Delayed Horner's syndrome following ultrasound- guided interscalene brachial plexus block
A healthy 29-year-old man (weight 75 kg, height 169 cm, American Society of Anesthesiologists class 1) was scheduled for elective arthroscopic repair of a left shoulder Bankart lesion. Aside from the orthopedic injury, the patient's history, physical examination, and laboratory data were normal. He was given 2 mg of lorazepam orally 2 h before arriving in the operating room. On arrival to the operating room, an 18-gauge venous cannula was inserted and the patient was connected to standard monitoring equipment, an oxygen face mask (5l/min) and was intravenously given 2 mg of midazolam. The patient was positioned supine with his neck extended to the contra-lateral side to facilitate performance of an ultrasound (US) interscalene brachial plexus block (ISBPB). After skin preparation with povidone-iodine and infiltration with lidocaine 1%, US-ISBPB was performed. An 18-gauge, 2-inch insulated needle (B. Braun Medical Inc., Bethlehem, PA, USA) was inserted into the middle scalene muscle immediately superior to and out of the plane with the L38 × 10−5 MHz transducer linear array. A 9 cm scan depth probe was used to visualize the brachial plexus using an M-Turbo US machine (SonoSite, Bothell, WA, USA). In the middle portion of the scalene muscle, the needle was redirected anteriorly and advanced toward the interscalene space. Normal saline (1-2 ml) was injected in increments into the anterior border of the middle scalene muscle to expand the fascial plane between the brachial plexus and the middle scalene muscle. While intermittently aspirating under direct US visualization, 10 ml of 0.25% bupivacaine was injected into the interscalene space. A 20-gauge catheter was then inserted into the skin through the thin-walled needle to a depth of 10 cm. To locate the catheter position before placement of a clear adhesive dressing, 0.5 ml of air was injected after negative aspiration while imaging the interscalene space. The US image clearly demonstrated echogenic contrast entering the interscalene space, thereby confirming appropriate positioning of the catheter. The surgical procedure was performed under general anesthesia using the propofol, fentanyl, and cis-atracurium with the patient in a beach chair position. Following an uneventful two-hour surgery, the patient was extubated and moved to the recovery room. Analgesia was maintained with a top-up of 0.2% bupivacaine every 8 h through the interscalene catheter. Free from pain and resting comfortably, the patient was discharged from the recovery room. Eight hours after the initial bolus (visual analog pain scale 1-2 at rest), the patient received 10 ml 0.2% bupivacaine, which was administered through the interscalene catheter by the on call team. One hour later, the patient developed Horner's syndrome on the ipsilateral side, including meiosis, ptosis, enophthalmia, anhydrosis, and conjunctival hyperemia. No swelling around the site of catheter insertion was noted. The catheter was withdrawn immediately and symptoms of Horner's syndrome disappeared approximately 2 h later. Analgesia was then changed to paracetamol and non-steroidal anti-inflammatory drugs.