Brachial plexus injury is a rare but potentially serious complication of laparoscopic surgery. Loss of motor and/or sensory innervation can have a significant impact on the patient’s quality of life following otherwise successful surgery. A 38-year-old underwent elective laparoscopic management of severe endometriosis during which she was placed in steep head-down tilt Lloyd-Davies position for a prolonged period. On awakening from anaesthesia, the patient had no sensation or movement of her dominant right arm. A total plexus brachialis injury was suspected. As advised by a neurologist, an MRI brachial plexus, nerve conduction study and electromyography were requested. She was managed conservatively and made a gradual recovery with a degree of residual musculocutaneous nerve neuropathy. The incidence of brachial plexus injury following laparoscopy is unknown but the brachial plexus is particularly susceptible to injury as a result of patient positioning and prolonged operative time. Patient positioning in relation to applied clinical anatomy is explored and risk reduction strategies described.
- peripheral nerve disease
- obstetrics and gynaecology
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Brachial plexus injury is one of the most common peripheral nerve injuries related to surgical positioning with an estimated incidence of 0.16%.1 The prevalence of peripheral nerve injury associated with laparoscopy is unknown but estimates range from 0.03% to 1.19%.2 3 During laparoscopic surgery, peripheral nerve fibres may be compressed, stretched, entrapped or transected as a result of a combination of patient-specific risk factors such as body habitus and patient positioning.4
Commonly adopted surgical positions in laparoscopic gynaecology procedures include Trendelenburg and Lloyd-Davies positions. Friedreich Trendelenburg originally described his eponymous position as head-down tilting of an otherwise supine patient (classically with the patient’s legs on the assistant’s shoulders) but the Trendelenburg position nowadays refers to any head-down tilt, usually at 45°. Lloyd-Davies position is also known as Trendelenburg position with legs apart or ‘head-down lithotomy’. The latter is associated with fewer lower limb neuropathological side effects compared with lithotomy where the hips are almost fully flexed.5 Safe intraoperative patient positioning must balance optimal operating field access and visualisation with risk of neurological compromise and is the responsibility of the multidisciplinary surgical team.
A 38-year-old ex-smoker, with a body mass index (BMI) of 19, underwent elective laparoscopic surgery for severe endometriosis, with a total procedure time of 270 min. During this prolonged period, the patient was placed in Lloyd-Davies position with steep head-down tilt for most of the operation. The right arm was pronated, abducted at less than 90° and secured to an anaesthetic arm board. Bilateral shoulder supports were placed and the limb was strapped at the mid-upper arm level (figure 1). On awakening from anaesthesia, the patient reported inability to move her right arm associated with numbness.
Initial neurological examination of the dominant right upper limb showed reduced tone, absent reflexes and 1/5 power on the Medical Research Council (MRC) scale. There was loss of all sensation below the level of the shoulder. Vascular supply was not impaired with findings of a warm hand, normal capillary refill time in all digits and easy palpation of the ulnar and radial pulses. There was minimal improvement of neurological function after 24 hours, and figure 2 shows that shoulder abduction, flexion and extension remained limited when assessed 3 days following surgery. MRI of the head and the brachial plexus was normal. Neurological examination at 1 week showed mild winging of the right scapula. Power in the muscles was as follows: deltoid (MRC grade 4/5), trapezius (4/5), latissimus dorsi (4−/5), biceps (4/5), triceps (4+/5); supraspinatus and infraspinatus and rhomboids (4/5); extensor digitorum (4/5), abductor digiti mini (4−/5), first dorsal interosseous and abductor pollicis brevis (3/5). There was patchy pinprick sensation throughout the right arm and reflexes remained absent.
At the time of injury, the main clinical suspicion was traumatic brachial plexus nerve injury with the potential causes of injury secondary to patient positioning include:
Steep head-down tilt of Trendelenburg.
Arm fixed to an arm board, possibly causing tourniquet paralysis syndrome or nerve entrapment.
The positioning of shoulder supports.
Protracted operating time.
Differential diagnoses for brachial plexus disorders include:
Infiltrative (brachial plexus neoplasm).
Anatomical (a cervical rib).
Specialist neurological advice was sought. Unfortunately, the peripheral neurophysiology study was significantly delayed due to the COVID-19 pandemic. Nevertheless, she was managed conservatively with physiotherapy-directed exercises and advised on limb support while sitting and mobilising. Initially, a broad arm sling was used to prevent further injury to the ipsilateral side. Neuropathic pain was managed with amitriptyline 10 mg at night. An occupational health assessment was sought to guide her phased safe return to work as a paediatric nurse.
Outcome and follow-up
At 6 weeks, there had been significant motor improvement with only minimal residual hypoaesthesia in the dermatomes of C5–C7. At 10 weeks, the electromyography (EMG) and nerve conduction study demonstrated a markedly attenuated right lateral antebrachial cutaneous response compared with the left. Upper limb sensory responses were normal, with no asymmetry between the two sides. Upper limb median and ulnar motor velocities were normal with no asymmetry in the distal compound muscle action potentials between the two sides. Needle EMG of right biceps revealed some mild neurogenic changes but no active denervation. The rest of the sampled muscles including trapezius, serratus anterior, rhomboid major, infraspinatus, deltoid, triceps, extensor digitorum, pronator teres, abductor pollicis brevis, abductor digiti mini and first dorsal interosseous were normal. The assessing neurophysiologist’s conclusion was of a ‘pan-brachial plexopathy which had improved both clinically and electrophysiologically, with a residual musculocutaneous neuropathy’.
