Post-operative Paralysis of the Brachial Plexus

Abstract

Post-operative Paralysis of the Brachial Plexus Several instances of post-operative injury to the brachial plexus have been reported recently by Ewing (1950) and by Kiloh (1950), and it seems reasonable that more publicity should be given to such an avoidable complication of surgical operation. The following two patients received a muscular relaxant, but it is considered a fallacy to associate the rising incidence of this complication entirely with the introduction of these drugs. CASE REPORTS Case 1.-A married woman aged 44 had a total hysterectomy performed on March 24, 1949. Anaesthesia was obtained by sodium thiopentone, nitrous oxide, and ether, and relaxation by "flaxedil " given into a right forearm vein, with the arm abducted to 90 degrees. The patient was tilted into a fairly steep Trendelenburg position, with padded shoulder-rests in support. The right arm was abducted for 100 minutes and the Trendelenburg position maintained for 50 minutes. On regaining consciousness the patient complained of generalized weakness of the right arm, with numbness of the right thumb

Electrophysiological findings in pressure palsy of the brachial plexus.

“…tion of involvement (Buidinger, 1894;Krumm, 1895;Garrigues, 1897;Clausen, 1942;Ewing, 1950;Kiloh, 1950;Raffan, 1950;Wood-Smith, 1952;Kwaan and Rappaport, 1970; Table 4). An affection of the whole brachial plexus occurred in about three-quarters of the cases, and was com-plete in about 60%.…”

“…Two main mechanisms of postoperative brachial plexus injury have been postulated: (1) stretching or traction of the plexus itself or its roots (Budinger, 1894) the degree of recovery could not be evaluated as they died shortly after the operation. (Clausen, 1942;Raffan, 1950;Wood-Smith, 1952;Jackson and Keats, 1965); (2) pressure injury either between the clavicle and the first rib (Budinger, 1894), or between the clavicle and the transverse processes of the fifth and sixth cervical vertebrae (Krumm, 1896), or by pressure of the plexus on the head of the humerus when the extended arm was in external rotation (Braun, cited by Garrigues, 1897;Gurry, 1954). It may reasonably be assumed, on account of clinical and electrophysiological findings, that the mechanism of injury is the same in the postoperative as in the pack palsy.…”

Peripheral nerve injuries associated with anaesthesia

“…In preventing brachial plexus lesions, abduction of the arm should preferably be limited to 90° or less. Even with the use of lockable armboards, plexus injury has been reported with the arm abducted to as little as 60°[63]. If 90° abduction is necessary, the elbow should not be fully extended.…”

“…If the arm is to be suspended, then limitation of arm abduction to 90° is essential. The dependent arm should be anterior to the thorax to avoid compression of the brachial plexus on that side [63]. In the lateral position the head must be properly supported so that the cervical and thoracic portions of the vertebral column are kept in the same horizontal position [63].…”

Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies

“…Five case reports 30,46,49,51,53 described radial or ulnar nerve damage occurring when a blood pressure monitoring device was used intraoperatively (category B3 evidence). Two case reports 20,54 described brachial plexus neuropathies occurring when shoulder braces or rests were used (category B3 evidence). One case re-port 50 described isolated radial nerve palsy occurring in a prone patient with an arm abducted over a Foster frame, and one case report 48 described radial neuropathy occurring in a supine patient undergoing coronary artery bypass grafting with an arm compressed by a self-retaining sternal retractor (category B3 evidence).…”