Brachial plexus injury following median sternotomy

Assessment of Upper Limb Nerves in Coronary Artery Disease Patients Undergoing Coronary Artery Bypass Graft

Background Many patients experience pain in their upper limbs following surgical procedures involving median sternotomy, particularly those undergoing coronary artery bypass grafting (CABG). This type of pain, commonly reported by CABG patients, is often overlooked in hospital settings. Our study aims to address this issue by utilizing electrodiagnostic studies to understand this postoperative discomfort better. Objectives Cardiovascular procedures are standard and are trending toward endovascular interventions. Through this study, we aim to assess the occurrence of neurological issues in the upper limbs after CABG by comparing patients' preoperative and postoperative electrophysiological studies of the upper limb nerves. Materials and methods A prospective study was performed on 32 coronary artery disease (CAD) patients undergoing CABG to determine the effects of surgery on the upper limb nerves (median and ulnar nerves). We performed nerve conduction studies (NCS) and analyzed different parameters of both median and ulnar nerves pre and post-surgery. Results A change was noted in different NCS parameters of the median and ulnar nerves when we compared the pre and post-surgical values. The mean latency of the median nerve sensory increased from a minimum of 3.01 milliseconds at the preoperative level to a maximum of 3.60 milliseconds when assessed two weeks post-surgery. The mean amplitude decreased from 16.49 microvolts to a minimum of 12.30 microvolts when assessed two weeks post-surgery. The mean velocity decreased from 55.83 m/s at the preoperative value to a minimum of 45.03 m/s at the two weeks post-surgery assessment. The ulnar nerve also underwent similar changes. Conclusion The observed changes in latency, amplitude, and velocity might be attributed to various factors, including surgical trauma, inflammation, or alterations in the physiological state post-surgery. The sternotomy technique and the position and extent of opening the sternal retractor determine the prevalence of complications by causing injury to the medial and lateral cords of the brachial plexus after CABG. Careful preoperative and postoperative assessments of patients may aid in preventing, minimizing, and treating these often undiagnosed complications.

Evaluation of Safety of Overhead Upper Extremity Positioning During Fenestrated-Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms

PURPOSE

Peripheral nerve and brachial plexus injury can occur from compression or stretching during positioning for operative procedures. The aim of this study was to evaluate the safety of overhead upper extremity positioning to optimize imaging during fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

Forty-four consecutive patients enrolled in a prospective non-randomized study underwent FB-EVAR with overhead upper extremity positioning. Patients underwent intra-operative neuromonitoring of upper and lower extremities and neurological examination prior to discharge and at 2 months following the procedure. End points were peripheral or brachial plexus nerve injury, quality of lateral projection and cone beam computed tomography (CBCT) and major adverse event (MAEs).

RESULTS

There were 28 (64%) male patients with mean age of 74 ± 8 years treated for 10 PRAs (23%) and 34 (78%) TAAAs. Mean body mass index was 29 ± 7 kg/m², with 17 obese patients (39%). Open surgical upper extremity access was used in 19 patients (43%). Three patients (16%) had access-related complications, all focal brachial artery dissections treated by patch angioplasty. Two patients (5%) developed upper extremity changes in neuromonitoring, which immediately resolved with repositioning of the upper extremity. Technical success was 95%. Lateral projection and rotational CBCT were feasible in all patients with satisfactory imaging quality for catheterization and stenting of the celiac axis and superior mesenteric artery. There was one mortality (2%) at 30 days, and six patients (14%) had MAEs. There were no upper extremity neurological injuries.

CONCLUSION

Overhead upper extremity position allows optimal imaging on lateral projections and rotational CBCT during FB-EVAR. There were no upper extremity neurological injuries in this study.

Brachial Plexus Injury Associated with Median Sternotomy during Cardiac Surgery: Three Cases of C8 Radiculopathy Due to the Fracture of the First Rib

In cardiac surgery, median sternotomy is often necessary during certain surgical processes and it can cause the rare complication of brachial plexus injury. Retraction of the rib cage during median sternotomy may produce a fracture of the first thoracic rib at the costovertebral junction which might penetrate or irritate the lower root of the brachial plexus. Because the C8 ventral root is located immediately superior to the first thoracic rib, the extraforaminal C8 root is thought to be the key location of brachial plexus injury by the first rib fracture. This report describes three cases of brachial plexus injury after median sternotomy in a single center. In our cases, fracture of the first rib and consequent brachial plexus injury is confirmed with imaging and electrophysiologic studies. The fracture of the first rib is not detected with standard plain images and it is confirmed only with CT or MRI studies. Advanced imaging tools are recommended to assess the first rib fracture when brachial plexus injury is suspected after median sternotomy.

