Intraoperative radial nerve injury during coronary artery surgery – report of two cases (original) (raw)
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Injury of the Radial Nerve in the Arm: A Review
Cureus, 2018
Compression of the radial nerve is most commonly described at the supinator muscle (i.e., arcade of Frohse). However, radial nerve compression can occur in the arm. Therefore, the purpose of this article is to review both etiologies of radial nerve entrapment and the sites at which this can occur in the arm. The clinical presentation of radial nerve entrapment in the arm and how it differs from that of entrapment at other sites is reviewed and the conditions potentially predisposing to nerve entrapment are described. Particular attention is paid to the nerve's course and potential variants of the anatomical structures in the arm. In each case, the recommended course of management for the neuropathy is described. Injury of the radial nerve can arise from a varied set of pathologies including trauma, tumors, anomalous muscles, and intramuscular injections. Physicians should have a good working knowledge of the anatomy and potential mechanisms for radial nerve injury.
Neurological Damage After Radial Artery Harvesting In Coronary Surgery: a Direct Measure
Interactive …, 2006
Background: The incidence of neurological complications in the forearm after radial artery harvesting varies in the literature, ranging from 2% to more than 50%. Also, the areas affected and the type of neurological complications differ a lot. Peripheral nerve injuries may be divided into three types: neuroapraxia (conduction block that recovers within 3 months), axonotmesis (recovers 1 ml/day) and neurotmesis (needs surgery for recovering). We decided to perform a neuroelectrophysiological study, before and after surgery, in peripheral nerves of the forearm to find out the real incidence and the type of lesion after radial artery harvesting. Methods: Fifteen consecutive patients whose RA was going to be harvested were selected. Emergency patients, patients with severe liver or renal dysfunction were excluded. A complete neuroelectrophysiological study was performed in the median, ulnar and radial nerve. The amplitude was measured to check mielina status, whereas with the latency and nerve velocity conduction (NVC) we checked the axonal integrity. An electromyogram was also performed in the forearm muscles. A neurological clinical exploration was also performed. All these tests were performed before surgery and two weeks and two months after surgery. Results: Median nerve: A significant decrease in the amplitude that improved over time was registered. This decrease was observed in the motor and sensitive part of the nerve. No changes were observed regarding latency or NVC. Ulnar nerve: A decrease in the amplitude of the sensitive part of the nerve was observed (11.7-9.2-10.4 mV; Ps0.006). No changes were observed regarding latency or NVC. Radial nerve: A statistical trend decrease observed regarding NVC of the sensitive part of the nerve branch was found (50.9 mys vs. 47.1 mys vs. 47.2 mys; Ps0.10). The electromyogram found no alterations. Clinically, three patients presented sensitive disorders in the median nerve territory and one of these also complained of sensitive disorders in the radial territory. Another patient referred dysesthesias in the ulnar nerve territory. All patients with the exception of one were asymptomatic two months after surgery. Conclusions: Although only a few patients refer symptoms, most patients suffer changes in the peripheral nerves of the forearm (especially in the sensitive part) after RA harvesting. In our study the median nerve and the sensitive part of the ulnar and radial nerve were affected. These changes were temporary, affecting mainly the axon. All these data suggest neuroapraxia as the main peripheral nerve type lesion. We think that physicians and patients must be aware of this.
European Journal of Cardio-Thoracic Surgery, 2005
Objective: Radial artery (RA) is now used widely as a conduit of choice in coronary artery bypass grafting. Although RA removal is considered safe in the presence of adequate collateral arterial supply, there is still a considerable suspicion on the functional status of the forearm and hand. However, a neurological dysfunction may occur owing to either surgical trauma or ischemic neuropathy. This study was aimed to investigate the functional outcome of the donor forearm nerves of the patients who underwent coronary artery bypass grafting surgery with RA conduits. Methods: A consecutive series of 50 patients who underwent coronary artery bypass graft surgery with one or two RA grafts were investigated in the study. Motor and sensory functions of donor forearm nerves were measured by ENMG studies, pre-and postoperatively at the third week and sixth month of the operation. The conduction velocities, distal latencies and amplitudes of action potentials for motor and sensorial conductions of radial, ulnar and median nerves were measured in each ENMG examination. Neurologic status of the donor forearm and hand was assessed by the same neurologist who performed a detailed neurologic physical examination and ENMG studies. Results were statistically compared using one-way ANOVA test. Results: The incidence of any neurologic symptoms was 32% in early postoperative period. All reported neurologic complaints were associated with sensory conduction deceleration in ENMG investigations of related nerves. In postoperative assessment, median nerve sensory-motor, and ulnar nerve motor conduction records were slightly lower than the preoperative values, but no statistical difference was observed. Pre-and postoperative radial nerve motor and sensory conduction records were statistically similar (PO0.05). Conclusions: We advocate that removal of RA does not lead to any major neurologic hand complications in the presence of adequate collateral arterial blood supply. ENMG studies confirmed minimal conduction alterations with no statistical significance, even if neurologic symptoms were stated.