Common symptoms of peripheral nerve injury include changes in sensation including anaesthesia, paraesthesia, dysaesthesia, hyperaesthesia in the dermatomes supplied by the afferent nerves affected or efferent nerve changes in motor function including paresis or paralysis of the muscles supplied.6 During brachial plexus injury, these changes may be detected in part or fully along its course which innervates motor function to the shoulder girdle and upper limb (with the exception of trapezius) and sensation to the upper limb and the most of the axilla.
Prolonged operative time, patient positioning and smoking status are key risk factors for peripheral nerve injury during laparoscopic surgery.2 7 Probable patient risk factors include increasing age, low BMI under 20 kg/m2, high BMI, pre-existing diabetes and vascular disease.4 Advanced laparoscopic procedures and the emerging field of robotic surgery have been associated with a higher risk of brachial plexus injury compared with open abdominal surgery as they require steep Trendelenburg positions to facilitate operative views for prolonged time periods.8 Brachial plexus injury can present immediately after recovery from anaesthesia or in the following days.
The brachial plexus originates from C5–T1 spinal nerve roots and terminates at the axilla to form five terminal nerves, namely, musculocutaneous, axillary, median, radial and ulnar. Pre-terminal nerves are produced along the course of the brachial plexus. The supraclavicular branches describe pre-terminal nerves given off before the brachial plexus passes under the clavicle, including: dorsal scapular nerve (C5), long thoracic nerve (C5, C6, C7), suprascapular nerve (C5, C6) and nerve to subclavius (C5, C6). The infraclavicular branches include all pre-terminal and terminal nerves produced after passing under the clavicle. The brachial plexus is most vulnerable to injury during gynaecological laparoscopy due to its superficial long course and the attachment of the nerves to bones (including the clavicle, first rib, humeral head and coracoid process) and fascia (prevertebral and axillary fasciae) at many points along their course.4 8
Pathophysiology of nerve injury
Neuropathy usually occurs when there is a disruption to the blood supply to the nerve and this can be described in three groups with worsening prognosis (table 1). Anaesthetised patient malposition can result in neuropathies because of the wide range of positioning required during surgery that can cause nerve stretching, or compression with vascular ischaemia.4 Concomitant use of muscle relaxants used during laparoscopic surgery removes the patient’s inherent ability to sense discomfort and readjust accordingly.1
Erb’s palsy (brachial plexus roots C5, C6) and Klumpke’s palsy (brachial plexus roots C8, T1) are well-known traumatic root injuries of the brachial plexus at birth. At vaginal delivery, Erb’s palsy is known to be caused by widening of the head shoulder angle from traction of the infants neck, while Klumpke’s palsy is caused from traction on the hyperabducted arm. During surgical positioning, brachial plexus injury can be caused by hyperabduction of the arm, for example, when arm boards extend beyond 90° from the long axis of the operating table.9 Hyperabduction may cause nerve injury by depression of the humeral head, causing stretching of the brachial plexus between its two anchoring points; or by compression between the clavicle and first rib, especially if abduction is combined with extension.8 The risk of injury is magnified with head rotation away from the abducted arm. The brachial plexus is at risk of stretch injury with the head-down tilt as gravity displaces the body cephalad while the arms are fixed. As the degree of tilt increases, so does the pressure on the shoulder, theoretically increasing the risk of injury.10 This is exacerbated by the use of stabilising devices such as wristlets and shoulder braces, which cause the brachial plexus to stretch by depressing the humeral head and clavicle, especially when combined with an abducted arm.4 8 Cephalad displacement can be reduced by using anti-slide devices such as memory foam or gel pads, either alone or in conjunction with securing mechanisms.11 This case describes transient traumatic injury in a majority of terminal and pre-terminal branches of the brachial plexus so it is likely all five nerve roots were included. Similar mechanisms of traumatic nerve injury can occur at any level of the brachial plexus (roots, trunks, divisions, cords) or in specific pre-terminal or terminal nerves leading to variations of motor and sensory deficits.
Assessment, management and sequelae
Where brachial plexus injury following surgery is suspected, a thorough assessment including consideration of risk factors, clinical history and neuromuscular examinations should be carried out. MRI provides soft tissue contrast which can aid location and causation of injury.12 Electrodiagnostics including nerve conduction study and EMG allow assessment of severity and timing of injury and subsequent evaluation of recovery.8 The majority of cases are managed conservatively with multidisciplinary input including physiotherapy and pain management.8 Analgesic options follow the WHO pain ladder with adjuvant use of gabapentinoids for neuropathic pain. The prognosis of surgical positional brachial plexus injury is promising with most cases exhibiting complete spontaneous recovery within months.4 In rare cases, surgery may be indicated depending on the site and severity of the injury.8 12
Brachial plexus injury is a preventable injury that can have a devastating effect on the patient’s life especially if recovery is prolonged or permanent.
We suggest that a patient positioning discussion is incorporated into the multidisciplinary theatre briefings, especially if specific risk factors are identified or prolonged surgical time is anticipated.
The risk of brachial plexus injury during laparoscopy can be mitigated by: (1) careful patient positioning including avoidance of abduction or external rotation of the upper limbs, minimising the use of arms boards, caution with shoulder braces (use only if both arms are tucked and the head and neck kept in a neutral position) and padding of pressure areas; (2) minimising time spent in surgical positions: keep operating times to a minimum and use the minimal angle of inclination head-down tilt; (3) reassessment of positioning intraoperatively: if the procedure is protracted, consider relieving the patient from steep Trendelenburg and interval repositioning of the upper and lower limbs.
Patient consent for publication
Dr Upeka Ranasinghe, Consultant Anaesthetist at North Middlesex University Hospital.
Contributors AKH and AM wrote the case report. PH and SR gave feedback, advice and edited the case report. WY supervised and edited the case report.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.