[Lower trunk brachial plexopathy due to hematoma following median sternotomy: a case report]

We present the case of an 81-year-old woman who underwent aortic valve replacement and coronary artery bypass surgery by median sternotomy. Following the operation, she experienced distal muscle weakness in her left upper limb and numbness in the medial part of her left forearm and palm. Nerve conduction study revealed low amplitudes of her left ulnar compound muscle action potential (CMAP) and sensory nerve action potential (SNAP), radial CMAP, and medial antebrachial cutaneous SNAP. Needle electromyography showed denervation potentials in the extensor digitorum communis and abductor pollicis brevis. CT and MRI showed a left first rib fracture and a hematoma nearby. Short-T1 inversion recovery image (STIR) showed a high-intensity area in the left root of C8. Based on these findings, we diagnosed the patient with lower trunk brachial plexopathy due to hematoma.

Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018

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The Prevention and Recognition of Ulnar Nerve and Brachial Plexus Injuries

Perioperative peripheral nerve injury is a serious yet preventable perioperative complication. Since the inception of the American Association of Anesthesiologists Closed Claim Project, the incidence of peripheral nerve injury has remained constant with an overall reported prevalence rate of 15% to 16%. To date, the most frequent nerve injuries are ulnar nerve neuropathy and brachial plexus injury. This article will review the clinical presentation, pathophysiology, causative and risks factors, and preventive measures for the two most common nerve injuries. Knowledge of the anatomical structures and components of peripheral nerves prone to injuries during surgery can assist in defining precautionary actions in the perioperative setting. Positioning techniques in the operating room, early recognition of neuropathies, and use of a perioperative tool in the postoperative setting are keys to reduce significant clinical complications.

“Other” Neurologic Complications After Cardiac Surgery

Compared to the neurologic morbidity of stroke and cognitive dysfunction, “other” neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.

Patient Positioning and Skin Sequelae: Ischemic Epidermal Necrosis from Tight Padding During Cardiac Surgery

Careful positioning and padding of pressure points during surgery are recommended to prevent pressure ulcers, vascular injury, and nerve damage in an immobilized patient. However, overpadding may have unintended consequences. We report a case of ischemia-induced full-thickness epidermal necrosis secondary to tight foam padding during a cardiac surgery.

Sternal force distribution during median sternotomy retraction

BACKGROUND

Median sternotomy is the access of choice in cardiac surgery. Sternal retractors exert significant forces on the thoracic cage and might cause considerable damage. The aim of this study was to determine the effects of retractor shape on local force distribution to obtain criteria for retractor design.

METHODS

Two types of sternal retractors (straight [SSR] and curved [CSR]) were equipped with force sensors. Force distribution, total force, and displacement were recorded to a spread width of 10 cm in 18 corpses (11 males and 7 females; age, 62 ± 12 years). Both retractors were used in alternating sequence in 4 iterations in every corpse. Data were compared with respect to the different retractor blade shapes.

RESULTS

Maximum total forces for full retraction of both retractors resulted in 349.4 ± 77.9 N. Force distribution during the first retraction for the cranial/median/caudal part of the sternum was 101.5 ± 43.9/29.1 ± 33.9/63.0 ± 31.4 N for the SSR and 38.7 ± 41.3/80.9 ± 64.5/34.0 ± 25.8 N for the CSR, respectively. During the 4 spreading cycles, the average force decreased from 224.6 ± 61.3 N in the first to 110.8 ± 39.8 N in the fourth iteration. The mean total force for the first retraction revealed 226.4 ± 71.9 N for the CSR and 222.8 ± 52.9 N for the SSR.

CONCLUSIONS

The shape of sternal retractors considerably influences the force distribution on the sternal incision. In the SSR, forces on the cranial and caudal sternum are significantly higher than in the median section, whereas in the CSR, forces in the median section are highest.

