ASRA Pain Medicine Update

When tailoring an anesthetic plan for orthopedic surgery, multiple factors must be balanced to achieve a good outcome. However, when the patient is a professional athlete, individual risk tolerance for potential side effects and complications of regional anesthesia and analgesia may be very different from those of the general population. The objectives of this article are to review some of the unique considerations that may be of interest to those who are caring for professional athletes (and translatable to other professions who rely on certain physical characteristics to perform their jobs) and to elevate the discussion that is required to gain informed consent.

Caring for a professional athlete is something we frequently face at the Hospital for Special Surgery (HSS) in New York, New York: We saw more than 350 professional athletes in 2018 alone. As a major orthopedic center, we encounter patients from all corners of the world and walks of life. Similar to all patients, athletes’ health status, activities of daily living, and goals of surgery must be considered. In addition, we need to assess how the anesthetic and surgery may affect their professional performance when discussing their anesthetic options.

As an analogy, we are frequently asked to make accommodations for patients undergoing general anesthesia who use their voices professionally, such as operatic singers. Here, we may choose a laryngeal mask airway or smaller endotracheal tube with or without the aid of video laryngoscopes to protect the vocal structures. I look at caring for professional athletes, or others who depend on physical skills for their livelihood, in much the same way. Because we perform regional anesthesia for most of our cases at HSS, this is something not to be taken lightly.

To a professional athlete or concert violinist, even the smallest of deficits may cause anxiety during recovery. A more permanent deficit may lead to a decrease in performance or an inability to perform their job and hence lose their livelihood.

We know from prior studies that regional anesthesia, including peripheral nerve blocks (PNBs) and neuraxial techniques, is not without risk. Although ultrasound has made regional anesthesia more accessible, it has not eliminated some of those risks. However, the Second ASRA Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia Executive Summary does support the use of ultrasound to decrease the incidence of local anesthetic toxicity (LAST) and the incidence and intensity of hemidiphragmatic paresis (HDP).^[1]

Minimizing HDP is a common goal when performing brachial plexus or upper-extremity PNBs. Interscalene blocks have a 100% incidence of HDP; supraclavicular blocks typically have a 50% incidence.^[2] Although those side effects rarely last longer than the duration of the block, persistent paresis for more than a few months has occurred in patients who have had an interscalene block performed with a peripheral nerve stimulator.^[2] Most patients would not necessarily be bothered by persistent HDP. However, it may render a marathon runner unable to compete and represents an unacceptable risk to assume in that patient population. Whether ultrasound guidance contributes to decreasing persistent phrenic nerve paralysis is unclear, but the complication could be problematic for some professional athletes and is worth considering in the same way we may avoid the risk of HDP in patients with advanced pulmonary disease.

Despite ultrasound guidance decreasing the incidence of LAST and HDP, the ASRA summary reported a lack of evidence for ultrasound decreasing the incidence of postoperative neurologic symptoms (PONS).^[1] PONS is perhaps the most complex and least predictable complication of regional anesthesia. We know from prior studies that the incidence of temporary (resolving in less than 6 months) PONS, such as paresthesia, can be as high as 19%. Permanent PONS can occur in as many as 5 in 10,000 patients (0.05%).^[3] When compared with the global benefits of regional anesthesia and analgesia for orthopedic surgery (including lower rates of thromboembolic events, infection, and pulmonary and renal complications), the low risk of PONS is usually well worth assuming for the general population—specifically because the majority of PONS cases resolve quickly and the chance of permanent injury is low. However, for professional athletes, any incidence may be too high, depending on whether and how their livelihood will be affected.

Blocks are rarely performed in a bubble without the companionship of a surgery. Given the low incidence of permanent PONS, designing a study to quantify the incidence of PONS after PNB without surgery in volunteers would be challenging and ethically questionable. However, we can look at the surgical literature to gain an understanding of the incidence of PONS for sports surgery conducted under general anesthesia.

When choosing to perform a PNB on a patient, especially a professional athlete, it is crucial to understand the inherent risks of the surgery itself in relation to PONS. Anterior cruciate ligament (ACL) reconstructions performed with hamstring autografts have become more common in recent years. We often use adductor canal blocks for postoperative analgesia in many ACL reconstructions. A systematic review of patellar tendon grafts versus hamstring autografts confirmed that surgical complication rates from ACL reconstruction could be significant.^[4] The review noted that the incidence of damage to the saphenous nerve and nerve branches could be as high as 88% depending on the approach of the incision.^[5] When the incisional approach was taken into consideration, the incidence was as low as 14.9%.^[6] A saphenous nerve injury may be inconsequential to some patients, given that it is solely a sensory nerve. However, at the other extreme, a permanent injury causing complex regional pain syndrome could be very detrimental to patients.

