Brachial Plexus Injury S/P ISB and Shoulder Surgery

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OpenMind10

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All,

I'm part of the quality committee at a surgery center and there is an interesting case involving an anesthesiologist and a surgeon, both of whom are quietly blaming one another for the complication. I'm a CRNA but I was not involved in the case, however, the anesthesiologist is a member of our group, and he's a friend of mine, and myself and the another anesthesiologist are on the committee and I'd like more input (I run the meetings and have been at the center for years) We're all very collegial and this has sort of rattled the center.

The patient is 2 weeks out from her shoulder surgery does not have motor abilities in her deltoid. I'm seeking input as to 1) determining the source of the injury and 2) prognosis/treatment options.


Here are the anonymized details:

38 yo female for shoulder surgery related to pain. No major cardiopulmonary disease. Has a history of tingling in the hands due to "disc issues" in her neck (per patient) which she didn't reveal in the preop eval with anesthesia or surgery. In either case, a decision was made to block presumably because of her history of pain and depression. On Wellbutrin, Seroquel, and gabapentin.

Block was without issue. Twitch monitor used, twitch gone at 0.3, Shoulder twitch present. I talked to my friend who stated he backed off the brachial plexus until the twitch was gone as everyone does. 1mg of versed only for block, 20cc of 0.5% Ropi with Dex. Classic interscalene signs after block (Horner's, mildly symptomatic one-sided diaphragmatic block)

Presumably the patient has a numb arm going into surgery, but in unusual fashion, she states she woke up with "severe cutting" pain in her shoulder immediately after surgery. Goes home after some pain medication. I'm going to review records but she didn't have a cuff repair done - seems only Subacromial decompression and distal clavicle excision.

Two weeks later the surgeon calls and complains about the block. We spoke to her.

It's an unusual presentation: Patient has full motion in her hand and elbow, and has sensory sensation though with "positional tingling" at times). She also has sensory innervation on her shoulder/deltoid area, but she has no motor. I've reviewed many mild sensory deficits after nerve blocks and shoulder surgery, all of which have resolved. I've not seen this sort of presentation previously (8 years in practice).

Obviously, everyone involved feels terrible for this woman, who is active, works as a Vet tech, and is a Mom. She is extremely nice and not accusatory at all and understands that nerve injuries happen (as she's seen in her work). But, everyone is also very concerned as well.

My questions are as follows:

It's been recommend that the patient have EMG and NCS studies in another week or two. Is there anything else that we should expect to see from the neurologist? She's already on increased amounts of OT.

It sounds to us (anesthesia) as though this is axillary nerve distribution (motor distribution to the deltoid) at the level of the divisions of the BP. If this was from the block, wouldn't we see significant motor involvement of the Medial and Radial nerve as well (coming off C7)?

Again to us (anesthesia) this sounds fairly definitive that something occurred during surgery - whether from the surgery or positioning or whatever - but we find it very unusual for the patient to be numb heading in and have "cutting pain" afterwards.

We've also advised the patient that if this doesn't heal within 3 months surgery may be necessary.

And my key question: will an EMG and NCS study be able to distinguish between an injury as a result from the inter scalene nerve block (at trunk level) vs at a lower level (i.e. divisions or cords where the axillary nerve eventually branches out)?

Thanks everyone -

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All,

I'm part of the quality committee at a surgery center and there is an interesting case involving an anesthesiologist and a surgeon, both of whom are quietly blaming one another for the complication. I'm a CRNA but I was not involved in the case, however, the anesthesiologist is a member of our group, and he's a friend of mine, and myself and the another anesthesiologist are on the committee and I'd like more input (I run the meetings and have been at the center for years) We're all very collegial and this has sort of rattled the center.

The patient is 2 weeks out from her shoulder surgery does not have motor abilities in her deltoid. I'm seeking input as to 1) determining the source of the injury and 2) prognosis/treatment options.


Here are the anonymized details:

38 yo female for shoulder surgery related to pain. No major cardiopulmonary disease. Has a history of tingling in the hands due to "disc issues" in her neck (per patient) which she didn't reveal in the preop eval with anesthesia or surgery. In either case, a decision was made to block presumably because of her history of pain and depression. On Wellbutrin, Seroquel, and gabapentin.