Does retraction of the sternum during median sternotomy result in brachial plexus injuries?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'does retraction of the sternum during median sternotomy result in brachial plexus injuries or peripheral neuropathies?' Altogether 58 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, date, journal and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Caudal placement of the retractor or relieving the pressure superiorly by removing the upper blades of a retractor (P = 0.02) and use of a caudally placed symmetrical retractor has been shown to reduce neuropathy. Positioning of the patient with 'hands up' positioning showed significant reduction in the incidence of brachial plexus injuries. Furthermore, how wide the retractor is opened and use of an asymmetrical retractor for internal mammary artery (IMA) harvesting are also important factors in quantifying risk of postoperative neuropathy. Wider sternal retraction and longer bypass time did increase the risk of developing postoperative neuropathy. Three asymmetrical retractors were looked at that demonstrates the Delacroix-Chevalier to be the safest (P < 0.05). We conclude that median sternotomy risks brachial plexus injury and where possible the sternum should be opened as small a distance as possible with symmetrical retractor and using a caudally placed retractor.

Pain symptoms accompanying chronic poststernotomy pain: a pilot study

OBJECTIVE

Despite the technical developments in surgical procedures, chronic poststernotomy pain (CPSP) is still very common. Many theories for its cause have been proposed in the literature, but the etiology is still not clear. Pain along the sternal scar and in the upper extremities (sometimes accompanied with paresthesia) persists in about 30% of cases. These symptoms have been regarded as two separate complications. This study investigated all pain symptoms in patients following sternotomy.

DESIGN

Retrospective pilot study.

SETTING

Outpatient clinic at the Leiden University Medical Center.

PATIENTS

A cohort of patients who underwent open heart surgery by median sternotomy between January 1, 2004 and January 1, 2006.

INTERVENTIONS

A questionnaire was completed by 631 patients, and a selected sample of 277 patients was examined for pain of the head, neck, back, and chest and upper extremities.

OUTCOME MEASURES

All pain locations were compared in two groups: 189 patients with sternal pain and 88 patients without sternal pain.

RESULTS

We found that pain and muscular tenderness in the investigated areas unrelated to the chest wall incision were significantly more common in patients with sternal pain compared to the nonsternal pain group. No surgical or demographic factors with the exception of female gender were consistent predictors of sternal pain.

CONCLUSION

CPSP is an extensive pain syndrome. Sternal pain is frequently accompanied by pain of the head, neck, back, and upper extremities. Further research on the possible etiology is warranted.

Compression of the brachial plexus during right lobe liver donation as a cause of brachial plexus injury: a case report

We present a case of brachial plexus injury in a living-related liver donor, most likely caused by compression of the plexus between the 1st rib and clavicle, the result of rib retraction for surgical exposure.

Intraoperative positioning nerve injuries

Intraoperative positioning nerve injuries are regrettable complications of surgery thought to arise from stretch and/or compression of vulnerable peripheral nerves. Generally thought to be preventable, these injuries still occur in patients despite rigorous preventative measures. Sometimes injuries, initially thought to be due to malpositioning, are caused by other factors, such as retraction injury or brachial plexitis. Because of the diversity of nerves susceptible to positioning injury, the clinician must be aware of a variety of presentations and must be able to distinguish them from other postoperative complaints. Prevention remains the mainstay of the management of positioning injuries. Diagnosed and managed appropriately, these lesions typically improve completely over time.

Brachial plexopathies: classification, causes, and consequences

The brachial plexus, which is the most complex structure of the peripheral nervous system, supplies most of the upper extremity and shoulder. The high incidence of brachial plexopathies reflects its vulnerability to trauma and the tendency of disorders involving adjacent structures to affect it secondarily. The combination of anatomic, pathophysiologic, and neuromuscular knowledge with detailed clinical and ancillary study evaluations provides diagnostic and prognostic information that is important to clinical management. Since most brachial plexus disorders do not involve the entire brachial plexus but, rather, show a regional predilection, a regional approach to assessment of plexopathies is necessary.

Shoulder function after thoracic surgery

Thoracic procedures are considered to be among the most painful surgical incisions and are associated with considerable postoperative pain and shoulder dysfunction, severely affecting mobility and activities of daily living. Improper patient positioning, muscle division, perioperative nerve injury, rib spreading, and consequent postoperative pain influence the patient's postoperative shoulder function and quality of life. To reduce access trauma and postoperative morbidity, various alternative modalities have been proposed to replace the standard PLT, including muscle-sparing techniques and VATS. Initial evaluations suggest that these alternatives are associated with significantly better postoperative shoulder function. Proper comparative studies using standardized questionnaires, objective evaluations, or quality-of-life assessments are scarce, however. Proper postoperative care, including early mobilization and effective physiotherapy, is a cornerstone in successful patient rehabilitation and rapid return to normal daily activities. Whether upper extremity exercises can contribute to improvement in postoperative shoulder function and the ability to perform activities of daily living needs to be studied further.

