Case Report: High Nerve Sensitivity Resulting in Burning Pain During PICC Line Insertion and Electromyography

By SWA

Abstract

We present a case of a patient who experienced acute burning pain during an attempted peripherally inserted central catheter (PICC) line placement and who reported similar sensations during a prior electromyography (EMG) study. Despite the use of ultrasound guidance during PICC insertion and the absence of visible nerve structures, the patient exhibited significant procedural discomfort. The findings suggest transient nerve fiber irritation, potentially due to contact with small peripheral nerves not easily visualized by imaging. This report explores the interplay of anatomical factors, procedural technique, patient anxiety, and peripheral nerve physiology in generating these symptoms.

Introduction

Procedures involving needle insertion near vascular or neural structures may occasionally result in acute neuropathic symptoms, even in the absence of direct nerve injury. Small peripheral nerves are not always visible on ultrasound, and patient-specific factors, including heightened nerve sensitivity and anxiety, can amplify the pain response. Understanding the pathophysiology of transient nerve irritation is essential for procedural planning, patient counseling, and management.

Case Presentation

Patient Characteristics

The patient presented for placement of a PICC line for long-term intravenous access. Prior to the procedure, the patient was noted to be extremely anxious, expressing significant apprehension about potential discomfort.

PICC Line Insertion Procedure

  • Preparation and Technique: The procedure was performed under sterile conditions utilizing ultrasound guidance to identify the right basilic vein.

  • Initial Insertion: As the insertion needle was advanced, the patient described a sensation of pressure.

  • Acute Symptom Onset: Shortly thereafter, the patient reported sudden burning pain radiating distally down the arm.

  • Ultrasound Findings: No nerve structures were identified on ultrasound. The needle tip was visualized within the lumen of the basilic vein.

  • Intervention and Outcome: Due to the onset of burning pain, the needle was promptly withdrawn. The patient requested termination of the procedure, citing fear of further discomfort. The procedure was discontinued, and the consult for PICC placement was deferred.

  • Post-Procedure Status: The patient subsequently denied any persistent numbness, weakness, or neuropathic symptoms, indicating a transient event without lasting nerve injury.

Differential Considerations for Burning Pain During PICC Insertion

1. Peripheral Nerve Contact or Irritation

While ultrasound guidance can identify major vascular and nerve structures, small peripheral nerves—particularly branches of the medial antebrachial cutaneous nerve and components of the median and ulnar nerves—may not be visualized. Needle contact, compression, or stretching of these fibers may result in:

  • Burning or radiating pain

  • Paresthesia

  • Transient sharp, electric sensations

Such transient symptoms suggest superficial nerve fiber irritation rather than structural nerve damage.

2. Vein Wall Trauma

Partial puncture or penetration through the vein wall may lead to irritation of adjacent tissues, with potential contributing factors including:

  • Localized hematoma formation

  • Tissue swelling or stretching

  • Chemical irritation secondary to blood leakage

These mechanisms can stimulate nearby sensory fibers, producing burning or aching sensations.

3. Anxiety-Related Heightened Sensitivity

The patient’s significant anxiety likely amplified the pain experience through:

  • Increased central nervous system sensitivity to peripheral input

  • Lowered pain thresholds

  • Sympathetic nervous system activation, potentially contributing to nerve hypersensitivity

Anxiety is well-documented to enhance both somatic and visceral sensory perception.

Similar Symptoms During EMG: A Shared Mechanism

The patient previously reported comparable burning sensations during an EMG procedure involving the lower extremity, particularly when the EMG needle was manipulated laterally within the muscle tissue.

Mechanism of EMG-Related Discomfort

  • Anatomical Proximity: Peripheral nerves such as the peroneal, tibial, and sural nerves lie adjacent to muscle groups commonly tested during EMG.

  • Needle-Induced Irritation: Insertion or manipulation of the EMG needle may inadvertently contact or stretch small nerve fibers.

  • Muscle Contraction: Induced muscle activity can place tension on nearby nerves, further contributing to nerve fiber activation.

The patient’s consistent symptoms in both procedural settings suggest a common underlying mechanism of mechanical nerve fiber irritation.

Pathophysiology: A-delta and C-fiber Involvement

The described pain characteristics are consistent with activation of both A-delta and C-fiber sensory neurons:

A-delta Fibers

  • Lightly myelinated

  • Rapid conduction velocity (5–30 m/s)

  • Mediate sharp, localized, immediate pain responses

C-fibers

  • Unmyelinated

  • Slow conduction velocity (0.5–2 m/s)

  • Mediate burning, aching, and diffuse pain sensations

  • Involved in prolonged discomfort following initial injury

The combination of these fiber types being stimulated can explain the patient’s acute sharp pain followed by burning, lingering sensations.

