Postoperative pain management with opioid-only epidural analgesia for upper extremity surgery in a patient with chronic inflammatory demyelinating polyneuropathy

Dear Editor,
This letter introduces a promising perioperative pain management stra­tegy using epidural analgesia with opioids alone, without local anaesthe­tics, for upper extremity surgery in a patient with motor and sensory deficits of the arms and fingers due to chronic inflammatory demyelinating polyneuropathy (CIDP).
This case concerns a 51-year-old man with CIDP (written informed consent for publication was obtained from the patient). Approximately 3 years ago, he experienced sensory disturbances in both lower limbs, mainly in bilateral plantar areas. He was treated with steroid pulse therapy, intravenous administration of immunoglobulin, and plasmapheresis repeatedly. However, his neurological symptoms repeatedly improved and worsened. Recently, he had palsy, gait disturbance in both lower limbs, and sensory disturbance in the plantar region due to the sensory ataxic neuropathy caused by CIDP. The left upper extremity had numbness, hypaesthesia, muscle weakness and difficulty of movement distally from the elbow including his left-side fingers. The right upper extremity had numbness distal to the wrist; however, he could still manage to move the right-hand fingers. Thus, he managed to use only his right hand at work and walked with the right hand on crutches.
He suffered a fall at home and had a left proximal humerus fracture (Figure 1). Upon examination, a humeral head replacement was indicated. This procedure is associated with very severe postoperative pain, and general anaesthesia with brachial plexus block is generally the first choice. However, it was unclear whether a brachial plexus block with local anaesthetic was appropriate for our patient as he had pre-existing difficulty in moving his left upper arm and fingers and paraesthesia in his left hand due to CIDP. Therefore, alternative postope­rative pain management strategies were considered, without worsening the numbness and difficulty of movement in the upper arm and fingers. The anaesthesiologist determined that epidural analgesia with opioids alone, without local anaesthetics, was the most suitable for postoperative pain management in this case. Although morphine and fentanyl are the opioids available for neuraxial analgesia in Japan, morphine was chosen to be administered using an epidural catheter. This was because hydrophilic morphine is slowly absorbed by the tissues, can diffuse into the cerebrospinal fluid (CSF), and exerts its analgesic effect in a wider...


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