Published by : PROFESSIONAL MEDICAL PUBLICATIONS
April - June 2009 (Part-II)
Brachial plexus injury due to median
sternotomy and lima harvesting
Halil Basel1, Unal Aydin2, Abdussamed
Aysenur Dostbil4, Özlem Tekin5, Sahin Kapan6
Objective: Brachial plexus injury is an unusual and under-recognised complication of coronary artery bypass grafting especially when internal mammary artery harvesting takes place. It is believed to be due to sternal retraction resulting in compression of the brachial plexus. Although the majority of cases are transient, there are cases where the injury is permanent and may have severe implications as illustrated in the accompanying case history. We investigated that injury to the brachial plexus was retrospectively assessed in the results of eight patients who underwent median sternotomy for open heart surgery.
Methodology: Between March 2006 and October 2008, 455 patients underwent cardiac surgery with median sternotomy. In post operative period peripheric neuropathy symptoms were observed in eight (1.7%) patients. All patients were placed in the hands up position after right internal jugular vein cannulation, and internal mammary artery was prepared for all those patients. The symptoms were classified as pain, sensory impairment and motor impairment.
Results: Brachial plexus injury was detected postoperatively in these eight patients. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables. Full recovery occured in seven of eight (87%) patients after six monthes, one (13%) patient suffered from disesthesia.
Conclusion: It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period.
KEY WORDS: Barchial Plexus Injuiry, LIMA Harvesting.
Pak J Med Sci April - June 2009 (Part-II) Vol. 25 No. 3 424-427
How to cite this article:
Basel H, Aydin U, Hazar A, Dostbil A, Tekin O, Kapan S. Brachial plexus injury due to median sternotomy and lima harvesting. Pak J Med Sci 2009;25(3): 424-427.
1. Halil Basel, MD
2. Unal Aydin, MD
1,2: Van Yüksek Ihtisas Education and Research Hospital,
Cardiovascular Clinics, Turkey.
3. Abdussamed Hazar, MD
Faculty of Medicine,
Harran University Cardiovascular Clinics, Turkey.
4. Aysenur Dostbil, MD
5. Ozlem Tekin, MD
4,5: Van Yüksek Ihtisas Education and Research Hospital Anestesia Clinics, Turkey.
6. Sahin Kapan, MD
Van Yüksek Ihtisas Education And Research Hospital
Cardiovascular Clinics, Turkey.
Dr. Halil Basel, MD
Van yüksek ihtisas egitim araştırma hastanesi,
E Mail: firstname.lastname@example.org
* Received for Publication: March 17, 2009
* Revision Received: April 11, 2009
* Revision Accepted: May 7, 2009
Brachial plexus injuries have been recognised for many years as a complication of cardiothoracic surgery. A prospective analysis of 455 patients undergoing coronary artery bypass graft (CABG) surgery as the sole cardiac procedure was carried out to assess the frequency of brachial plexus injury complications. In all, 455 variables were assessed in each patient. In several published retrospective series prevalence varied between 2% and 38%, but previously reported prospective studies prevalance varried between 0.5% and 9.6%.1 The neurological poblem that affects cervical eight and thoracal one vertebra is mostly caused by mechanical trauma secondary to improperly applied sternal retractors, preperation of the internal mamarial artery, canulation of internal juguler vein.2
Our objective is to report our experience by describing the clinical details of eight patients, since the condition my not always be recognised in cardiac surgical units.
A prospective study is reported of the prevalence, the clinical picture and the course of plexus brachialis lesions following median sternotomy during heart operations. The study comprises 455 patients operated in two years. In 8 patients (1.7%) a lesion of the lower plexus brachialis was found postoperatively. The neurological examination considered of a detailed history regarding upper extremity pain, paresthesia, numbness, and weakness and of a thorough examination of all motor and sensory functions supplied by the brachial plexus (Table-I). In two patients the plexus lesion was combined with an ipsilateral Horner syndrome. The present study suggests that in spite of cautious use of the sternal retractor, the appearance of a postoperative plexus lesion cannot be completely avoided. The Horner syndromes, however, may remain for a longer time period.3 It is advisable that patients who have to undergo a heart operation with median sternotomy should be informed before hand about the possible side-effects described here.
Right internal jugular vein canulation was performed. All operations were performed with membrane oxigenators, aortic and bicaval cannulation, and moderate hypothermia (30 C). All patients were placed in the hands-up position, and internal mamarial artery was prepared for all these patients. Within the first three days each patient was reexamined. Whenever a difference between the preoperative and the postoperative state was found, the patients were reviewed with a consulting neurologist to examine the relationship of the assumed neurologic deficits to the brachial plexus. Nerve conduction measurements and electromyography were performed besides neurological examination. These examinations were performed seven days after the operation and were repeated about four weeks and six months postoperatively. Brachial plexus injury was detected in 8 cases (1.7%) of 455 patients who had undergone coronary artery bypass grafting with median sternotomy after investigation of the whole group of patients.
Brachial plexus injury was detected in eight cases (1.7%) of 455 patients who had undergone median sternotomy for open heart operation in our clinic. There were two female and six male patients, and the mean age was 58.12 years. Diabetes mellitus was assesed in two patients as a multisystemic disorder. In all these cases the initial symptoms were pain, motor and sensorial disturbances at the affected upper limb (in the left arm in all cases).
