Parsonage-turner syndrome after interscalene block for diagnostic arthroscopic surgery of shoulder joint

Parsonage-Turner Syndrome With an Uncommon Trigger: A Case Study and Literature Review

Patients with Parsonage-Turner syndrome (PTS) are often misdiagnosed due to overlapping symptoms with other conditions and coinciding procedures. Because it is most commonly seen following viral infection, it is often not considered in other cases. We present a rare case in which a 79-year-old female, with no significant past medical history, was diagnosed with PTS two months after a biopsy of the right levator scapulae muscle. Forty-eight hours after the procedure, she developed sudden-onset pain and weakness in the right scapulae and neck, followed by worsened weakness. This case report highlights the importance of considering PTS before proceeding with treatment. Patients with suspected PTS should undergo electromyography (EMG) to confirm diagnosis and monitor disease progression and resolution.

Development of Parsonage-Turner Syndrome After Interscalene Brachial Plexus Block Including 10-Year Follow-up: A Case Report

CASE

A 22-year-old female patient demonstrated physical examination findings of Parsonage-Turner syndrome (PTS) 5 days after left shoulder arthroscopic surgery with interscalene brachial plexus block. The diagnosis was confirmed with electrodiagnostic testing 2 weeks after surgery. Symptoms resolved spontaneously within 2 years with full return-to-preinjury sport and job activity. These outcomes were maintained at the 10-year follow-up.

CONCLUSIONS

PTS should be considered in the differential diagnoses for any postsurgical neurological variations after upper extremity surgery under regional anesthesia.

Anterior Interosseous Nerve Palsy After Shoulder Arthroscopy Treated With Surgical Decompression: A Case Series and Systematic Review of the Literature

Background: Anterior interosseous nerve (AIN) palsy is a very uncommon cause of upper extremity pain and weakness that comprises less than 1% of all upper extremity nerve palsies. Rarely reported but also mentioned in the literature is AIN palsy after shoulder arthroscopy. Methods: A systematic review of the literature to date using PubMed was conducted to identify patients who suffered AIN palsy after shoulder arthroscopy procedures. Articles included met the following criteria: (1) published in English; (2) primary presentation of the data; (3) patients had undergone shoulder arthroscopy before developing symptoms of AIN palsy; and (4) diagnosis was confirmed with clinical symptoms of AIN palsy. Measured outcomes included patient demographics, specific shoulder procedure, anesthesia procedure, intra-operative patient positioning, intra-operative compressive dressing, intra-operative traction, surgical versus conservative treatment, abnormal findings during decompression procedure, proposed mechanism of injury, and follow-up. Results: The search yielded 6 articles, of which 4 (13 cases) met inclusion criteria. An additional 2 cases were included in this report totaling 15 cases. The average patient age was 49 years (range: 31-64) with 73% males. At average follow-up of 24 months, 67% of patients experienced complete resolution of symptoms-more than half of which underwent surgical decompression. Patients who failed to progress experienced weakness of the flexor digitorum profundus and flexor pollicis longus muscles. Conclusions: Proposed injury mechanisms for AIN palsy after shoulder arthroscopy range from mechanical trauma, compressive hematoma, and direct anesthetic neurotoxicity. Management should be directed by clinical symptoms, imaging, and patient factors with majority of patients expected to have excellent clinical outcomes.

Anterior Interosseous Nerve Neuropraxia Secondary to Shoulder Arthroscopy and Open Subpectoral Long Head Biceps Tenodesis

Arthroscopic rotator cuff tendon repair is a common elective procedure performed by trained orthopaedic surgeons with a relatively low complication rate. Specifically, isolated neuropraxia of the anterior interosseous nerve (AIN) is a very rare complication of shoulder arthroscopy. An analysis of peer-reviewed published literature revealed only three articles reporting a total of seven cases that describe this specific complication following standard shoulder arthroscopic procedures. This article reports on three patients diagnosed with AIN neuropraxia following routine shoulder arthroscopy done by a single surgeon within a three-year period. All three patients also underwent open biceps tenodesis immediately following completion of the arthroscopic procedures. The exact causal mechanism of AIN neuropraxia following shoulder arthroscopy with biceps tenodesis is not known. This case report reviews possible mechanisms with emphasis on specific factors that make a traction injury the most likely etiology in these cases. We critically analyze our operating room setup and patient positioning practices in light of the existing biomechanical and cadaveric research to propose changes to our standard practices that may help to reduce the incidence of this specific postoperative complication in patients undergoing elective shoulder arthroscopy with biceps tenodesis.

Complex Scapular Winging following Total Shoulder Arthroplasty in a Patient with Ehlers-Danlos Syndrome

This is a unique case of a female patient with features of classical and hypermobile types of Ehlers-Danlos syndrome (EDS) who developed complex scapular winging from spinal accessory and long thoracic neuropathies. These neurological problems became manifest after an uncomplicated total shoulder arthroplasty (TSA). The patient had a complex postoperative course with extensive work-up in addition to revision shoulder surgery and manipulations to treat shoulder stiffness. It was eventually suspected that the periscapular nerve impairments occurred during physical therapy sessions after her TSA. This interpretation was further supported by genetic evidence that, in addition to EDS, the patient had an unrecognized genetic propensity for nerve palsies from stretch or pressure (“hereditary neuropathy with liability to pressure palsies” (HNPP)). By two years after the TSA the neuropathies had only partially improved, leaving the patient with persistent scapular winging and shoulder weakness. With this case we alert surgeons and physical therapists that patients with EDS can have not only a complicated course after TSA, but rare concurrent conditions that can further increase the propensity of neurological injuries that result in compromised shoulder function.