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

Brachial plexus injury and upper rib fracture after median sternotomy in cardiac surgery

OBJECTIVES

Sternal retractors utilized during open-heart surgeries through median sternotomy can cause upper rib fractures which sometimes further leads to brachial plexus injury. We aimed to investigate the incidence of brachial plexus injury and upper rib fractures in open-heart surgeries and how these injuries are associated with each other.

METHODS

We investigated 1050 cases during the past five years. The incidence of brachial plexus injury and upper rib fractures after median sternotomy was assessed in all patients and the patients who sustained were evaluated for the affected side, the level of paralysis.

RESULTS

Ten cases (0.95%) exhibited brachial plexus injury after median sternotomy. Nine cases developed paralysis on left upper extremity. In all ten cases, sensory and motor nerve impairment were exhibited in the lower plexus. Rib fractures were observed in 35.0% of cases after median sternotomy and the usage of asymmetric sternal retractors to harvest left internal thoracic artery (LITA) significantly affected the side of fracture.

CONCLUSION

Sternal retractors utilized during open-heart surgeries through median sternotomy may cause rib fractures and brachial plexus injury, so operators should be aware of these complications.

Monitoring cardiac and ascending aortic procedures

Although cardiac and aortic operations have been successfully performed for more than 60 years, the risk of neurologic complications remains high. In particular, the rate of stroke with cardiac operations continues to be significant in the 1%-5% range. Similarly, the risk of stroke with aortic operations remains in the range of 7%-10% despite many years of improving techniques. Because of this persistently high risk, the use of intra-operative neurophysiologic monitoring (IONM) has the potential of improving outcomes. This chapter provides an overview of cardiac/aortic arch procedures from the neurophysiologic standpoint and discusses the roles of different monitoring modalities in detecting injury.

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.

Electrodiagnostic Assessment of Plexopathies

Disorders of the brachial and lumbosacral plexus are complex and may occur as a consequence of trauma, compression, inflammatory disorders, malignant infiltration, or delayed effects of radiation therapy. An understanding of plexus anatomy and surrounding structures will allow the electromyographer to facilitate an efficient and comprehensive assessment of the plexus. A careful and thorough electrodiagnostic assessment allows for localization within the plexus and may provide important information about underlying pathology and prognosis.

Rib fracture after median sternotomy for thymoma: an unreported complication

A 47-year-old man was admitted to the clinic with histologically diagnosed thymoma of the anterior mediastinum, pT3N0M1a, stage IYA, type B3. He underwent surgery for primary tumor resection through a median sternotomy and left thoracotomy at the 7th intercostal space to remove pleural metastases. On the first postoperative day, massive bleeding occurred, a resternotomy was carried out but failed to save the patient. A fracture of the right first rib, which injured the right vertebral artery, had caused massive bleeding and was diagnosed at autopsy. Surgeons should keep in mind this potentially fatal complication of a median sternotomy.

Brachial and lumbosacral plexopathies: A review

Diseases of the brachial and lumbosacral plexus are uncommon and complex. The diagnosis of plexopathies is often challenging for the clinician, both in terms of localizing a patient's symptoms to the plexus as well as determining the etiology. The non-specific clinical features and similar presentations to other root, nerve, and non-neurologic disorders emphasize the importance of a high clinical index of suspicion for a plexopathy and comprehensive clinical evaluation. Various diagnostic tests, including electrodiagnostic (EDX) studies, neuroimaging (including ultrasound, MRI, or PET), serologic studies, and genetic testing, may be used to confirm a plexopathy and assist in identifying the underlying etiology. EDX testing plays an important role in confirming a plexopathy defining the localization, pathophysiology, chronicity, severity, and prognosis. Given the complexity of the plexus anatomy, multiple common and uncommon NCS and an extensive needle examination is often required, and a comprehensive, individualized approach to each patient is necessary. Treatment of plexopathies often focuses on symptomatic management although, depending on the etiology, specific targeted treatments may improve outcome. This article reviews the clinical features, EDX approaches, and evaluation and treatment of brachial and lumbosacral plexopathies.

Osteopathic treatment in a patient with left-ventricular assist device with left brachialgia: a case report

This study deals with an osteopathic approach used for a patient with left-ventricular assist device (L-VAD) affected by left brachialgia. Clinical examination revealed the presence of thoracic outlet syndrome and pectoralis minor syndrome, with compression of the left proximal ulnar nerve, related to the surgical sternotomy performed. The osteopathic techniques used can be classified as indirect and direct, addressed to the pectoralis minor and the first left rib, respectively. To our knowledge, this is the first text in literature with an osteopathic treatment in a patient with L-VAD.

Neurovascular Complications of the Upper Extremity Following Cardiovascular Procedures

BACKGROUND

Cardiovascular procedures are common and are trending toward endovascular interventions. With this increase in endovascular procedures, there is also increasing awareness of upper extremity morbidity resulting from treatment.

METHODS

Articles indexed within PubMed between the years 1975 and 2015 that discussed such complications were reviewed.

RESULTS

Percutaneous radial artery access can lead to nerve ischemia, especially in the setting of an incomplete arterial arch, whereas radial artery harvesting for bypass surgery more commonly causes frank tissue ischemia and radial neuropathy. Transulnar catheterization may cause ischemic hand injuries, while transbrachial angiography has resulted in compartment syndrome. Injuries to the nerves themselves often result from surgical equipment, such as sternal retractors, or from patient positioning leading to compression of the ulnar nerve. For percutaneous radial artery access, the incidence of ischemic injury is as high as 24%, whereas nerve injury is too rare to be estimated. In the setting of radial artery harvesting, ischemic injury is limited to case reports, and radial neuropathy is estimated to occur in as many as 25% of patients at discharge. Open heart surgery is the primary setting in which equipment or patient positioning plays a role, affecting 10% of patients with brachial plexus injuries and 15% with ulnar neuropathies.

CONCLUSION

Complications following cardiovascular interventions are varied and are typically associated with specific procedures. Careful preoperative and postoperative assessments of patients may aid in preventing, minimizing, and treating these often undiagnosed complications.

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.