The common characteristic was that LIMA was grafted to the left anterior descending artery in all cases. A significiant difference in surgical procedure wasnt determined in any of the patient. Age wasnt determined as an influencing factor for brachial plexopathy. Predisposing factors were diabetes and carpal tunnel syndrome in the group, however a meaningful relationship between predisposing factors and pathology couldnt be concluded because of small number of patients. Seven of eight patients (87%) achieved full recovery at the mean time of 8.2 (range 1-24) weeks. One patient persisted suffering from disesthesia in the affected upper limb, and still full recovery couldnt be achieved . It was observed that recovery of sensory disorders were the first and fast when compared to the other disorders.
Brachial plexus injury during median sternotomy is a rare complication. The 1.7% incidance of upper extremity brachial plexus injury in this study is smilar to that in several proviously reported prospective studies (Table-II). Several factors have been associated with brachial plexus injury, including concomitant patient disease, anatomical variations, positioning of the patient, surgical and physiological factors.4,5
These pathogenetic concepts are supported by the most striking result of our study: the coincidence between LIMA preparation as graft for CABG and the subsequent prevalence of brachial plexus lesions. Internal mammary artery (IMA) preparation requires both a wide opening of the retractor and asymmetric traction to allow visualization of the costosternal junctions. The Favaloro retractor fulfills this requirement by constant traction of the left sternal half during the IMA preparation. However, this period of constant traction may lead to brachial plexus lesions.6,7 In addition, in our patients positioning of the arm did correlate with the prevalence of brachial plexus lesions. The causes of brachial plexus injury may have been asymmetric traction of the retractor for good exposure in our eight cases. It was reported that placement of an internal jugular cannula had been implicated as a cause of brachial plexus injury.8 In our series internal jugular cannula was performed to the patients from the right side and symptoms were determined at the left side of the patients. Therefore we believe that there were no brachial plexus injury relited to internal juguler vein cannulation in this series.
Vander Salm et al. have documented that median sternotomy can cause first rib fractures and the fractured ribs can cause brachial plexus pathologies.7,8 In our series chest X-rays were detected and first rib fracture or another musculosceletal injury wasnt observed. Brachial plexus injuries can be seen in two various forms. The former is characterized by a predominance of sensory complaint in the lower roots of the plexus and the latter by a predominance of motor deficit in the upper and middle roots. The former is far more frequent than the latter, with an excellent prognosis for recovery.9,10 In one of our eight cases the inferior roots were affected and there was completely no improvement.
To avoid these serious complications there are some preventive measures; Exact median sternotomy should be performed. Caudal localization of the retractor should be attempted.11,12 Constant traction on the sternal halves should be reduced. Asymmetric traction should be avoided when possible. Retractors designed for asymmetric traction should be used with extreme caution. Postoperative neurologic assessment should be performed in every patient to allow early detection and therapy of nerve lesions.13,14
There are no reports in the literature of routine preoperative and postoperative electrophysiological studies in large patient groups to evaluate brachial plexus injury during open heart surgery.15,16 It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk.17,18 However, these peripheral nerve problems are usually not considered clinically important and are not investigated.19 Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period. Plexus injury after median sternotomy differs in that it is common, with an estimated incidence of 2%38% despite care to avoid malposition of the arms and typically involves the lower plexus roots .
Increasing use of internal mammary artery grafts in coronary artery bypass demands measures to protect the brachial plexus. The most important measure for the low incidence and benign course of brachial plexus problems in these patients resulted from careful sternal retraction and use of the hands-up positions. Inappropriate sternal retraction during preparation of internal mammary artery should be avoided.
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10. Tajiri O,Tateda T, Sugihara H,Yokoyama H, Nishikido O, Mukumoto C. Brachial plexus neuropaty following open-heart surgery. Masui 2004;53(4):407-10.
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12. Ben-David B, Stahl S. Prognosis of intraoperative brachial plexus injury: a review of 22 cases. Br J Anaesth 1997;79:440-5.
13. Bonatti J, Coulson AS, Bakhshay SA, Posch L, Sloan TJ. The subclavian and axillary arteries as inflow vassels for coronary artery bypass grafts combined experience from three cardiac surgery centers. Heart Surgery Forum 2000;3(4):307-11.
14. Bonatti J, Hangler H, oturanlar D, posch L, Müler LC, Voelckel W et all. Beating heart axillo coronary bypass for management of the untouchable ascending aorta in coronary bypass grafting. Eur J Cardiothoracic Surg 1999;16(2):18-23.
15. Stoelting RK. Brachial plexus injury after meian sternotomy an unexpected liability for anestesiologists. J Cardiothorac Vasc Anesth 1994;8(1):2-4.
16. Hudson DA, Boome R, Sanpera I. Brachial plexus injury after median sternotomy. J Hand Surg 1993;18(2):282-4.
17. Marganitt B, Shemesh Y, Golan M, Lin E, Engel J. Subclinical brachial plexopathy following median sternotomy. Orthop Rev 1986;15:305-10.
18. Suziki S, Kikuchi K, Takagi K, Masuda H, Yoshizu H, Tanaka S, et al. Nippon Kyubu geka Gakkai Zasshi 1990;38(9):1459-62.
19. Grocott HP, Clark JA, Homi HM, Sharma A. Other Neurologic Complications After Cardiac Surgery. Seminars in Cardiothoracic & Vascular Anesthesia 2004;8(3):213-26.
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