Bilateral brachial plexus injury after liver transplantation

Abstract

We report a case of bilateral brachial plexus injury following living-donor liver transplantation. A 35-year-old man with hepatitis C cirrhosis underwent liver transplantation under general anesthesia, performed in the supine position with 90 degrees arm abduction. The surgery lasted for 14 h, and the anesthesia for 16 h. On postoperative day 1, it was noticed that he had brachial plexus injuries. We investigated the cause of the nerve injuries, in particular, the possible involvement of stretching, compression, or nerve ischemia, which can often result from excessive abduction, the use of shoulder braces, compression by the poles used in the operating theater or compression caused by surgeons leaning on the patient, or serious general status (e.g., hypotension or hypoxemia). Our findings were inconclusive, but we postulated that 90 degrees abduction of the arms per se may have resulted in excessive stretching of the brachial nerves, causing his injuries.

Severe brachial plexus injury after retropubic radical prostatectomy -A case report-

“…Four of these cases were due to the use of shoulder braces in the head-down position, three cases were due to improper positioning of the arm, and one case was due to sustained neck extension [2]. Hida et al [1] suggested that relatively frequent neurologic injuries during liver transplantation, including brachial plexus injury, were probably related to prolonged anesthesia, invasive central venous monitoring catheters, and surgical procedures such as veno-veno bypass and rib cage retraction. Even though we are aware of the risk of brachial plexus injury and we take precautions, these nerve injuries can still occur despite adequate padding of the affected nerve [6].…”

“…Jackson and Keats [3] reported that there was no noticeable effect when the arm was abducted to 90°. However, Hida et al [1] reported severe brachial plexus injury even when their patient's arms were abducted to 90°, which was considered safe. Michaels and Keats [7] reported three brachial plexus injuries after 113 consecutive radical retropubic prostatectomy cases with the arms secured laterally on arm boards.…”

“…Hida et al [1] also reported a severe bilateral brachial plexus injury after liver transplantation that lasted for 16 h. They did not use shoulder braces, but there was a severe bilateral brachial plexus injury that was caused by arm abduction. They concluded that slightly excessive stretching of the nerves for a long time caused the injury.…”

“…Brachial plexus injury is a well-known complication that is associated with anesthesia and surgery [1,2]. Its mechanisms are unclear, but known contributing factors are the following: abduction of the arm more than 90° (hands-up position), a low elbow level, shoulder braces with head-down position, diabetes mellitus, low-body temperature, and a longer duration of the disability [1,3].…”

“…Its mechanisms are unclear, but known contributing factors are the following: abduction of the arm more than 90° (hands-up position), a low elbow level, shoulder braces with head-down position, diabetes mellitus, low-body temperature, and a longer duration of the disability [1,3]. Brachial plexus injuries typically exhibit relatively good prognosis and resolve within 10 weeks [4].…”