A review of perioperative nerve injury to the upper extremities

Perioperative nerve injuries can be a complication of surgical procedures and accounts for approximately 16% of all anesthesia-related claims in the United States. Whereas ulnar neuropathy at the elbow is the most common, other nerve injuries of the upper extremity and the phrenic nerve are not rare occurrences. A number of possible etiologies have been proposed to explain perioperative nerve injury to include stretch, compression, ischemia, and metabolic derangement. There appears to be additional factors making some patients more prone to nerve injury than others, for example, the sex of the patient and pre-existing disease. Also, in some cases there is a discrepancy between the timing of the surgery and the injury manifestations that can be the result of delayed recognition or an insult in the postoperative setting.

Musculoskeletal and neurological complications following coronary artery bypass graft surgery: A comparison between saphenous vein and internal mammary artery grafting

The internal (thoracic) mammary artery (IMA) is currently the vessel of choice for coronary artery bypass grafting (CABG), due to its long term patency. The purpose of this study was to compare the incidence and nature of musculoskeletal and neurological complications following saphenous vein grafting (SVG) and internal mammary artery grafting (IMAG). Ninety-seven patients were screened by a physiotherapist for musculoskeletal and neurological complications three to six weeks following cardiac surgery. The incidence of new musculoskeletal and neurological complications was significantly higher in patients following IMAG (78.5 per cent) than SVG (45 per cent) (p < 0.001, chi2(1) = 17.04). A significant association between musculoskeletal complications affecting the anterior chest and harvesting of the IMA was also demonstrated.

Pain pattern and left internal mammary artery grafting

BACKGROUND

This study was designed to determine whether the pain pattern in patients with an internal mammary artery (IMA) harvest differs from that in other cardiac operations and whether these patients present specific characteristics with clinical implications.

METHODS

One hundred patients with left IMA grafting (IMA group) were compared prospectively with 100 patients who had a heart operation without IMA harvest (non-IMA group). Pain assessment was performed on postoperative days (POD) 1, 2, 3, and 7, and included pain intensity (10-point scale) and pain localization.

RESULTS

In the IMA group, pain intensity was higher on POD 2 (4.2 +/- 2.4 versus 3.2 +/- 2.3, p < 0.01), and there were more patients without pain on POD 7 (32 versus 19, p = 0.03). In the IMA group, more patients had left basal thoracic pain throughout the entire study period and had sternal pain on POD 7, whereas more patients in the non-IMA group complained about back pain during the early postoperative period.

CONCLUSIONS

The impact of IMA harvest on pain intensity is moderate, but the pain localization pattern of each group exhibits specific features that could help to better target pain management.

Peripheral nerve injuries associated with anaesthesia

Peripheral nerve injuries can occur at any time during the peri-operative period. The long-term disability that results may have serious consequences for a patient. The incidence of peri-operative nerve injuries can be reduced by anaesthetists being aware of their causes and pathophysiology. This review article aims to explain the incidence, pathophysiology and medicolegal implications of peri-operative nerve injury and provides suggestions as to how they may best be avoided.

[The involvement of the brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium: clinical evaluation]

To evaluate the involvement of brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium 113 patients (87 men and 26 women) were clinically examined in the preoperative and between the fifth and eight post-operative days. The internal thoracic artery was used in 65 of the 113 patients. The electroneuromyography was not effected in any of the patients. A lesion of the brachial plexus was found in three patients though the internal thoracic artery was used in only one patient. We believe that factors such as posture of the patient, hypothermia, thoracic braces and use of the internal thoracic artery are relevant in the lesions. Hence one must be attentive to all the factors mentioned above so as to avoid or minimize the lesions.

