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Factors Impacting Outcomes of Peripheral Nerve Blockade in Children With Charcot-Marie-Tooth Disease Undergoing Foot
Maryse Bouchard1,2, María Galán-Olleros1, Lipika Soni3
1Division of Orthopaedics, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Peripheral nerve blockade (PNB) is safe for pediatric Charcot-Marie-Tooth (CMT) patients undergoing foot surgery, with no permanent neurologic complications observed. Pain management was effective, though some patients experienced prolonged block duration, particularly those with CMT1F.
Area of Science:
- Neurology
- Pediatric Surgery
- Anesthesiology
Background:
- Charcot-Marie-Tooth (CMT) disease is a common inherited peripheral neuropathy in children, often necessitating surgical correction for foot deformities.
- Peripheral nerve blockade (PNB) is a key component of perioperative pain management, but its safety in pediatric patients with pre-existing neuropathy is not well-established.
- Concerns exist regarding a potential 'double crush' phenomenon, where PNB might worsen existing neurologic deficits.
Purpose of the Study:
- To evaluate the neurologic outcomes and postoperative analgesia following peripheral nerve blockade (PNB) in pediatric patients diagnosed with Charcot-Marie-Tooth (CMT) undergoing foot surgery.
- To assess the safety and efficacy of PNB as part of multimodal analgesia in this specific patient population.
Main Methods:
- Retrospective review of pediatric patients (<18 years) with genetically confirmed CMT who underwent foot surgery with PNB between 2017 and 2023.
- Primary outcome: incidence of new or worsened postoperative neurologic deficits potentially linked to PNB.
- Secondary outcomes: postoperative pain scores, opioid consumption within 72 hours, and block duration; exploratory genotype-specific analyses were conducted.
Main Results:
- The study included 15 children (22 operative sessions, 24 limbs, 56 PNBs), with 71% undergoing bilateral surgery and 53% requiring combined soft-tissue and bony correction.
- Postoperative pain scores were generally low and decreased over 72 hours; 50% of sessions required low-dose opioids.
- Transient neurologic deficits occurred in 8% of limbs, and prolonged block duration in 29%. CMT1F patients showed a trend towards higher frequencies of these outcomes.
Conclusions:
- Peripheral nerve blockade (PNB) did not result in permanent neurologic complications in pediatric Charcot-Marie-Tooth (CMT) patients undergoing foot surgery.
- Multimodal analgesia including PNB provided effective pain control, with opioid use in approximately half of the cases.
- The higher incidence of prolonged block in the small CMT1F subgroup warrants further investigation in larger, genotype-stratified studies.
Background:
Charcot-Marie-Tooth (CMT) disease is the most common inherited peripheral neuropathy in children and frequently causes progressive foot deformities requiring surgical correction. Peripheral nerve blockade (PNB) is central to multimodal perioperative analgesia, yet concerns persist that it may exacerbate pre-existing neuropathy through a "double crush" mechanism. Evidence on PNB safety in pediatric CMT remains limited.
Aims:
This study evaluated neurologic outcomes and postoperative analgesia after PNB in children with CMT undergoing foot surgery.
Methods:
As part of a quality-improvement initiative, we retrospectively reviewed all patients under 18 years of age with genetically confirmed CMT who underwent foot surgery with PNB between 2017 and 2023. The primary outcome was the presence of new or worsened postoperative neurologic deficits potentially attributable to PNB. Secondary outcomes included postoperative pain scores, opioid use within 72 h, and prolonged block duration. PNB-related variables were analyzed descriptively, with exploratory genotype comparisons.
Results:
Fifteen children underwent 22 operative sessions involving 24 limbs, corresponding to 34 foot procedures and 56 PNBs. Seventy-one percent of foot procedures were performed as part of bilateral simultaneous surgery, and 53% included combined soft-tissue and bony correction. Median age was 12 years (IQR 10.5-12.5), and 67% were female. A popliteal/sciatic block was performed in all procedures, often combined with saphenous (50%) or adductor canal (15%) blocks. Pain scores were generally low and decreased over the first 72 postoperative hours, with low-dose opioid use documented in 11/22 operative sessions (50%). Two limbs (8%) developed transient postoperative neurologic deficits, and seven limbs (29%) had prolonged block duration. In exploratory patient-level analyses, both outcomes occurred more frequently among patients with CMT1F (p = 0.057 and p = 0.0037, respectively), who comprised four patients (27% of the cohort).
Conclusions:
In this pediatric CMT cohort, no permanent neurologic complications potentially attributable to PNB were observed. Pain scores were generally low in the context of multimodal analgesia, although low-dose opioids were required in about half of cases. The increased frequency of prolonged block in patients with CMT1F should be interpreted cautiously given the small subgroup size and may warrant prospective genotype-stratified investigation.
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