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Interact CardioVasc Thorac Surg 2007;6:235-237. doi:10.1510/icvts.2006.137380
© 2007 European Association of Cardio-Thoracic Surgery
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Negative results - Cardiac general

Brachial plexus injury following median sternotomy{star}

Yahya Ünlü*, Yusuf Velioglu, Hikmet Koçak, Necip Becit and Münacettin Ceviz

Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University, Erzurum, Turkey

Received 29 May 2006; received in revised form 11 December 2006; accepted 12 December 2006

{star} This Clinical article was presented at the XVIth Annual Meeting, Mediterranean Association of Cardiology and Cardiac Surgery, Bodrum, Turkey, September 26–29, 2004.

*Corresponding author. Universite Loj, 38/8, 25240 Erzurum, Türkiye. Tel.: +90 442 3166333 – ext. 2144, +90 442 3166044; fax: +90 442 3166340.

E-mail addresses: yahyaunlu{at}hotmail.com; dr_unlu{at}yahoo.com


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Case reports
 4. Discussion
 References
 
Objective: Brachial plexus injury is a rare complication after median sternotomy. We investigated that injury to the brachial plexus was retrospectively assessed in the results of three patients who underwent median sternotomy for open heart surgery. Materials and methods: All patients were placed in the hands-up position after right internal jugular vein cannulation, and the internal mammary artery was prepared for all of those. Nerve conduction measurements and electromyography were performed besides neurological examination. Results: Brachial plexus injury was detected in three cases (0.5%) of 575 patients who underwent coronary artery bypass grafting with median sternotomy. The main symptoms were continuous pain, and motor and sensory disturbances at the affected upper extremity (left arm in all cases). The common feature was that in all cases the left internal mammary artery was harvested. While the symptoms were relieved in two patients about six months after the operation, the other one had intractable pain and paresthesia. Conclusion: The most important measure is careful sternal retraction and use of the hands-up position for the low incidence and benign course of brachial plexus problems. Inappropriate sternal retraction during preparation of internal mammary artery should be avoided.

Key Words: Brachial plexus injury; Complications; Nerve damage; Sternotomy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Case reports
 4. Discussion
 References
 
Brachial plexus injury during median sternotomy is a rare complication. In several published series [1–15] prevalence varied between 2% and 38% (Table 1). The neurological problem that affects cervical 8 (C8) and thoracal 1 (T1) vertebra is mostly caused by mechanical trauma secondary to improperly applied sternal retractors, preparation of the internal mammary artery, cannulation of internal jugular vein, penetration of fractured rib and cold application [15–17]. Brachial plexus injuries have not any specific treatment. Recovery can be as long as six months, whereas in some cases the dysfunction can be intractable. We investigated three cases which had brachial plexus injury after a median sternotomy for open heart surgery and the results of them.


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  		Table 1 Prevalence of brachial plexus lesions after cardiac operations

 

   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Case reports
 4. Discussion
 References
 
Five hundred and seventy-five consecutive adult patients who were undergoing cardiac operations necessitating median sternotomy and extracorporeal circulation were evaluated before and after operation for symptoms and signs of neurologic deficits related to brachial plexus dysfunction. The neurologic examination consisted 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.

Right internal jugular vein cannulation was performed. All operations were performed with membrane oxygenators, aortic and bicaval cannulation, and moderate hypothermia (30–32 °C). All patients were placed in the hands-up position, and internal mammary artery was prepared for all of those.

Within the first three days after extubation of the trachea 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 three cases (0.5%) of 575 patients who underwent coronary artery bypass grafting with median sternotomy after investigation of the whole group of patients.


   3. Case reports
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Case reports
4. Discussion
 References
 
3.1. Case 1

A 35-year-old man underwent coronary artery bypass grafting (CABG) (four-vessel bypass) for coronary artery disease. The left internal mammary artery (LIMA) was harvested at the operation. Pain, motor and sensorial disturbances developed at the left upper extremity after the operation. The electromyography (EMG) revealed no significant findings. The patient was managed with palliative treatment and the symptoms relieved six months later.

3.2. Case 2

A 65-year-old man underwent CABG (four-vessel bypass) for coronary artery disease. The LIMA was harvested at the operation. Pain, motor and sensorial disturbances developed at the left upper extremity after the operation. The EMG revealed incomplete lesion with severe axonal degeneration at the inferior trunk of the left brachial plexus. The patient received palliative treatment but the paresthesia and pain continued in the left arm.

3.3. Case 3

A 50-year-old man underwent CABG (four-vessel bypass) for coronary artery disease. This patient had diabetes mellitus (DM) for seven years. The LIMA was harvested at the operation. Pain, motor and sensorial disturbances developed at the left upper extremity after the operation. The EMG was normal. The patient received palliative treatment and the symptoms relieved after six months.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Case reports
 4. Discussion
References
 
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 [1–11, 15].

Injury to the brachial plexus was retrospectively assessed in results of three patients who underwent median sternotomy for open heart operation in our clinic. Brachial plexus injury was detected in three cases (0.5%) of 575 patients. 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. In two cases the symptoms regressed after six months whereas one patient had intractable paresthesia and pain. One patient had DM for the past seven years.

Several factors have been associated with brachial plexus injury, including concomitant patient disease, anatomical variations, positioning of the patient, surgical and physiological factors (Table 2) [18]. 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.