Somatosensory evoked potential monitoring used to compare the effect of three asymmetric sternal retractors on brachial plexus function

We compared the effect of three different asymmetric sternal retractors on brachial plexus dysfunction using intraoperative somatosensory evoked potentials (SSEPs). We studied 60 patients undergoing coronary bypass and internal mammary harvest. Assessment of brachial plexus function was performed pre- and postoperatively. Patients were assigned the use of a Pittman (MN Scientific Instruments Inc., Minneapolis, MN), Rultract (Rultract Inc., Cleveland, OH), or Delacroix-Chevalier (Delacroix-Chevalier, Paris, France) asymmetric sternal retractor for internal mammary exposure. SSEP changes from baseline during asymmetric retractor use and removal were determined, and average changes were compared among the retractor groups. Patient demographics and baseline SSEP values were similar. Fewer patients in the Delacroix-Chevalier group had decreases in SSEP amplitudes after retractor placement. Of the patients in the Rultract and Pittman groups, 45% and 25%, respectively, had amplitude decreases of >50%, compared with only 5% of the Delacroix-Chevalier patients. Three patients in both the Pittman and Rultract groups and one patient in the Delacroix-Chevalier group suffered brachial plexus symptoms postoperatively. We conclude that the Delacroix-Chevalier retractor is associated with less neurophysiologic evidence of brachial plexus dysfunction during asymmetric sternal retraction compared with either the Pittman or Rultract sternal retractors.

IMPLICATIONS

We used somatosensory evoked potentials to assess the effect of several different asymmetric sternal retractors on brachial plexus dysfunction and to determine which produced the least evidence of nerve damage during surgical exposure of the internal mammary artery.

Iatrogenic nerve injuries

Iatrogenic nerve injuries are an undesired byproduct of the practice of medicine and have been so since antiquity. The majority of such injuries occur perioperatively, and are, therefore, attributed to surgeons and anesthesiologists. Nonetheless, the members of almost every clinical specialty are at risk to some degree. Iatrogenic nerve injuries can affect almost any portion of the peripheral nervous system, and can result from many different causes. This article reviews many of the more common iatrogenic nerve lesions.

Somatosensory evoked potential monitoring during cardiac surgery: an examination of brachial plexus dysfunction

OBJECTIVE

To observe the effects of the Favoloro and sternal retractors on the ulnar and median nerve somatosensory evoked potentials (SSEPs) and to identify any relationship with postoperative brachial plexus injury.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Twenty cardiac patients.

INTERVENTIONS

SSEPs were studied in patients undergoing cardiac surgery using normothermic cardiopulmonary bypass. Evoked potentials were obtained from bilateral median and ulnar nerves.

MEASUREMENTS

The incidence of nerve-specific SSEP changes and their temporal relationship to retractor usage were determined. The overall incidence of SSEP changes was 75%. There were no differences (p > 0.05) between the group showing changes (n = 15) and the group with no changes (n = 5) with respect to age, body surface area, weight, cross-clamp or cardiopulmonary bypass times. There also were no differences (p > 0.05) between the frequencies of left- and right-sided changes, or in nerve-specific SSEP changes. Seventy-four percent of SSEP changes correlated with retractor usage. No SSEP changes were associated with the Favoloro retractor. Significant SSEP depression, assessed by either percentage reduction in amplitude or persistent amplitude reduction, occurred in the absence of postoperative neurological deficits. There were no detected postoperative brachial plexus injuries.

CONCLUSIONS

SSEP changes correlate with the use of the sternal retractor but not the Favoloro retractor. It was not possible to replicate the results of previous investigators in predicting postoperative neurological deficits based on the SSEP changes, and therefore the routine application of SSEP as a monitor cannot be recommended on the basis on these data.

Hands-up positioning during asymmetric sternal retraction for internal mammary artery harvest: a possible method to reduce brachial plexus injury

This study compares the hands-up (HU) with the arms at side (AAS) position to determine whether one is beneficial in reducing brachial plexus stress during asymmetric sternal retraction. Eighty patients undergoing cardiac surgery were assigned to either Group 1 (AAS) or Group 2 (HU). Perioperative neurologic evaluations of the brachial plexus were performed and somatosensory evoked potentials (SSEPs) were collected during internal mammary artery harvest using asymmetric sternal retraction. Demographic data, SSEP changes, and postoperative brachial plexus symptoms were compared between groups. SSEP amplitude decreased in 95% of all patients during retractor placement with substantial decreases (> 50%) observed on the left side in 50% of the AAS and 35% of the HU patients. Amplitude recovery was normally seen in both groups after asymmetric retractor removal. Similar changes were noted, to a lesser degree, on the right side. During asymmetric sternal retraction, HU positioning offered minimal benefit in reducing brachial plexus stress as measured by SSEP. Three of the seven AAS patients who reported brachial plexus symptoms had an ulnar nerve distribution of injury. However, none of the four patients with plexus symptoms in the HU group had ulnar nerve problems, suggesting that the higher incidence of postoperative symptoms observed with AAS positioning may occur from ulnar nerve compression.

