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Postoperative occipital nerve injury in a child.

Positioning of anaesthetised patients requires meticulous care and ongoing vigilance by anaes-thetists cognisant of the potential for long-term physical morbidity. Nerve injury associated with anaesthesia can cause significant functional disability or pain syndromes, and often results from malpositioning of patients on operating tables with stretch and/or compression of nerves (1). A review of the American Society of Anesthesiologists Closed Claims Study revealed that 15% of all claims against anaesthetists were related to nerve injury (2). The incidence of peri-operative neuropathy has been estimated at between 1 in 350 to 1000, with the ulnar nerve most commonly affected (3). Occipital nerve injury is an uncommon complication after anaesthesia and surgery (4), although maybe under-recognised5. Here, we describe the first reported case of postoperative occipital neuropathy in a child.

A seven-year-old boy suffered 25% second and third degree burn injuries to his abdomen, chest and right arm. He underwent rehabilitation and multiple skin grafting. Six months after the primary injury he was scheduled for a free flap graft of the latissimus dorsi muscle to his right forearm. The operation lasted 12 hours and general anaesthesia consisted of sevoflurane in a 50:50 oxygen and air mix with additional fentanyl and muscle relaxation (rocuronium) to facilitate endotracheal intubation. An ultrasound-guided infraclavicular block was placed after the induction of anaesthesia and a catheter was inserted. An infusion of levobupivacaine 0.2% at a rate 0.2 [ml.kg.sup.-1].[hour.sup.-1] was used throughout the entire procedure. The patient was supine with the head positioned on a round silicon 'doughnut' head rest. Despite the prolonged length of the procedure, surgery was uneventful and the patient was haemodynamically stable without respiratory complications. The patient was awake and extubated 15 minutes after the end of surgery. In the post-anaesthesia care unit, one hour after the end of surgery, routine assessment revealed severe pain in the sacral area secondary to pressure sores and severe pain at the left occiput. The occipital area was painful and even light touch evoked an excruciating burning sensation. Examination of the left arm showed that the patient had an excellent sensory block. The patient was treated with continuous infusion of levobupivacaine 0.2% via the infraclavicular catheter as well as a continuous infusion of morphine sulphate 30 /Ag.kgMiour-1 and regular ibuprofen. The sacral injury completely resolved within four days, the infraclavicular catheter was removed after five days as the graft appeared to be healing well. At the same time the patient's main complaint was ongoing pain in the occipital area that was described as burning. It was graded at 10 out of 10 (numerical verbal scale) in severity and the pain did not respond to morphine or ibuprofen. The area was warm and extremely painful when touched. The diagnosis of occipital neuralgia was suspected. We performed a greater occipital nerve block with bupivacaine 0.25% and methylprednisolone and the patient reported an immediate relief of pain. He was treated with pregabalin 75 mg per day that was increased to 150 mg per day after two days. At six months of follow-up the patient reported complete resolution of pain and sensory changes.

Occipital neuropathy resulting from prolonged nerve compression against a head-ring is the most likely diagnosis given the history and physical findings. We believe the combination of prolonged immobility and compression of the occipital nerves between the bony superior nuchal ridge and the head rest are the most likely aetiology. The fast response to local anesthetics and anti-neuropathic pain medications such as pregabalin also support the diagnosis. Many individuals will improve with therapy involving heat, rest, anti-inflammatory medications and anti-neuropathic pain medications. Complete recovery, as described in this case, is expected. This case reinforces the need for meticulous care when positioning children and that the risk of nerve compression at unusual sites is ever-present.

I. KEIDAN

E. BEN-MENCHEM

Tel Aviv, Israel and Gainesville, Florida, USA

References

(1.) Dhuner KG. Nerve injuries following operations: a survey of cases occurring during a 6-year period. Anesthesiology 1950; 11:289-293.

(2.) Cheney FW, Domino KB, Caplan RA, Posner K. Nerve injury associated with anesthesia: a close claims analysis. Anesthesiology 1999; 90:1062-1069.

(3.) Sawyer R, Richmond M, Hickey J, Jarratt J. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000; 55:980991.

(4.) 4Schulz-Stubner S. Bilateral occipital neuropathy as a rare complication of positioning for thyroid surgery in a morbidly obese patient. Acta Anaesthesiol Scand 2004; 48:126-127.

(5.) Singh B. Bilateral occipital neuropathy, not so rare. Acta Anaesthesiol Scand 2004; 48:1216.
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Article Details
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Title Annotation:Correspondence
Author:Keidan, I.; Ben-Menchem, E.
Publication:Anaesthesia and Intensive Care
Article Type:Case study
Geographic Code:9INDI
Date:Mar 1, 2012
Words:750
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