, compared with other approaches to the brachial plexus. To that end, we felt that an infraclavicular blockade, even with ultrasound, would have been difficult to perform. In our experience, the supraclavicular blockade achieves faster surgical anesthesia of the entire distal upper extremity with a single needle puncture and small amounts of local anesthetic.13
Fig 2. Transverse sonogram of the right axillary region. Arrows indicate spread of LA around the nerves. M, median nerve; U, ulnar nerve; R, radial nerve; A, axillary artery; LA, local anesthetic.
This case demonstrates the value of US for regional anesthesia in patients with abnormal anatomy, for whom "blind" nerve-localization techniques could be hazardous, and perhaps even life-threatening. Ultrasound allows the operator to trace the target nerve along its expected trajectory, thereby enabling selection of the safest needle approach to the nerve. This report also highlights the use of Doppler imaging for determining the safest approach to blocking the brachial plexus. Color Doppler imaging captures the change in frequency of reflected sound waves, to detert blood flow through a vessel. We think that color Doppler imaging is an important addition to the regional anesthesiologist's armamentarium, and that any patient with a suspected vascular abnormality should undergo sonographic anatomical assessment with color Doppler imaging prior to peripheral nerve blockade. Although multiple glomangiomatosis is a rare condition that most anesthesiologists will never encounter, similar considerations may apply to patients with arteriovenous malformations or space-occupying tumors that distort normal anatomy. Numerous recent case reports highlighted the successful use of US in patients with coagulation abnormalities, underlying neurologic disease, and altered anatomy.14,15 Together with the present report, these cases illustrate the valuable contribution that US has made to the management of patients with risk factors in whom traditional nerve-localization techniques could result in serious complications.
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Edel Duggan, M.B., F.C.A.R.C.S.I., Richard Brull, M.D., F.R.C.P.C, Jacob Lai, M.D., F.R.C.P.C, and Sherif Abbas, M.D.
From the Department of Anesthesia and Pain Management, Toronto Western Hospital University Health Network, Toronto, Ontario, Canada.
Accepted for publication October 23, 2007.
Reprint requests: Richard Brull, M.D., F.R.C.P.C, Department of Anesthesia and Pain Management, Toronto Western Hospital University Health Network, 399 Bathurst St., Toronto, Ontario M5T 2S8, Canada. E-mail: [email protected]
(c) 2008 by the American Society of Regional Anesthesia and Pain Medicine.
Copyright Churchill Livingstone Inc., Medical Publishers Jan/Feb 2008
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