Review of the technique and complications of median sternotomy in the dog and cat

The surgical and medical records of 67 dogs and nine cats which underwent median sternotomy over a five-year period were reviewed. The indication for median sternotomy and the short and longer term complications were recorded. Twenty-six of the dogs died or were euthanased within 48 hours of the surgery as a consequence of the pre-existing disease or complications of the intrathoracic surgical procedure. A further four dogs were enthanased between 48 hours and 14 days following confirmation of neoplastic processes. Thirty-seven dogs were alive at 14 days: of these, seven dogs (19 per cent) experienced short-term wound complications, including haemorrhage, wound infection, thoracic limb neurological deficits and excessive postoperative discomfort. Of the 37 dogs alive for longer term follow-up, eight dogs (22 per cent) experienced wound complications, including haemorrhage, sternal fracture, sternal osteomyelitis and delayed wound healing. No complications were noted in the cats.

Somatosensory evoked potential monitoring of the brachial plexus to predict nerve injury during internal mammary artery harvest: intraoperative comparisons of the Rultract and Pittman sternal retractors

Brachial plexus injury after coronary artery bypass grafting (CABG) continues to be a common problem postoperatively. With the use of somatosensory evoked potential monitoring (SSEP), neurologic integrity of the brachial plexus during internal mammary artery (IMA) harvest was assessed and the Rultract and Pittman sternal retractors were compared to determine what effect they had on SSEP characteristics. Results showed that the Rultract and Pittman retractors caused large decreases in SSEP amplitudes after insertion, (1.25 +/- 0.14 versus 0.72 +/- 0.09, P < 0.05; and 1.64 +/- 0.27 versus 0.91 +/- 0.14, P < 0.05) respectively. This decrease was noted in 85% of Rultract and 68.75% of Pittman patients, respectively. Amplitudes increased after retractor removal but never returned to baseline values. Cooley retractor placement in the patients not undergoing IMA harvest (control) produced only mild decreases in amplitude. Waveform latency increased in all groups after retractor placement, but these increases were thought to be clinically insignificant. Postoperatively, three patients in each of the IMA retractor groups had brachial plexus symptoms (18%), whereas only one patient in the control group had symptoms. Somatosensory evoked potential monitoring seems to be a sensitive intraoperative monitor for assessing brachial plexus injury during CABG. The nerve plexus seems to be most at risk for pathologic injury during retraction of the sternum for IMA harvest. Though the Rultract retractor caused greater changes in SSEP characteristics than the Pittman, no clinical outcome differences between the two could be ascertained. Using SSEP monitoring may reduce brachial plexus injury during IMA harvest by allowing early detection of nerve compromise and therapeutic interventions to alleviate the insult while under general anesthesia.

Brachial plexus injury after median sternotomy

Serious brachial plexus injury after median sternotomy is uncommon. However, affected patients experience considerable morbidity and their return to regular employment is often delayed. The pathogenesis of the injury is multifactorial. Wide sternal retraction is the major etiologic factor. Management is primarily conservative and should be guided by a team experienced in upper limb and hand surgery. Our experience at a major referral center during a 3-year period is described.

Rib fractures complicating median sternotomy

The postoperative chest radiographs of 100 consecutive patients undergoing median sternotomy were reviewed for the presence of acute rib fractures. The majority of patients underwent coronary artery bypass grafting. Thirteen patients sustained 15 fractures. Eleven of these fractures were of the left first rib and 7 of the 15 fractures occurred at the costotransverse articulation. The fractures tended to be subtle on the postoperative portable chest radiographs and were initially overlooked in 4 patients. Heavier patients and those with larger body surface areas were more susceptible to the development of fractures. There was no statistical correlation to total operating time, bypass time, or global ischemic time.

