To the Editor:—

The four dramatic case reports reported by Benumof 1in a recent issue of Anesthesiology deserve comment because regional anesthesia techniques are becoming more frequently used. Indeed, interscalene block may result in better postoperative conditions as compared with general anesthesia. 2A perineural catheter can also provide better postoperative pain control, fewer side effects, and greater patient satisfaction as compared with classic intravenous analgesia. 3,4 

We disagree with Benumof’s statement that “Performing an interscalene block (ISB) during general anesthesia . . . is a common procedure.”1In our experience, this practice must be the exception. Patients should be awake or lightly sedated when performing an ISB to increase the safety of this procedure. In addition, the precise ISB technique used in these cases is not clearly described. In case 3, we read, “by ‘walking’ the needle off the posterior aspect of the C6 transverse process . . .” For people regularly performing these nerve blocks, this approach is frightening. We surmise the Winnie approach has been used in the other patients, an approach that has already been associated with several complications, such as spinal or epidural anesthesia. 5,6We believe this approach should be replaced by the modified lateral approach in which the needle is directed slightly medial and caudal in the direction of the plane of the interscalene groove. Moreover, the statement in case 1 that “right upper extremity . . . muscle twitches were obtained”1is too rough and imprecise to be accepted as a block description in modern regional anesthesia.

Regional techniques are not easy techniques to master and necessitate practice. 7The lesson from these cases should not be that general anesthesia is a relative contraindication for ISB but that it should be a near absolute contraindication. The emphasis on the length of the needle should be replaced by the need for anesthesiologists to be well-trained in that field to prevent these avoidable complications.

Benumof JL: Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000; 93: 1541–4
Brown AR, Weiss R, Greenberg C, Flatow EL, Bigliani LU: Interscalene block for shoulder arthroscopy: Comparison with general anesthesia. Arthroscopy 1993; 9: 295–300
Borgeat A, Schappi B, Biasca N, Gerber C: Patient-controlled analgesia after major shoulder surgery: Patient-controlled interscalene analgesia versus  patient-controlled analgesia. Anesthesiology 1997; 87: 1343–47
Singelyn FJ, Seguy S, Gouverneur M: Interscalene brachial plexus analgesia after open shoulder surgery: Continuous versus patient-controlled infusion. Anesth Analg 1999; 89: 1216–20
Tetzlaff JE, Yoon HJ, Dilger J, Brems J: Subdural anesthesia as a complication of an interscalene brachial plexus block. Reg Anesth 1994; 19: 357–9
Passannante AN: Spinal anesthesia and permanent neurologic deficit after interscalene block. Anesth Analg 1996; 82: 873–4
Konrad CH, Schupfer G, Wietlisbach M, Gerber H: Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 96: 635–9