Block was without issue. Twitch monitor used, twitch gone at 0.3, Shoulder twitch present. I talked to my friend who stated he backed off the brachial plexus until the twitch was gone as everyone does. 1mg of versed only for block, 20cc of 0.5% Ropi with Dex. Classic interscalene signs after block (Horner's, mildly symptomatic one-sided diaphragmatic block)

Presumably the patient has a numb arm going into surgery, but in unusual fashion, she states she woke up with "severe cutting" pain in her shoulder immediately after surgery. Goes home after some pain medication. I'm going to review records but she didn't have a cuff repair done - seems only Subacromial decompression and distal clavicle excision.

Two weeks later the surgeon calls and complains about the block. We spoke to her.

It's an unusual presentation: Patient has full motion in her hand and elbow, and has sensory sensation though with "positional tingling" at times). She also has sensory innervation on her shoulder/deltoid area, but she has no motor. I've reviewed many mild sensory deficits after nerve blocks and shoulder surgery, all of which have resolved. I've not seen this sort of presentation previously (8 years in practice).

Obviously, everyone involved feels terrible for this woman, who is active, works as a Vet tech, and is a Mom. She is extremely nice and not accusatory at all and understands that nerve injuries happen (as she's seen in her work). But, everyone is also very concerned as well.

My questions are as follows:

It's been recommend that the patient have EMG and NCS studies in another week or two. Is there anything else that we should expect to see from the neurologist? She's already on increased amounts of OT.

It sounds to us (anesthesia) as though this is axillary nerve distribution (motor distribution to the deltoid) at the level of the divisions of the BP. If this was from the block, wouldn't we see significant motor involvement of the Medial and Radial nerve as well (coming off C7)?

Again to us (anesthesia) this sounds fairly definitive that something occurred during surgery - whether from the surgery or positioning or whatever - but we find it very unusual for the patient to be numb heading in and have "cutting pain" afterwards.

We've also advised the patient that if this doesn't heal within 3 months surgery may be necessary.

And my key question: will an EMG and NCS study be able to distinguish between an injury as a result from the inter scalene nerve block (at trunk level) vs at a lower level (i.e. divisions or cords where the axillary nerve eventually branches out)?

Thanks everyone -
I am an anesthesiologist, not a neurologist, so I can’t really answer your question. However, I am quite interested in both what the neurology folks will add to this and what the NCS/EMG shows. Please update this thread after the EMG. Keep in mind her pre-existing what sounds like possible cervical radiculopathy preoperatively. I would consider a C spine MRI, too.

It wouldn’t surprise me if the NCS/EMG comes back relatively normal without a definite cause.
 
I am an anesthesiologist, not a neurologist, so I can’t really answer your question. However, I am quite interested in both what the neurology folks will add to this and what the NCS/EMG shows. Please update this thread after the EMG. Keep in mind her pre-existing what sounds like possible cervical radiculopathy preoperatively. I would consider a C spine MRI, too.

It wouldn’t surprise me if the NCS/EMG comes back relatively normal without a definite cause.

You haven't gotten many responses here and a big factor is that the exam provided is not detailed enough to really comment on etiologies or even localization. It sounds like there is severe deltoid weakness but no detail is given on suprascapular/infraspinatus strength et cetera and 'ROM intact at elbow' could mean substantial biceps/triceps weakness is present. A chronic or active and chronic cervical radiculopathy is not going to result in new motor weakness, and usually doesn't cause much motor weakness at all to begin with. The EMG will be able to separate any chronic radiculopathy out regardless. The tingling in the hands is more likely carpal tunnel or ulnar neuropathy. The EMG will absolutely be abnormal if there is any objective motor weakness, unless it is done too early. Localizing is possible but depends on the extent of the injury- eg a traction injury to the plexus can be localized to upper or lower trunk, but this would not be able to be separated from the block versus operating room position traction injury. EMG does not provide 'definite cause'- it is only an extension of the neuromuscular exam.

Obviously something happened in the OR. EMG should be able to tell where the injury in the plexus is (if the neurologist is good at EMG- this is one of the more complex cases), but won't tell the etiology, and traction injuries can absolutely hit the trunk just like the block. If it is more straightforward like transection of the axillary nerve from the surgery itself, then EMG can show this, provide a prognosis on potential healing, and your problem will be solved.
 
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You haven't gotten many responses here and a big factor is that the exam provided is not detailed enough to really comment on etiologies or even localization. It sounds like there is severe deltoid weakness but no detail is given on suprascapular/infraspinatus strength et cetera and 'ROM intact at elbow' could mean substantial biceps/triceps weakness is present. A chronic or active and chronic cervical radiculopathy is not going to result in new motor weakness, and usually doesn't cause much motor weakness at all to begin with. The EMG will be able to separate any chronic radiculopathy out regardless. The tingling in the hands is more likely carpal tunnel or ulnar neuropathy. The EMG will absolutely be abnormal if there is any objective motor weakness, unless it is done too early. Localizing is possible but depends on the extent of the injury- eg a traction injury to the plexus can be localized to upper or lower trunk, but this would not be able to be separated from the block versus operating room position traction injury. EMG does not provide 'definite cause'- it is only an extension of the neuromuscular exam.

