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I have a young male client in need of a PNA for a persistant IGTN. However he is a recent paraplegic caused by falling out of a tree. He is paralysed from the waist down and has no feeling in his feet or lower limbs. Should I use a local aneasthetic before the surgery?

No. Not unless you must use epinephrine for hemorrhage control. A digital tourniquet might be better. Review the patient's medical history carefully and do your own assessment before you start. If there is infection, you may want to do partial avulsions and wait for the infection to resolve.
Tony Jagger

Personally I would use LA prior to surgery. Whilst the young man may be a paraplegic and have no sensation below the waist, a painful stimulus such as having a nail removed will have an effect on the autonomic system, and cause an increase in blood pressure.

Autonomic Dysreflexia is a complication of spinal injuries. Mild dysreflexia will present as blotching of the skin,sweating, ranging through headaches (often pounding) to CVA and even death in extreme cases. Depending on the actual level of injury will depend on the systemic effect on the patient. The higher the level of injury the more serious the consequences as there is less mechanism for vasodilation to reduce blood pressure. Even treating involuted nails can have this effect on patients.

In our area most spinal patients have total nail avulsions (usually Zadeks under GA of the both 1st only) before leaving hospital to prevent this condition. I have in the past referred a patient back for all her nails to be removed as the oedema in her feet was causing frequent mild dysreflexic attacks. (I think her level of injury was C4).

Incedentally other stimuli can cause Dysreflexia, one of the most common being simple bladder infections.

Nikki

Try to do a simple nail avulsion first and you can always do the P and A at a later date.

I did a simple nail avulsion on a pt with quadriplegia many moons ago as a student. I didn't use LA. The pt said that as soon as the wedge was removed, a pain present for two weeks in his left upper abdomen instantly resolved!
One word of advice-hold onto the leg for dear life! The reflex arc still goes off with a bang! LA would at least stop that, but the administering might also set off the reflexes.
Cheers
Mahtay

A great ending to a knotty problem.I've not done too many nail procedures on quadriplegics but if it helps,it helps.

A work of caution to re-iterate what Nikki has said.

An anaesthetist I have trained with regularly once asked me as a knowledge test whether it is appropriate to use local anaesthetic in the foot in people with spinal cord injuries.

His answer: it is imperative you use local anaesthesia in these patients to reduce the risk of autonomic dysreflexia. You can easily kill a patient from a seemingly trivial painful stimulus, even the local anaesthesia injection procedure can do it. It is important to have resuscitation equipment available in the unlikely event of this occuring. If this went to court, you would likley be held negligent for not administering a local to reduce this risk of this complication.

Be very aware of this risk in spinal cord injury patients!

LL

I consider this to be pretty significant information. How easy it would be to be as a Foot Professional to assume to know enough about this area and confidently go ahead without a local. Congratulations to Devine80 for posing the question and Thanks for your expertise you LuckyLisfranc. You have made me a more cautious practitioner.

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My location

I'm with Kate Patty. Thank you all for this very valuable information.

http://en.wikipedia.org/wiki/Autonomic_dysreflexia

Regards,

Mandy

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:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

Devine80
It may also be wise to wait until the client is 12 months post injury as susceptibility to Autonomic Dysreflexia occurs within the 1st 12 months. If the IGTN is so severe that it cannot wait then referral may be the best where the procedure can take place either within a hospital environment or where there is easy access to emergency services.
Hope this is helpful.
Sharon

Devine80

I echo Sharons caution, and without casting doubt on your ability, would it not be safer for this patient to be treated in a hospital environment ? I do regular nail surgery but I dont think I would want to take any chances with this one.

Good post by the way, we have all learned something I think.

regards
cornmerchant

I had done a nail surgery (partial nail avulsion without phenolisation) on a paraplegic man before. Yes, a local anasthetic had been adminstered even though he has no pain sensation on his foot. I did get my fellow colleagues to hold down the foot while I'm doing the LA adminstration though. Another round of partial nail avulsion with phenolisation was arranged once the ingrown nail infection had settled. Like what the previous members had said, it is wise to do a good medical history taking prior surgery.

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Miss Gangrene

I think that it is very wise in all cases where there is any doubt at all about the patient's ability to undergo any procedure, to firstly consult with their G P and follow their advice. It is so easy to allow oneself to forget the limitations of our profession and be led into the taking of risks that can have very far reaching results

Hello All
I am so glad I browsed this thread! I have been doing nail surgery for 9 years post graduaton and I cannot recall a single mention of this phenomenom. I will certainly be passing this info on to the rest of the Pods I work with.
Many thanks
Yvonne