Case Reports

Tension Pneumothorax After Ultrasound-Guided Interscalene Block and Shoulder Arthroscopy

Am J Orthop. 2015 October;44(10):E407-E410

References

1. Oldman M, Peng Pi P. Pneumothorax after shoulder arthroscopy: don’t blame it on regional anesthesia. Reg Anesth Pain Med. 2004;29(4):382-383.

2. Singh A, Kelly C, O’Brien T, Wilson J, Warner JJ. Ultrasound-guided interscalene block anesthesia for shoulder arthroscopy: a prospective study of 1319 patients. J Bone Joint Surg Am. 2012;94(22):2040-2046.

3. Bishop JY, Sprague M, Gelber J, et al. Interscalene regional anesthesia for shoulder surgery. J Bone Joint Surg Am. 2005;87(5):974-979.

4. Winnie AP. Interscalene brachial plexus block. Anesth Analg. 1970;49(3):455-466.

5. Mian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M. Brachial plexus anesthesia: a review of the relevant anatomy, complications, and anatomical variations. Clin Anat. 2014;27(2):210-221.

6. Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU. Interscalene block for shoulder arthroscopy: comparison with general anesthesia. Arthroscopy. 1993;9(3):295-300.

7. Marhofer P, Harrop-Griffiths W, Willschke H, Kirchmair L. Fifteen years of ultrasound guidance in regional anaesthesia: Part 2 - recent developments in block techniques. Br J Anaesth. 2010;104(6):673-683.

8. Sites BD, Spence BC, Gallagher J, et al. Regional anesthesia meets ultrasound: a specialty in transition. Acta Anaesthesiol Scand. 2008;52(4):456-466.

9. Ilfeld BM, Fredrickson MJ, Mariano ER. Ultrasound-guided perineural catheter insertion: three approaches but few illuminating data. Reg Anesth Pain Med. 2010;35(2):123-126.

10. Choi WI. Pneumothorax. Tuberc Respir Dis (Seoul). 2014;76(3):99-104.

11. Klaastad O, Sauter AR, Dodgson MS. Brachial plexus block with or without ultrasound guidance. Curr Opin Anaesthesiol. 2009;22(5):655-660.

12. Perlas A, Niazi A, McCartney C, Chan V, Xu D, Abbas S. The sensitivity of motor response to nerve stimulation and paresthesia for nerve localization as evaluated by ultrasound. Reg Anesth Pain Med. 2006;31(5):445-450.

13. Bryan NA, Swenson JD, Greis PE, Burks RT. Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy, and complications. J Shoulder Elbow Surg. 2007;16(4):388-395.

14. Mandim BL, Alves RR, Almeida R, Pontes JP, Arantes LJ, Morais FP. Pneumothorax post brachial plexus block guided by ultrasound: a case report. Rev Bras Anestesiol. 2012;62(5):741-747.

15. Dietzel DP, Ciullo JV. Spontaneous pneumothorax after shoulder arthroscopy: a report of four cases. Arthroscopy. 1996;12(1):99-102.

16. Lee HC, Dewan N, Crosby L. Subcutaneous emphysema, pneumomediastinum, and potentially life-threatening tension pneumothorax. Pulmonary complications from arthroscopic shoulder decompression. Chest. 1992;101(5):1265-1267.

In contrast, several cases of pneumothorax after shoulder surgery have been reported in the absence of nerve block. Oldman and Peng¹ reported a 41-year-old nonsmoker who underwent arthroscopic labral repair and subacromial decompression. The preoperative nerve block was cancelled, and the patient received general endotracheal anesthesia alone. Fifty minutes after the case, the patient developed chest pain and hypoxia. A chest radiograph showed a small pneumothorax that was managed conservatively. The pneumothorax was attributed to spontaneous rupture of a preexisting lung bulla, suggesting that blocks are not always the cause of this complication. Furthermore, Dietzel and Ciullo¹⁵ reported 4 cases of spontaneous pneumothorax within 24 hours of uncomplicated arthroscopic shoulder procedures under general anesthesia in the lateral decubitus position. The patient ages ranged from 22 to 38 years, and medical histories were all significant for preexisting lung disease, remote history of pneumonia, and heavy smoking. Three of the patients experienced symptoms at home the day after surgery. The authors concluded that these cases were likely caused by rupture of blebs or bullae from underlying lung disease; these ruptured blebs or bullae are difficult to detect and usually located in the upper lung. The pressure gradient from the positive pressure of anesthesia and the ipsilateral upper lung is thought to be highest in the lateral decubitus position, increasing their chance of rupture.¹⁵

Finally, Lee and colleagues¹⁶ described 3 patients aged 40 to 45 years who underwent uncomplicated subacromial decompression in the beach-chair position under general anesthesia. Significant shoulder, neck, and axillary swelling were noted after surgery, and a chest radiograph showed tension pneumothorax, subcutaneous emphysema, and pneumomediastinum. The authors speculated that pressure in the subacromial space may become negative relative to atmospheric pressure when the shaver and suction are running, drawing in air through other portals. When the suction is discontinued, fluid infusion may push air into the surrounding tissue, leading to subcutaneous emphysema, which may spread to the mediastinum.¹⁶

Conclusion

Ultrasound-guided interscalene nerve blocks have successfully provided anesthesia for shoulder surgeries with low complication rates. Although the incidence of pneumothorax has decreased significantly with ultrasound guidance, the success of this procedure is highly operator-dependent. We present the case of an otherwise healthy patient without known pulmonary disease who developed a tension pneumothorax after the administration of ultrasound-guided regional and general anesthesia for arthroscopic shoulder surgery. Orthopedic surgeons and anesthesiologists must remain vigilant for pneumothorax during the perioperative period after shoulder surgery performed under interscalene regional aesthesia, particularly in the setting of hypotension, hypoxia, and/or tachycardia. Risk factors, such as history of smoking and preexisting lung disease, may predispose patients to the development of pneumothorax. Timely recognition and placement of a chest tube result in satisfactory clinical outcomes.