To the Editor:—

The report by Benumof 1about the permanent loss of cervical spinal cord function associated with interscalene blocks performed during general anesthesia fails to address a larger problem. The techniques that these anesthesiologists used, such as injection of local anesthetic after obtaining nerve stimulation at 0.80 mA or more and “walking off” the transverse process of C6 are unconventional and are not consistent with accepted techniques of interscalene brachial plexus blockade. 2It is likely that a common factor in all four of the cases is a lack of expertise in the performance of interscalene block, not the use of general anesthesia, the needle size, or the direction and depth of insertion.

It has been suggested that many US residency training programs may be failing to prepare residents adequately for the practice of regional anesthesia. 3,4,5Few residency training programs have structured rotations in regional anesthesia, and graduating anesthesiologists often perform only the simplest peripheral nerve block techniques, such as Bier and ankle blocks, to satisfy training requirements. Consequently, the majority of US anesthesiologists commonly use neuraxial anesthesia in their practice, but far fewer practice peripheral nerve blocks. 4It is possible that a failure to differentiate peripheral nerve blocks from neuraxial anesthesia by traditionally labeling both as “regional anesthesia” has contributed to this lapse in training. For neuraxial anesthesia, the Program Requirements for Residency Training in Anesthesiology specifies 50 subarachnoid blocks and 50 epidural blocks as the minimum clinical experience that should be obtained by each graduating resident. *In contrast, training requirements for peripheral nerve blocks are vague, currently consisting of any 40 peripheral nerve blocks. *

The technology, techniques, equipment, and scope of practice of peripheral nerve blocks have become substantially more complex in the past decade, while the consumer pressure in favor of peripheral nerve blocks has also significantly increased. Accordingly, many anesthesiologists feel compelled to introduce peripheral nerve blocks into their practice and may do so without adequate training in these techniques. Benumof’s report affirms the importance of proper training in peripheral nerve blocks to preserve and enhance the value of regional anesthesia in today’s practice. We believe that the time has come that the Residency Review Committee and the American Board of Anesthesiology reevaluate the training guidelines in light of the increasing trend for use of peripheral nerve blocks or, more specifically, recommend the training requirements for commonly used regional anesthesia techniques.

Benumof JL: Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology 2000; 93: 1541–4
Chelly EJ: Peripheral Nerve Blocks: A Color Atlas, 1st edition. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 7–33
Kopacz DJ, Bridenbaugh LD: Are anesthesia residency programs failing regional anesthesia? The past, present, and future. Reg Anesth 1993; 18: 84–7
Hadzic A, Vloka JD, Kuroda MM, Koorn R, Birnbach DJ: The practice of peripheral nerve blocks in the United States: A national survey. Reg Anesth Pain Med 1998; 23: 241–6
Blumenthal D, Gokhale M, Campbell EG, Weissman JS: Preparedness for clinical practice. Reports of graduating residents at academic health centers. JAMA 2001; 286: 1027–34