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ICVTS on-line discussion A Brachial plexus injury following median sternotomy

Division of Cardiovascular Surgery, National Cheng Kung University Hospital, Tainan 70124, Taiwan

Brachial plexus injury following median sternotomy

eComment: Congratulations to Unlu et al. for their excellent work [1]. Post-sternotomy brachial plexus injuries are annoying, common complications, whose incidence has always been underestimated. The symptoms often manifest as a variety of upper extremity neuropathies, such as pain, numbness, dysesthesia, or loss of motor function in the hand, forearm, or arm. And, in the vast majority of these patients, the neurological symptoms are transient and usually resolved within six months.

We experienced several patients who presented with transient brachial plexus neuropathies with full recovery in our practices. And, we had one reported patient on whom we performed coronary artery bypass surgery with left internal mammary artery harvesting also who experienced persistent, unrecovered brachial plexus injury [2]. One recent experienced permanent brachial plexus injury patient who received aortic graft transposition operation for his acute aortic dissection was concluded to be related to nerve injury during brachial cannulation procedure.

We are interested in the mechanism of brachial plexus injury related to surgical procedures. The constituent nerve roots of the plexus are fixed proximally at their points of exit from the vertebral canal, and distally the nerves are tethered to the axillary fascia. Excessively spreading the sternal retractor will increase the distance between these fixation points and thus stretch the brachial plexus. A downward-pushed clavicle with an upwardrotating first rib by asymmetrical sternal retractor will also compress the distal part of the plexus. Both of them might more often affect upper trunk (C5-C7) rib fractures near costotransverse articulation or punctures for the internal jugular vein. Where the lower trunk (C8-T1) of the plexus lies immediately medial to them, they might often affect the lower trunk.

We agree with the preventive measures proposed by Unlu et al., we cautiously use the asymmetric sternal retractor, put a lower position and the smallest possible opening for sternal retractor, and prevent the prolong traction on the sternal halves to minimize the brachial plexus injury following median sternotomy.

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1. Unlu Y, Velioglu Y, Kocak H, Becit N, Ceviz M. Brachial plexus injury following median sternotomy. Interact CardioVasc Thorac Surg 2007; 6:235–237.[Abstract/Free Full Text]
2. Lin PY, Luo CY, Kan CD, Yang YJ, Jou IM. Brachial plexus injury following coronary artery bypass surgery: a case report. Kaohsiung J Med Sci 2000; 16:638–42.[Medline]

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