Arm Positioning and Tissue Manipulation

Patient positioning during PICC line insertion may also contribute to nerve irritation:

  • Hyperextension or rotation of the arm may place tension on nerves running alongside vascular structures.

  • Tissue manipulation during vein cannulation may compress or stretch nearby nerves, leading to transient paresthesias.

Clinical Outcome and Implications

The patient’s symptoms resolved fully without residual neurological deficits, strongly suggesting transient nerve irritation rather than permanent injury.

Discussion

This case highlights several critical considerations for clinicians performing procedures near peripheral nerves:

  • Small nerve branches are often not visible on ultrasound.

  • Even brief mechanical contact with peripheral nerves can provoke significant symptoms.

  • Anxiety can significantly heighten procedural pain and sensory amplification.

  • A-delta and C-fiber activation explain the combination of sharp and burning sensations often reported.

  • Immediate recognition of nerve irritation and prompt cessation of the procedure may prevent further distress or injury.

Conclusion

Procedures involving needle insertion near vascular or neuromuscular structures carry inherent risks of transient nerve irritation, even when performed with meticulous technique. Recognizing the role of peripheral nerve anatomy, procedural mechanics, and patient-specific factors such as anxiety is essential for minimizing discomfort and ensuring safe outcomes. This case underscores the importance of clinician awareness and patient-centered management strategies when confronted with acute neuropathic symptoms during invasive procedures.

References

Peripheral Nerve Injury

  1. Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol. 2008;119(9):1951-1965.
    doi:10.1016/j.clinph.2008.03.018

  2. Mackinnon SE. Pathophysiology of nerve injury. Clin Plast Surg. 2003;30(1):109-126.
    doi:10.1016/S0094-1298(02)00044-8

  3. Kline DG, Hudson AR. Nerve injuries: operative results for major nerve injuries, entrapments, and tumors. Philadelphia: W.B. Saunders; 1995.

PICC Line Complications

  1. Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382(9889):311-325.
    doi:10.1016/S0140-6736(13)60592-9

  2. Dawson RB, Murray L. PICC complications: a review. J Infus Nurs. 2003;26(2):88-92.
    doi:10.1097/00129804-200303000-00004

  3. Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol. 2003;14(5):527-534.
    doi:10.1097/01.RVI.0000071090.52594.CE

  4. Oliver G, Jones M. PICC placement complications. Br J Nurs. 2014;23(Suppl 2):S16-S22.
    doi:10.12968/bjon.2014.23.Sup2.S16

Procedural Pain and Anxiety

  1. Kain ZN, Sevarino F, Alexander GM, et al. Preoperative anxiety and postoperative pain in women undergoing hysterectomy: a repeated-measures design. J Psychosom Res. 2000;49(6):417-422.
    doi:10.1016/S0022-3999(00)00180-0

  2. McGreevy K, Bottros MM, Raja SN. Preventing chronic pain following acute pain: risk factors, preventive strategies, and their efficacy. Eur J Pain Suppl. 2011;5(2):365-372.
    doi:10.1016/j.eujps.2011.08.002

  3. Geva N, Defrin R. Chronic pain and acute pain intensity: a comparative study. J Pain. 2018;19(3):378-387.
    doi:10.1016/j.jpain.2017.10.010

Nerve Fiber Physiology (A-delta and C fibers)

  1. Treede RD, Kenshalo DR, Gracely RH, Jones AK. The cortical representation of pain. Pain. 1999;79(2-3):105-111.
    doi:10.1016/S0304-3959(98)00184-5

  2. Dubin AE, Patapoutian A. Nociceptors: the sensors of the pain pathway. J Clin Invest. 2010;120(11):3760-3772.
    doi:10.1172/JCI42843

  3. Basbaum AI, Bautista DM, Scherrer G, Julius D. Cellular and molecular mechanisms of pain. Cell. 2009;139(2):267-284.
    doi:10.1016/j.cell.2009.09.028

  4. Fields HL. Pain modulation: expectation, opioid analgesia and virtual pain. Prog Brain Res. 2000;122:245-253.
    doi:10.1016/S0079-6123(08)62138-1

General Pain Mechanisms (Good for Background)

  1. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in pain. Science. 2000;288(5472):1765-1769.
    doi:10.1126/science.288.5472.1765

  2. Tracey I, Mantyh PW. The cerebral signature for pain perception and its modulation. Neuron. 2007;55(3):377-391.
    doi:10.1016/j.neuron.2007.07.012

 

© 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742

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