Cite as: May K, Aziz K, Tran B, et al. Iatrogenic nerve injury: can we do better for our patients?. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra020126.006.

Introduction

Postoperative nerve injury (PNI) remains a rare, potentially severe complication which can result in persistent pain and sensory/motor deficits. For patients, it represents a dramatic departure from the expected surgical recovery; for clinicians, it can be a challenge to properly triage and manage. We offer two valuable perspectives—those of peripheral nerve surgeons and of anesthesiologists—to explore how to better collaborate with one another and serve patients who suffer from nerve injuries in the perioperative period.

Surgeon’s Perspective

Background

Peri-procedural PNI can present a difficult challenge to physicians and can cause significant distress to patients.^1-3 Such injuries can cause pain, disability, and functional impairment.^4,5 While some PNIs are attributed to regional anesthesia, many result from surgical complications, patient positioning, or traumatic insults from the initial injury, which are unrecognized until after surgery.^2,6,7 While the underlying etiology of these nerve injuries is often unclear, the mechanism may involve traction, compression, or direct trauma to the nerve. In shoulder surgery, for example, the brachial plexus can be compromised due to arm positioning, intraoperative stretching during implant placement, or direct nerve injury.⁸ With regional anesthesia, there is an additional risk of the local anesthetic’s direct cytotoxic effect. This effect has been found to be more pronounced in lab studies evaluating intra-fascicular injection of local anesthetics.^9,10

In a study evaluating the mean annual incidence of PNI, the incidence of upper-extremity nerve injuries was 43.8 per 1,000,000. The incidence of lower extremity nerve injuries was 13.6 per 1,000,000.¹¹ The most injured isolated upper extremity nerves in descending order included the ulnar nerve, radial nerve, median nerve, and axillary nerves, with “other” upper extremity nerve injuries being listed as the most common overall.¹¹ The most commonly injured isolated lower extremity nerves in descending order included the peroneal nerve, sciatic nerve, femoral nerve, and tibial nerves, with “other” lower extremity nerve injuries being listed as the most common overall.¹¹

Diagnosis and Management

Early identification of PNI after a procedure is paramount. Delays in recognition and referral often limit treatment options and compromise outcomes. For patients with PNI, comparison to a normal contralateral side can help facilitate diagnosis. For sensory deficits, evaluation by moving and static two-point discrimination, as well as Semmes-Weinstein monofilament testing, provides objective data to supplement the patient’s subjective reporting. For motor deficits, comparing strength to the uninjured side and using the Medical Research Council scale are most appropriate. Patients with PNI causing motor deficits should be promptly referred to a therapist to ensure that affected joints can be appropriately splinted to prevent contracture and mobilized with therapy.¹² In many instances, even if full motor recovery does not occur, a supple joint remains amenable to tendon transfers. If sensory deficits are present, patients should be educated to perform regular skin checks to prevent pressure ulcers, skin breakdown, and infection.¹³ In patients with mixed PNI, both strategies must be employed to prevent adverse sequelae.

Once a PNI is identified, the patient should be referred not only to physical therapy but also to a peripheral nerve surgeon, ideally within 1 to 3 months of injury. Initial management of PNIs involves a baseline examination, baseline electrodiagnostic studies, referral to physical therapy, and close monitoring. Within 1 week of injury, some electrodiagnostic changes will be evident—notably in the sensory nerve action potential and compound muscle action potential, depending on the ratio of injured to uninjured axons; however, more severe injuries resulting in muscle denervation require 2 to 4weeks for abnormal insertional activity to manifest on electromyography (EMG).^14,15 In PNIs less likely to require surgical intervention, improvements in clinical exam and electrodiagnostic study findings are expected within 3 months. 

Surgical Intervention

In patients who do not show signs of improvement clinically or in electrodiagnostic studies, surgical intervention is often considered. Surgery may involve exploration and neurolysis, nerve repair, nerve reconstruction, and possible nerve transfer. In a case series of 36 patients with lower extremity nerve injury, 64% were treated with neurolysis, 33% with nerve reconstruction with autograft, and 3% with direct repair.⁴ Often the range of possible treatment options is extensively discussed with the patient, with the intraoperative appearance and response to direct nerve stimulation dictating the most appropriate treatment. When nerve transfer is considered, the approach can be much more nuanced and influenced by the patient’s age, affected muscle groups, duration of denervation, and available nerve transfer options. In cases where nerve transfers are no longer viable due to atrophy and loss of motor endplates, tendon transfer options may be available.

