Brachial Plexus Neuropathies During the COVID-19 Pandemic: A Retrospective Case Series of 15 Patients in Critical Care

Abstract

Objective The utilization of the prone position to treat patients with COVID-19 pneumonia who are critically ill and mechanically ventilated is well documented. This case series reports the location, severity, and prevalence of focal peripheral nerve injuries involving the upper limb identified in an acute COVID-19 rehabilitation setting. The purpose of this study was to report observations and to explore the challenges in assessing these patients. Methods Participants were patients with suspected peripheral nerve injuries following discharge from COVID-19 critical care who were referred to the peripheral nerve injury multidisciplinary team. The patients studied had suspected peripheral nerve injuries following discharge from COVID-19 critical care and were referred to the peripheral nerve injury multidisciplinary team. Data were collected retrospectively on what peripheral neuropathies were observed, with reference to relevant investigation findings and proning history. Results During the first wave of the COVID-19 pandemic in the United Kingdom, 256 patients were admitted to COVID-19 critical care of Queen Elizabeth Hospital, Birmingham, United Kingdom. From March to June 2020, a total of 114 patients required prone ventilation. In this subgroup, a total of 15 patients were identified with clinical findings of peripheral nerve injuries within the upper limb. In total, 30 anatomical nerve injuries were recorded. The most commonly affected nerve was the ulnar nerve (12/30) followed by the cords of the brachial plexus (10/30). Neuropathic pain and muscle wasting were identified, signifying a high-grade nerve injury. Conclusion Peripheral nerve injuries may be associated with prone positioning on intensive care units, although other mechanisms, such as those of a neuroinflammatory nature, cannot be excluded. Impact Proning-related upper limb peripheral nerve injuries are not discussed widely in the literature and may be an area of further consideration when critical care units review their proning protocols. Physical therapists treating these patients play a key part in the management of this group of patients by optimizing the positioning of patients during proning, making early identification of peripheral nerve injuries, providing rehabilitation interventions, and referring to specialist services if necessary.

Peripheral neuropathy in COVID-19 is due to immune-mechanisms, pre-existing risk factors, anti-viral drugs, or bedding in the Intensive Care Unit

“…Altogether, 105 articles about SARS-CoV-2-associated neuropathy describing 220 patients with Guillain-Barré syndrome (GBS) 4 and 41 patients with non-GBS neuropathy were retrieved 5,6,7,8,9,10,11,12,13,14 . The age of these 261 patients, reported in 244 of them, ranged from 8 to 94 years.…”

“…Drugs known to cause neuropathy and given to patients included daptomycin 15 , linezolid 16 , lopinavir 17 , ritonavir 18 , hydro-chloroquine 19 , cisatracurium 20 , clindamycin 21 , tocilizumab 22 , and glucocorticoids 23,24 . Compression neuropathy was diagnosed in 18 cases 9,10,14 . Nerve conduction studies (NCSs) showed axonal lesion in four patients 6 and plexopathy in one patient 10 .…”

“…Unfortunately, no further details about this patient were provided. A disadvantage of the study of 15 patients with brachial plexopathy conducted by Miller et al is that the latency between onset of COVID-19 and onset of neuropathy, treatment, and outcome were not provided and that no NCSs had been carried out 14 . In the case reported by Faquihi et al, weakness of lower limbs had developed already prior to application of lopinavir/ritonavir, ribavirin, interferon beta-1b, broad spectrum antibiotics, vasopressors, and hydrocortisone 8 .…”

Neurological update: COVID-19

“…Interestingly, there appears to be a predominance of frontal lobe EEG abnormalities in COVID-19, which has been raised as a potentially pathognomonic feature of encephalopathy in COVID-19; other described abnormalities, such as epileptiform discharges, are commonly the result of underlying or pre-existing neurological pathology [115]. Prolonged periods of immobility, and particularly the use of pronepositioning for the amelioration of refractory hypoxaemia are associated with compressive and traction neuropathies and plexopathies [50,116,117]. Common risk factors for the development of critical illness polyneuromyopathy, such a prolonged ventilation, systemic inflammatory response syndrome, acute respiratory distress syndrome and multiorgan failure [118] are all frequently seen in COVID-19 [63], leading to a high occurrence of this condition [119].…”

Biosensing surfaces and therapeutic biomaterials for the central nervous system in COVID-19

“…6 Pro-sensing biohybrids for the generation of accelerated antiviral immunity applicable to the first sensory interface between the host and SARS-CoV-2 associated proteins, myelin-associated glycoprotein, neurite outgrowth inhibitor (Nogo-A), oligodendrocyte/myelin glycoprotein, ephrins, chondroitin sulfate proteoglycans, and semaphorin 3A (Sema3A) along with activated microglia and macrophages and glial scar, and providing guidance cues to neural stem cells (NSC) by different mechanisms that contribute to the regulation of NSC differentiation [133]. COVID-19-associated nerve injuries mostly rooted in the ulnar nerve and the cords of the brachial plexus are presented by neuropathic pain and muscle wasting and affect the upper limb [134]. In addition to the effect of prolonged prone positioning [135] and related nerve compression injuries and vascular suppression and hematoma and related entrapment of the nerve(s) [136], neuroinflammation plays a role in nerve damages due to COVID-19.…”