Interact CardioVasc Thorac Surg 2009;9:309-310. doi:10.1510/icvts.2008.198085
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Thoracic non-oncologic |
Post-thoracotomy Horner syndrome associated with extrapleural infusion of local anesthetic
Keith M. Blechman* and
Michael Zervos
New York University Langone Medical Center, New Bellevue North 1, 550 First Avenue, New York, NY 10016, USA
Received 10 November 2008;
received in revised form 13 April 2009;
accepted 14 April 2009
*Corresponding author. Tel.: +1-212-263-2225; fax: +1-212-263-8216.
E-mail address: keith.blechman{at}med.nyu.edu (K.M. Blechman).
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Abstract
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Continuous incisional infusion of local anesthetic through an extrapleural catheter to achieve an intercostal nerve block is a safe and effective adjunct to control postoperative pain after thoracotomy. Local and systemic complications are rare. Here we present a case of an acute, reversible, post-thoracotomy Horner syndrome associated with the use of local anesthetic infusion via an intraoperatively placed extrapleural catheter.
Key Words: Thoracotomy; Horner syndrome; Nerve block
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1. Introduction
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Continuous incisional infusion of local anesthetic through an extrapleural catheter is a safe and effective adjunct to control postoperative pain after thoracotomy [1, 2]. A soaker-hose catheter with multiple sideholes (On-Q PainBuster Post-Op Pain Relief System, I-Flow Corporation, Lake Forest, CA) is commonly used for this purpose. Placement of the catheter is performed by the surgeon prior to closure of the thoracotomy. A blunt obturator covered by a tear-away sheath is introduced percutaneously inferior to the thoracotomy and advanced superodorsally in a curvilinear fashion within the extrapleural plane. Proper placement of the obturator is confirmed by both palpation and direct visualization through the thoracotomy. The obturator is then removed and the catheter is fed through the sheath, which tears away. The catheter is then connected to an elastomeric pump with a flow-limiting valve. This method allows controlled infusion of the anesthetic into the extrapleural plane with subsequent diffusion to achieve an intercostal nerve block.
Bupivacaine is a widely used agent for extrapleural infusion as it is generally well tolerated. Local and systemic complications occur in less than one percent of cases (Detterbeck 2005). Here we present a patient who developed a new-onset, reversible Horner syndrome post-thoracotomy associated with the use of local anesthetic infusion via an extrapleural catheter.
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2. Case report
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A 58-year-old African-American female, weighing 54 kg and measuring 160 cm, was found to have a right upper lobe pulmonary mass on a preoperative chest radiograph for carpal tunnel surgery. Past medical history was significant for active smoking, hypertension, and chronic sinusitis. Her only medication was amlodipine. Review of systems was unremarkable. Pulmonary exam was clear to auscultation bilaterally, gross sensorimotor function was intact globally, and no obvious deformities of the spine or rib cage were evident. Evaluation of the pulmonary mass with PET/CT revealed hypermetabolic activity consistent with a primary bronchogenic malignancy. No mediastinal involvement or additional sites of abnormal uptake were found. The patient was brought to the operating room for elective right upper lobe wedge resection.
The patient was placed under general anesthesia. A right fifth intercostal posterolateral thoracotomy was performed and the fifth rib was shingled. A large mass was found within the right upper lobe and was resected. Intraoperative frozen section confirmed non-small cell adenocarcinoma and a completion lobectomy was performed. Prior to closure of the thoracotomy, an On-Q system containing 450 ml of 0.25% bupivacaine was introduced extrapleurally using a 20-gauge soaker-hose catheter by the technique described above. After proper placement was confirmed, the bupivacaine was allowed to infuse at 3 ml/h. The wound was closed and two chest tubes were placed anteriorly and posteriorly. The surgical procedure did not involve the spine or thoracic nerve roots. The patient tolerated the procedure well and there were no complications.
On postoperative day one the patient complained of heaviness of the right eyelid. She was noted to have new-onset right-sided blepharoptosis and pupillary miosis. She also reported symptoms consistent with ipsilateral facial anhidrosis. Her neurologic exam was otherwise unremarkable. An acute unilateral Horner syndrome was diagnosed. The extrapleural catheter was promptly removed and complete resolution of the Horner syndrome occurred by postoperative day two. Her postoperative course was otherwise unremarkable except for an air leak in the chest tube which resolved after 72 h of low continuous wall suction. Postoperative chest radiographs revealed no masses in the thorax. No other complications related to the extrapleural catheter were encountered during her admission. Further work-up was deemed unnecessary by the consulting neurologist.
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3. Discussion
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Horner syndrome, also referred to as oculosympathetic paresis, is a classic neurologic constellation of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis resulting from disruption of the sympathetic pathway supplying the head, eye, and neck [3]. Common etiologies include stroke, tumor, trauma, or injury as a complication of surgery.
Horner syndrome can also result from infusion of local anesthetic. This is most often described as an infrequent complication of lumbar epidural analgesia in obstetrical procedures [4, 5], although it can also occur with thoracic epidural infusion [6]. Horner syndrome resulting from intercostal nerve blockade is exceedingly rare. There is one case report in the literature of a unilateral Horner syndrome associated with interpleural catheter infusion of 0.5% bupivacaine for atypical chest pain [7]. No formal case reports of Horner syndrome associated with extrapleural catheter use exist, however, brief mention is made of this complication in a single patient from a study of 80 pulmonary and esophageal procedures in which 0.5 mg/kg/h bupivacaine was administered continuously through a percutaneous paravertebral epidural cannula inserted via a 16-gauge Tuohy needle [8]. Interestingly, this is the only observation cited in a review of twelve studies in which a total of 311 patients received extrapleural bupivacaine infusion for post-thoracotomy pain management.
In summary, this case report substantiates the finding that extrapleural infusion of bupivacaine with a soaker-hose catheter may result in a new-onset, reversible Horner syndrome post-thoracotomy and should be considered as part of the differential diagnosis in patients manifesting the characteristic findings.
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References
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- Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg 2005;80:1550–1559.[Abstract/Free Full Text]
- Wheatley GH 3rd, Rosenbaum DH, Paul MC, Dine AP, Wait MA, Meyer DM, Jessen ME, Ring WS, DiMaio JM. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg 2005;130:464–468.[Abstract/Free Full Text]
- Walton KA, Buono LM. Horner syndrome. Curr Opin Ophthalmol 2003;14:357–363.[CrossRef][Medline]
- Biousse V, Guevara RA, Newman NJ. Transient Horner's syndrome after lumbar epidural anesthesia. Neurology 1998;51:1473–1475.[Abstract/Free Full Text]
- Wong SY, Lin CF, Lo LM, Peng TC, Chuah EC. Postpartum unilateral Horner's syndrome following lumbar epidural anesthesia after a cesarean delivery. Chang Gung Medical Journal 2004;27:624–628.[Medline]
- Liu M, Kim PS, Chen CK, Smythe WR. Delayed Horner's syndrome as a complication of continuous thoracic epidural analgesia. J Cardiothorac Vasc Anesth 1998;12:195–196.[CrossRef][Medline]
- Parkinson SK, Mueller JB, Rich TJ, Little WL. Unilateral Horner's syndrome associated with interpleural catheter injection of local anesthetic. Anesth Analg 1989;68:61–62.[Free Full Text]
- Eng J, Sabanathan S. Continuous extrapleural intercostal nerve block and post-thoracotomy pulmonary complications. Scand J Thorac Cardiovasc Surg 1992;26:219–223.[Medline]
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Abstract
1. Introduction