Optimal treatment of patients with PNIs requires a nuanced, evidence-based approach that integrates anatomical, etiological, and procedural considerations. The regional anesthesiologist, initial treating surgeon, and peripheral nerve surgeon are important parts of a multidisciplinary team to help identify and treat PNI patients. The regional anesthesiologist and initial treating surgeon are integral to early detection and documentation. Timely recognition and accurate reporting of the block type, technique, and any peri-injection concerns can assist surgical colleagues in localizing the lesion and guiding appropriate intervention. As further advances are made in surgical technique, imaging, and additional therapies, patients with PNIs may have a more favorable prognosis.

Anesthesiologist’s Perspective

Background

Approximately 40 million anesthetics are delivered in the United States per year, with a small percentage of patients receiving a regional anesthetic.¹⁶ The incidence of PNI is a rare but serious occurrence, with some estimates ranging from 0.02 to 0.04% of regional anesthesia procedures.¹⁷ Some anesthesiologists will never care for a patient with a nerve injury secondary to regional anesthesia. Many consider the 2015 ASRA Pain Medicine practice advisory as the gold standard for directing management.¹⁸

Transient numbness or weakness after elective orthopedic surgery is common. For example, shoulder replacement surgery has an incidence of transient brachial plexus injury in as many as 17% of patients.¹⁹ Special attention should be paid to (a) patient comorbidities, such as diabetic neuropathy, in which nerves can be more susceptible to injury, and (b) protective measures employed during a nerve block procedure, such as avoiding direct needle trauma to the nerve, maintaining low injection pressure of local anesthetic, and using the lowest concentration and dose of local anesthetic that will achieve the desired analgesic effect. If neuropraxia persists, the anesthesiologist and surgeon should candidly discuss critical portions of the surgical procedure in which the patient was at risk of sustaining the injury. In one study, more than 90% of surgically explored iatrogenic nerve injuries were linked to intraoperative causes.²⁰

Diagnosis and Management

According to the ASRA Pain Medicine Practice Advisory, when no or incomplete improvement occurs within 3 to 5 months, referral to a peripheral nerve surgeon is recommended. We advocate for this recommendation to be revisited and for the peripheral nerve surgeon to be moved forward in the timeline. Therefore, we recommend an EMG and a consultation after 3 weeks of symptoms. In most medical systems, surgeons and anesthesiologists have an existing relationship, with teamwork having been shown to enhance patient outcomes.²¹ Because PNI in this setting is considered a perioperative complication, and surgical intervention might enhance recovery, a peripheral nerve surgeon can be best positioned to take the lead. The surgeon may partner with anesthesiologists, who have expertise in regional anesthesia and acute pain medicine.

However, some anesthesiologists may not know or work with a peripheral nerve surgeon. Bridging this gap can be an opportunity to establish a pathway for collaboration. At the institutional level, designated champions from anesthesiology and surgery can work at the systems level to facilitate communication when nerve injury is a concern. Physicians performing regional anesthesia should have a peripheral nerve surgeon in their “Rolodex.”

Conclusions and Recommendations

PNI remains a rare but devastating complication that demands honesty, accountability, and collaboration across specialties. Surgeons and anesthesiologists bring different vantage points; yet both are responsible for early detection, transparent documentation, and ensuring patients receive timely access to expert care. With their unique diagnostic and reconstructive expertise, peripheral nerve surgeons should be consulted promptly, not after months of symptoms. In many cases, they are best positioned to help lead the recovery process, guiding both diagnostic workup and therapeutic strategy. Institutional pathways must shift from fragmented handoffs to proactive, team-based approaches that directly confront these injuries rather than deferring them. Only by eliminating silos and embracing shared ownership can we deliver on the promise of safer surgery and improved recovery for our patients. We recommend the following:

• Promote early multidisciplinary evaluation of nerve injuries.
• Shift initial referrals for EMG and consultation orders for peripheral nerve surgery when deficits are profound, persistent, or of significant distress to the patient at 3 weeks of symptoms.
• Improve documentation from all perioperative team members (eg, block technique, surgical details, positioning).
• Encourage shared electronic medical record access across anesthesia and surgical teams.
• Build bridges between specialties through case conferences and joint quality improvement and morbidity reviews.

References

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