Case 1
A 28-year-old male patient undergoing venous blood sampling was punctured in the middle of the antecubital fossa of the left arm with a 21-gauge needle. During the procedure, he felt a sharp, electrical pain throughout his arm, extending from the venipuncture site to the tip of the fingers. The intensity of the pain was rated as 8/10 in the visual analog scale (VAS). After the needle was withdrawn, he experienced dysesthesia and burning pain in the anterior wrist and the anterior, lower half of his forearm, which was rated as 7-8/10 on the VAS and lasted for more than 24 h.
Since the pain and discomfort did not subside even after 24 h, he visited the pain clinic for evaluation and management. After a brief medical interview and physical examination to rule out peripheral neuropathy, ultrasonographic examination of the venipuncture site was performed to accurately assess the nerve. It revealed segmental swelling and perineural echogenic changes in the lateral antebrachial cutaneous branch of the musculocutaneous nerve at the forearm level (Fig. 1A), between the biceps brachii tendon and the punctured cephalic vein at the antecubital level, compared with contralateral side, suggestive of neuritis with perineural hemorrhage (Fig. 1B).
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Low amplitudes in the left lateral and medial antebrachial cutaneous nerves were observed on a sensory nerve conduction study (NCS) performed on the same day, suggesting left lateral and medial antebrachial cutaneous neuropathy.
Consequently, a nerve block of the injured nerve was promptly performed on the same day. After local infiltration with 2% mepivacaine, a mixture of 0.75% ropivacaine (1 ml) , triamcinolone (20 mg) , and normal saline (2.5 ml) was injected around the nerve (Fig. 2). The patient experienced immediate pain relief, with no adverse effect. After the procedure, the patient reported a pain intensity of 1/10 on the VAS. Additionally, he was prescribed with prednisolone (5 mg), pregabalin (75 mg), tramadol (75 mg), acetaminophen (650 mg), and esomeprazole (20 mg) per os bis in die for a week.
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The patient experienced an intermittent shooting, electrical pain (2-3/10 in the VAS) extending anteriorly from his forearm to his wrist for a week after administering the nerve block. The medications, including pregabalin (75 mg), naproxen (500 mg), and esomeprazole (20 mg) bis in die per os were prescribed for another week. In the following two weeks after the injury, his pain and discomfort gradually reduced to a degree that was ignorable.
A follow-up ultrasonographic examination at three weeks after the injury showed an improvement in the segmental swelling and perineural echogenic changes around the affected nerve, suggesting an improvement in the neuritis and perineural hemorrhage (Fig. 1C). The patient no longer experienced pain, discomfort, or paresthesia.
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