Other surgeries are also associated with PONS when performed under general anesthesia. Shoulder surgery is one of the higher risk surgeries for neurologic complications. In typical sports procedures, injuries to the brachial plexus are seen in 1% to 2% of rotator cuff surgeries and 1% to 8% of anterior instability surgeries; this increases to 3% for shoulder replacements and 2% to 4% for reverse shoulder replacements.^[7] The Latarjet procedure, typically performed for shoulder instability, is associated with even higher rates of PONS. In a study of 34 patients undergoing a Latarjet procedure under total intravenous anesthetic, 20.6% of patients had a clinically detectable nerve deficit after surgery. Interestingly, intraoperative neuromonitoring, comprising somatosensory evoked potentials and transcranial motor evoked potentials, was used in the study; in 76.5% of cases, an “alert” for nerve injury was recorded, followed by alteration in surgical and anesthetic conditions to restore baseline nerve signals.^[8]

Patients undergoing ulnar collateral ligament (UCL) reconstruction at the elbow (which is common to baseball pitchers and known colloquially as “Tommy John” surgery) by nature of the injury have a high risk of postoperative ulnar neuropathy. A systematic review of UCL surgeries found that the incidence of ulnar neuropathy was as high as 12%, with some of those patients additionally having an ulnar nerve transposition at the time of the original surgery.^[9]

As anesthesiologists, we are asked to look at the big picture, taking into account the surgery, the patient’s medical history, and socioeconomic factors. As regional anesthesiologists, we must additionally consider how complications of our blocks and the surgery may affect patients on a long-term basis. Although the incidence of complications from PNBs appears to be low, it may not be low enough for certain patient populations. Many people may not mind or even notice a small sensory deficit postoperatively as they recover. But to a professional athlete or concert violinist, even the smallest of deficits may cause anxiety during recovery. A more permanent deficit may lead to a decrease in performance or an inability to perform their job and hence loss of their livelihood. This is not to say that regional anesthesia is not without benefit for most patients: We perform tens of thousands of regional anesthetics a year, and our patients greatly benefit from them.

We are fortunate to have surgical colleagues who not only support the use of regional anesthesia but also request it for most of their patients. Although our surgeons have anesthetic preferences, they trust that we will make the right decision for patients in terms of risk versus benefit of a regional technique, even in a professional athlete. On occasion, our surgeons, who are worried about their own complications, will ask us not to perform a PNB so that they are able to assess neurologic function postoperatively.

We have open and honest discussions with all of our patients regarding the potential risks and benefits and what that may mean for their recovery and future. Many professional athletes have been coached from their trainers, team physicians, and agents to be extremely risk adverse and therefore elect to have a general anesthetic or simply a neuraxial technique, not wishing to gamble on the extraordinarily rare complications from PNBs. It is important to remember that this does not prevent all risk of PONS, and we emphasize this to them as well. Even patients undergoing general anesthesia for shoulder surgery, for example, need to have special attention given to positioning of the head and neck, given that they are often in a beach chair position with their head in a fixed position during surgery. The potential contribution of surgical complications cannot be ignored, although our surgical colleagues are better suited to address that conversation with patients. Having a command of surgical risks in addition to anesthetic complications, either regional or general, and discussing this in depth with your patients are the most important aspects of caring for anyone—especially a professional athlete having orthopedic surgery.

References

1. Neal JM, Brull R, Horn JL, et al. The second American Society of Regional Anesthesia and Pain Medicine evidence-based medicine assessment of ultrasound-guided regional anesthesia: executive summary. Reg Anesth Pain Med 2016;41(2):181–194.
2. Pakala SR, Beckman JD, Lyman S, Zayas VM. Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block. Reg Anesth Pain Med 2013;38(3):239–242.
3. Neal JM. Ultrasound-guided regional anesthesia and patient safety: update of an evidence-based analysis. Reg Anesth Pain Med 2016;41(2):195–204.
4. Hardy A, Casabianca L, Andrieu K, Baverel L, Noailles T. Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: systematic review of literature. Orthop Traumatol Surg Res 2017;103(8S):S245–S248.
5. Kjaergaard J, Fauno LZ, Fauno P. Sensibility loss after ACL reconstruction with hamstring graft. Int J Sports Med 2008;29:507–511.
6. Wilson TJ, Lubowitz JH. Minimally invasive posterior hamstring harvest. Arthrosc Tech 2013;2:e299–e301.
7. Kam AW, Lam PH, Haen PSWA, Tan M, Shamsudin A, Murrell GAC. Preventing brachial plexus injury during shoulder surgery: a real-time cadaveric study. J Shoulder Elbow Surg 2018;27(5):912–922.
8. Delaney RA, Freehill MT, Janfaza DR, Vlassakov KV, Higgins LD, Warner JJ. 2014 Neer award paper: neuromonitoring the Latarjet procedure. J Shoulder Elbow Surg 2014;23(10):1473–1480.
9. Clain JB, Vitale MA, Ahmad CS, Ruchelsman DE. Ulnar nerve complications after ulnar collateral ligament reconstruction of the elbow: a systematic review. Am J Sports Med 2018:363546518765139.