Kyphosis – A risk factor for positioning brachial plexopathy during spinal surgeries

Abstract

Objective The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials – TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes. Methods In the period of January 2011–January 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10–32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neurofibromatosis, posterior thoracic hemivertebra), and the rest of the 53 patients had a scoliotic trunk deformity (mostly adolescent idiopathic scoliosis – AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy. Results Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (≥65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, confirming significant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group. Conclusion It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb. Level of Evidence Level IV Therapeutic Study.

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“…Additionally, PP may cause traction on the humerus, either on its flexion or extension, leading to increased intraneural venous pressure, local edema, and impairment in the axoplasmic transmission of the elements that compose the brachial plexus (33) . as well as palpating the tendon of the pectoralis major muscle to monitor its tension (34)(35) .…”

Upper Extremity Monoplegia following Prone Surrender Position for Spinal Surgery

“…6,7 Other rare idiopathic and inflammatory factors likely play a significant role in its presentation. 8,9 However, the leading cause of PPNI development is positioning during long-lasting surgeries in the prone steep Trendelenburg position, with shoulder or wrist traction. 1 The proximity of the brachial plexus to mobile bony structures increases the risk of damage when stretched or compressed secondary to improper surgical positioning.…”

“…6 7 Other rare idiopathic and inflammatory factors likely play a significant role in its presentation. 8 9 However, the leading cause of PPNI development is positioning during long-lasting surgeries in the prone steep Trendelenburg position, with shoulder or wrist traction. 1…”

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“…34 In one study, the risk of position-related brachial plexopathy was elevated in patients with kyphotic deformities. 35 For lower extremity SSEPs, the tibial nerve is stimulated at the ankle. Alternatively, the common peroneal nerve may be stimulated at fibular head or popliteal fossa in patients in whom tibial SSEPs are difficult to obtain due, for example, to peripheral neuropathy.…”

“…34 In one study, the risk of position-related brachial plexopathy was elevated in patients with kyphotic deformities. 35…”