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  		Table 2 Factors associated with intraoperative brachial plexus injury

 
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. 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 three cases.

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 [18]. In one of our cases the inferior roots were affected and there was completely no improvement.

To avoid these serious complications there are some preventive measures; (1) Exact median sternotomy should be performed. (2) Caudal localization of the retractor should be attempted. (3) Constant traction on the sternal halves should be reduced. (4) Asymmetric traction should be avoided when possible. (5) 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 [11, 15, 18].

In conclusion, 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.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Case reports
 4. Discussion
 References
 

  1. Baisden CE, Greenwald LV, Symbas PN. Occult rib fractures and brachial plexus injury following median sternotomy for open heart operations. Ann Thorac Surg 1984; 38:192–194.[Abstract]
  2. Benecke R, Klingelhöfer J, Rieke H, Conrad B, de Vivie R. Manifestations form und Verlauf von Plexusläsionen nach medianer Sternotomie. Nervenarzt 1988; 59:388–392.[Medline]
  3. Hanson MR, Breuer AC, Furlan AJ, Lederman RJ, Wilbourn AJ, Cosgrove DM, Loop FD, Estafanous FG. Mechanism and frequency of brachial plexus injury in open heart-surgery: a prospective analysis. Ann Thorac Surg 1983; 36:675–679.[Abstract]
  4. Lederman RJ, Breuer AC, Hanson MR, Furlan AJ, Loop FD, Cosgrove DM, Estafanous FG, Greenstreet RL. Peripheral nervous system complications of coronary artery bypass graft surgery. Ann Neurol 1982; 12:297–301.[CrossRef][Medline]
  5. Marganitt B, Shemesh Y, Golan M, Lin E, Engel J. Subclinical brachial plexopathy following median sternotomy. Orthop Rev 1986; 15:305–310.[Medline]
  6. Morin JE, Long R, Elleker MG, Eisen AA, Wynands E, Ralphs-Thibodeau S. Upper extremity neuropathies following median sternotomy. Ann Thorac Surg 1982; 34:181–185.[Abstract]
  7. Roy RC, Stafford MA, Charlton JE. Nevre injuries and musculoskeletal complaints after cardiac surgery: influence of internal mammary dissection and left arm position. Anesth Analg 1988; 67:277–279.[Free Full Text]
  8. Seyfer AE, Grammer NY, Bogumill GP, Provost JM, Chandry U. Upper extremity neuropathies after cardiac surgery. J Hand Surg [Am] 1985; 10:16–19.[Medline]
  9. Shaw PJ, Bates D, Cartlidge NEF, Heaviside D, Julian DB, Shaw DA. Early neurological complications of coronary artery bypass surgery. Br Med J 1985; 291:1384–1387.[Medline]
  10. Sotaniemi KA. Brachial plexus lesion complicating sternotomy. J Neurol Neurosurg Psychiatry 1982; 45:568.[Medline]
  11. Tomlinson DL, Hirsh IA, Kodali SV, Slogoff SV. Protecting the brachial plexus during median sternotomy. J Thorac Cardiovasc Surg 1987; 94:297–301.[Abstract]
  12. Treasure T, Garnett R, O'Connor J, Treasure J. Injury of the lower trunk of the brachial plexus as a complication of median sternotomy for cardiac surgery. Ann R Coll Surg Engl 1980; 62:37.
  13. Vander Salm TJ, Cereda JM, Cutker BS. Brachial plexus injury following median sternotomy. J Thorac Cardiovasc Surg 1980; 80:447–452.[Abstract]
  14. Vander Salm TJ, Cutler BS, Okike ON. Brachial plexus injury following median sternotomy. Part II. J Thorac Cardiovasc Surg 1982; 83:914–917.[Abstract]
  15. Vahl CF, Carl I, Muller-Vahl H, Struck E. Brachial plexus injury after cardiac surgery, the role of internal mammary artery preparation: a prospective study on 1000 consecutive patients. J Thorac Cardiovasc Surg 1991; 102:724–729.[Abstract]
  16. Sakai M, Morimoto M, Tanaka Y, Morimoto M, Hara N, Hyodo M. A case of right phrenic nerve paralysis as a complication of internal jugular vein cannulation by anterior approach. Masui 1993; 42:1355–1358.[Medline]
  17. Caplan LR. In: Furter V, Alexander RW, O'Rourke R. Serebrovasküler hastalik ve kalp hastaliginin nörolojik belirtileri. 2003; Hurst's The Heart (çeviri)2406.
  18. Ben-David B, Stahl S. Prognosis of intraoperative brachial plexus injury: a review of 22 cases. Br J Anaesth 1997; 79:440–445.[Abstract/Free Full Text]

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ICVTS on-line discussion A Brachial plexus injury following median sternotomy
Chung-Dann Kan
Interactive CardioVascular and Thoracic Surgery 2007 6: 237. [Full Text] [PDF]



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ICVTS on-line discussion A Brachial plexus injury following median sternotomy
Interactive CardioVascular and Thoracic Surgery, April 1, 2007; 6(2): 237 - 237.
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This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
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Services
Right arrow Email this article to a friend
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Right arrow Author home page(s):
Yahya Ünlü
Hikmet Koçak
Münacettin Ceviz
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