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Ipsilateral Brachial Plexus Block and Hemidiaphragmatic Paresis as Adverse Effect of a High Thoracic Paravertebral Block
  1. Steven H. Renes, MD*,
  2. Geert J. van Geffen, MD, PhD*,
  3. Miranda M. Snoeren, MD,
  4. Matthieu J. Gielen, MD, PhD* and
  5. Gerbrand J. Groen, MD, PhD,§
  1. From the Departments of *Anesthesiology and
  2. Radiology, Radboud University Nijmegen Medical Center, Nijmegen;
  3. Pain Centre Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands; and
  4. §Division of Perioperative Care and Emergency Medicine, Department of Anesthesiology, University Medical Center, Utrecht, The Netherlands.
  1. Address correspondence to: Steven H. Renes, MD, Department of Anesthesiology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands (e-mail: s.renes{at}


Background: Thoracic paravertebral block is regularly used for unilateral chest and abdominal surgery and is associated with a low complication rate.

Case Reports: We describe 2 patients with an ipsilateral brachial plexus block with Horner syndrome after a high continuous thoracic paravertebral block at T2-3. One patient also developed an ipsilateral hemidiaphragmatic paresis, an adverse effect that has not been reported before.

Subsequent radiologic examination revealed a limited thoracic cephalad spread of the radiopaque dye and a laterally ascending spread from the thoracic paravertebral space toward and around the brachial plexus. We offer potential explanations for these phenomena.

Conclusions: Brachial plexus block can occur by a route parallel to a nerve connecting the second intercostal nerve and T1 nerve, that is, Kuntz nerve. The hemidiaphragmatic paresis was attributed to the ascending spread of local anesthetic toward the area where the phrenic nerve bypasses the subclavian artery and vein.

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  • This work was sponsored by an ESRA Research Grant and supported by departmental funding.