Obviously something happened in the OR. EMG should be able to tell where the injury in the plexus is (if the neurologist is good at EMG- this is one of the more complex cases), but won't tell the etiology, and traction injuries can absolutely hit the trunk just like the block. If it is more straightforward like transection of the axillary nerve from the surgery itself, then EMG can show this, provide a prognosis on potential healing, and your problem will be solved.
You quoted my reply but I am not the OP. If there was an issue with positioning in the OR and she already had a cervical HNP that became acutely worsened by some sort of neck extension, etc with positioning or intubation then that could certainly cause an acute change in neurological function and certainly could cause motor weakness. I have never heard anyone say that a radic can’t cause motor weakness and I would argue against that conclusion all day. I am an interventional pain doc and I see patients with both acute and chronic radic with motor weakness all day. I think the MRI would be beneficial bc if I remember correctly, EMG changes for an acute radic will take weeks to develop, where if she has a big cervical HNP causing this then you would catch it on an MRI right away and could consult a surgeon. I don’t necessarily 100% think this issue is coming from the Cspine, but you open yourself up to a lot of liability by not even considering it and investigating it in a timely fashion.

Also when I said it wouldn’t surprise me if the EMG was normal I was getting at the possibility of something along the lines of conversion disorder. A youngish person with a psych history that has a new neurologic complaint and doesn’t seem very bothered by it… Of course you have to rule out everything else first, but it should be in the differential. I have seen conversion disorder a number of times in my career. Just something to keep in mind.
 
You quoted my reply but I am not the OP. If there was an issue with positioning in the OR and she already had a cervical HNP that became acutely worsened by some sort of neck extension, etc with positioning or intubation then that could certainly cause an acute change in neurological function and certainly could cause motor weakness. I have never heard anyone say that a radic can’t cause motor weakness and I would argue against that conclusion all day. I am an interventional pain doc and I see patients with both acute and chronic radic with motor weakness all day. I think the MRI would be beneficial bc if I remember correctly, EMG changes for an acute radic will take weeks to develop, where if she has a big cervical HNP causing this then you would catch it on an MRI right away and could consult a surgeon. I don’t necessarily 100% think this issue is coming from the Cspine, but you open yourself up to a lot of liability by not even considering it and investigating it in a timely fashion.

Also when I said it wouldn’t surprise me if the EMG was normal I was getting at the possibility of something along the lines of conversion disorder. A youngish person with a psych history that has a new neurologic complaint and doesn’t seem very bothered by it… Of course you have to rule out everything else first, but it should be in the differential. I have seen conversion disorder a number of times in my career. Just something to keep in mind.
Sure, you can have motor weakness with a radiculopathy. But severe weakness, like not being able to abduct the shoulder at all against gravity strongly suggests one should consider other etiologies (a lesion distal to the root). Almost all muscles receive contribution from multiple roots, thus the amount of weakness is mild with most radiculopathies, and a severe, active polyradiculopathy is rare and unlikely. The idea that a disc herniation occurred on the table and accounts for her symptoms would also be exceedingly rare compared to direct injury from the surgery, traction injury from position, or direct injury from the block, and would have to acutely affect more than one root to cause severe deltoid weakness. A MRI cervical spine is reasonable, but unlikely to find the etiology for her symptoms. I especially wouldn't waste the patient's money on it prior to the EMG, as the EMG may clearly demonstrate the issue if it is straightforward. Conversion is always a possibility, but this is a patient complaining of severe pain with weakness with multiple realistic potential etiologies for her symptoms. Very unlikely to be psychogenic. There should be EMG changes present between 2-3 weeks out from the injury at the latest.
 
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An EMG study should provide insight as to the localization of the nerve injury, if present, especially if a few weeks have passed. The disclaimer is that EMG should be performed someone trained in EMG and NM disorders, as the quality of study varies as it is often operator dependent. A cervical spine MRI is reasonable, but to me an acute cerv radiculopathy injury in this clinical context is less likely, although it may have been present pre-operatively. The acute change afterwards suggests an injury, traction or direct compression to nerve structure. A NM consult to correlate with EDx study would be a good way to go.
 
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