2010
The incidence of neurological complications in the forearm after radial artery harvesting varies in the literature, ranging from 2% to more than 50%. Also, the areas affected and the type of neurological complications differ a lot. Peripheral nerve injuries may be divided into three types: neuroapraxia (conduction block that recovers within 3 months), axonotmesis (recovers 1 ml/day) and neurotmesis (needs surgery for recovering). We decided to perform a neuroelectrophysiological study, before and after surgery, in peripheral nerves of the forearm to find out the real incidence and the type of lesion after radial artery harvesting. Methods: Fifteen consecutive patients whose RA was going to be harvested were selected. Emergency patients, patients with severe liver or renal dysfunction were excluded. A complete neuroelectrophysiological study was performed in the median, ulnar and radial nerve. The amplitude was measured to check mielina status, whereas with the latency and nerve velocity conduction (NVC) we checked the axonal integrity. An electromyogram was also performed in the forearm muscles. A neurological clinical exploration was also performed. All these tests were performed before surgery and two weeks and two months after surgery. Results: Median nerve: A significant decrease in the amplitude that improved over time was registered. This decrease was observed in the motor and sensitive part of the nerve. No changes were observed regarding latency or NVC. Ulnar nerve: A decrease in the amplitude of the sensitive part of the nerve was observed (11.7-9.2-10.4 mV; Ps0.006). No changes were observed regarding latency or NVC. Radial nerve: A statistical trend decrease observed regarding NVC of the sensitive part of the nerve branch was found (50.9 mys vs. 47.1 mys vs. 47.2 mys; Ps0.10). The electromyogram found no alterations. Clinically, three patients presented sensitive disorders in the median nerve territory and one of these also complained of sensitive disorders in the radial territory. Another patient referred dysesthesias in the ulnar nerve territory. All patients with the exception of one were asymptomatic two months after surgery. Conclusions: Although only a few patients refer symptoms, most patients suffer changes in the peripheral nerves of the forearm (especially in the sensitive part) after RA harvesting. In our study the median nerve and the sensitive part of the ulnar and radial nerve were affected. These changes were temporary, affecting mainly the axon. All these data suggest neuroapraxia as the main peripheral nerve type lesion. We think that physicians and patients must be aware of this.
Subclinical Injury to Forearm Nerves During Radial Harvesting: Electrophysiologic Study
Journal of Cardiac Surgery, 2006
There are few reports about injury to forearm nerves and its potential mechanisms during radial artery (RA) harvesting. We studied electrophysiologic changes in these nerves not sought until now. Among 152 consecutive patients who underwent coronary artery bypass surgery between February 2002 and August 2002, 20 were randomized for RA harvesting and formed the study group and 20 were randomized as control group. Neurologic examination and electrophysiologic studies were performed for sensory and motor impairment of the nerves in both groups pre- and postoperatively. There was no change on neurologic examinations before and after surgery. Electromyography (EMG) revealed significant reduction in sensory and motor conduction amplitudes of median, ulnar, and radial nerves and motor conduction velocities of median and ulnar nerves at the level of forearm in the study group. In the control group, ulnar nerve was mostly affected. When two groups are compared, sensory and motor amplitude drops of median and radial nerves and motor velocity impairment of median nerve in the study group are significant. Ulnar nerve impairments are identical in both groups. Handling of tissues, minor hematoma or edema along with chest retraction best explains these impairments. Patients were asymptomatic after surgery showing that EMG is highly sensitive and is not predictive of clinical impairment.