Morbidity following coronary artery revascularisation with the internal mammary artery

To investigate the morbidity after coronary artery bypass grafting, one hundred and seventy-eight patients were retrospectively studied with a minimum follow-up period of one year. Although there was no difference in the incidence and distribution of pain in hospital, seventy percent of patients who had an internal mammary artery used as one of the bypass conduits experienced chest wound pain after discharge from hospital compared to 51.7% of patients who had vein grafts alone (P less than 0.05). Twenty-three percent of patients who had left internal mammary arteries harvested experienced chronic left-sided chest wall pain compared to 4.5% of patients who had vein grafts only (P less than 0.005). The possible factors responsible are discussed and a review made of the complications which may result from using the internal mammary artery in coronary artery surgery.

Brachial plexus lesions following cardiac surgery with median sternotomy and cannulation of the internal jugular vein

There are many possible complications after cannulation of the internal jugular vein (IJV) including injury to the brachial plexus. Neurologic injuries can also occur from sternal splitting. The present study looked at the incidence of brachial plexus lesions after cardiac surgery with and without IJV cannulation. Over 12 months, 815 patients were studied after all types of cardiac surgery. In one half of the group, cannulation of the IJV was avoided when possible. Reducing the incidence of IJV catheterization did not lower the overall incidence of brachial plexus lesions (1.8% to 1.4%). However, there was a higher incidence of neurologic lesions in patients with IJV catheters (3.0% to 0.8%) during the entire study period. All 13 plexus lesions were in the C8-T1 distribution, and seven of the patients had a Horner's syndrome on the same side. No posterior first rib fractures could be detected by radiographs. The brachial plexus lesions were transient but the Horner's syndromes were longer-lasting. It is concluded that the injuries are due to compression and traction of the plexus due to stretching and possibly from hematoma formation from the IJV punctures.

Neurological complications of central venous cannulation

The reports of neurological damage after central venous cannulation over the past 20 yrs have been gathered, summarized, and analyzed. We found 59 cases of nerve lesions: 32 serious or even fatal, and 27 light or transient ones. They included: Lesions of the cervical sympathetic chain: needle trauma, compression by hematoma, anesthetic blockade; brachial plexopathies: needle trauma or compression by hematoma; phrenic or recurrent nerve palsies: anesthetic blockade, needle trauma, or compression by hematoma; cerebral damage following venous air embolism, carotid artery embolism or obstruction (thrombosis, compression), or internal jugular vein obstruction (thrombosis or catheter tip); lesions of the IX, X, XI, and XII cranial nerves by hematoma compression or spilling of histotoxic solutions; and, massive lesions of the anterior rami of the cervical nerves by spillage of histotoxic solutions. We believe that the following simple and well-known measures can substantially reduce the incidence of those serious complications. 1. Avoiding the subclavian or jugular central routes in patients with marked anatomical changes, coagulopathies, and carotid artery or lung diseases. 2. Using only small amounts of dilute concentrations of short-acting local anesthetics before the puncture. 3. Using a small gauge "seeking" needle and placing a finger on the carotid artery during a jugular venipuncture to avoid accidental arterial puncture. 4. Using radiopaque catheters long enough to have their tip in midsuperior vena cava. The position of the catheter must be checked radiographically immediately after insertion and even at later periods. The catheter must be meticulously fixed to the skin to avoid its movement.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurologic and neuropsychological morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery

As part of a prospective study of the neurologic and neuropsychological complications of coronary artery bypass graft surgery, 312 patients were compared with a control group of 50 patients undergoing major surgery for peripheral vascular disease. The purpose of comparing the 2 groups was to determine to what extent neurologic complications after heart surgery can be attributed to cardiopulmonary bypass. The 2 groups were similar with respect to age, preoperative neurologic and intellectual status, anesthetic methods, duration of operation, perioperative complications, and time spent in the intensive therapy unit. Certain potential risk factors for cerebrovascular disease were more common in the control than the coronary bypass patients. The important difference between the 2 groups was that only the latter group underwent cardiopulmonary bypass. In this group 191 of 312 (61%) and 235 of 298 (79%), respectively, developed early neurologic and neuropsychological complications. By the time of hospital discharge 17% had neurologic disability and 38% had significant neuropsychological symptoms. In the control group 9 of 50 (18%) developed neurologic complications resulting largely from trauma to lower limb sensory nerves. Two patients developed primitive reflexes. Fifteen of 48 (31%) showed neuropsychological impairment on 1 or 2 subtest scores. Moderate or severe intellectual dysfunction was not seen in the control patients in contrast to the 24% thus affected in the coronary bypass group. The difference in frequency and severity of central nervous system complications between the 2 groups is likely to reflect cerebral injury resulting from cardiopulmonary bypass.