Harvesting Radial Artery and Neurologic Complications*
Journal of Cardiac Surgery, 2004
Background: Determination of the incidence, mechanisms, and diagnosis of hand complications after radial artery (RA) harvesting in coronary surgery (CABG). Methods: The study group (RA group) includes 54 patients who underwent RA harvesting in CABG operation. The control group (noRA group) consists of 131 patients who underwent CABG without the use of RA graft. The average follow-up time was 16.36 ± 5.13 months. The patients were examined clinically, (a) for motor function abnormalities associated with radial and median nerve damage and (b) for sensory abnormalities, and the function of radial nerve was determined by eliciting the brachioradialis reflex. They answered in a formal scripted questionnaire to elicit symptoms and clinical points attributable to nerve damage during RA harvest, such as hand weakness, thumb weakness, sensation abnormalities on the back and on the palm side of the forearm, hand numbness, hand-reversible paresis or forearm infection postoperatively, and any other upper limb abnormality.Results: Of the patients in the RA group, 34.09% reported left-hand abnormality after operation. On the other hand, in the noRA group left-hand abnormality was reported in 18.68% of patients. In the RA group sensation abnormality was reported in 34.09% of patients and thumb weakness alone was reported in 6.82% of patients. There was a statistically significant difference between the two groups. Low EuroSCORE was the predicting factor for motor abnormalities. Conclusions: More knowledge has been added about the neurologic complications after RA harvesting lately. We demonstrated the rate of motor and sensory abnormality, the potential mechanisms of these complications caused by surgical trauma or devascularization, and any predictive factors of complications. Optimal surgical techniques to avoid the damage of the responsible nerves are recommended
Radial nerve injury after general anaesthesia in the lateral decubitus position
Anaesthesia, 2005
A 43-year-old female patient underwent pyelolithotomy in the left lateral decubitus position. Her upper right arm was placed on a padded armboard. Surgery lasted for 240 min. Postoperatively, she complained of numbness of the dorsal part of her right hand and wrist drop. Neurological examination revealed hypoaesthesia of the dermatome of the right forearm and hand innervated by the radial nerve. Electromyography revealed advanced axonal degeneration of the radial nerve below the level of the elbow. Treatment with diclofenac, vitamin B and physiotherapy was started. Her symptoms improved gradually and at the 60th postoperative day, motor weakness had completely resolved. In order to prevent peri-operative nerve injury, careful positioning of every patient on the operating table with proper padding is essential, with attention paid to time-dependent risks.
Avoiding peripheral nerve injury in arterial interventions
Diagnostic and Interventional Radiology, 2019
A lthough peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually are not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The paired nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or manual pressure. Nerve injuries have been reported most frequently with axillary and brachial arterial access due to the anatomic proximity of the vessels and nerves at this location in combination with anatomic challenges for hemostasis. Given the higher rate of complications, axillary and brachial arterial access is typically reserved for situations where the interventionalist needs upper extremity arterial access, but the radial or ulnar arteries are not options due to anatomic or other factors. Subclavian arterial access is rarely used owing to high complication rates due to hemostasis challenges as it traverses the thoracic inlet (1). Femoral nerve injury, associated with common femoral artery access, is the second most frequently encountered. This is likely due to the high frequency of use of this access site in combination with the proximity of the femoral nerve just lateral to the common femoral artery in the femoral triangle. It has been suggested that nerve injuries related to angiography may be under-reported due to delayed onset of symptoms, their impermanent nature, lack of recognition, or reluctance of operators to report complications (2-5). Given the increasing frequency of endovascular arterial procedures and the increasing use of non-traditional access points, it is important that interventionalists have a working knowledge of peripheral nerve anatomy and function as it relates to arterial access sites. Upper limb Radial artery Radial artery access has gained popularity as a safe and technically useful technique, particularly for coronary, upper limb, mesenteric, renal, and neurovascular interventions since it has been associated with a lower incidence of major access site related complications compared to the traditional transfemoral approach (6-9). Although transient sensory impair-ABSTRACT Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury. Diagnostic and Interventional Radiology Kuo et al. MCP, metacarpophalangeal; IP, interphalangeal; PIP, proximal IP; DIP, distal IP. *Branches of the anterior interosseous nerve. **Brachialis shares innervation from the radial and musculocutaneous nerves. Figure 3. Color doppler ultrasound image of the brachial artery (A), paired brachial veins (V), and median nerve (MN) above the elbow.
Texas Heart Institute …, 2001
After heart surgery, complications affecting the brachial plexus have been reported in 2% to 38% of cases. The long thoracic nerve is vulnerable to damage at various levels, due to its long and superficial course. This nerve supplies the serratus anterior muscle, which has an important role in the abduction and elevation of the superior limb; paralysis of the serratus anterior causes "winged scapula, " a condition in which the arm cannot be lifted higher than 90° from the side. Unfortunately, the long thoracic nerve can be damaged by a wide variety of traumatic and nontraumatic occurrences, ranging from viral or nonviral disease to improper surgical technique, to the position of the patient during transfer to a hospital bed. Our patient, a 62-year-old man with triple-vessel disease, underwent myocardial revascularization in which right and left internal thoracic arteries and the left radial artery were grafted to the right coronary, descending anterior, and obtuse marginal arteries, respectively. Despite strong recovery and an apparently good postoperative course, the patient sued for damages due to subsequent winging of the left scapula. In this instance, the legal case has less to do with the cause of the lesion (which remains unclear) than with failure to adequately inform the patient of possible complications at the expense of the nervous system. The lesson is that each patient must receive detailed written and oral explanation of the potential benefits and all conceivable risks of a procedure.