Brachial Plexus Injury and Musculocutaneous Nerve Palsy During Prone Positioning in a Patient With COVID-19

Abstract

Prone positioning is crucial in the respiratory management of patients with acute respiratory distress syndrome (ARDS) and reduces mortality. However, this may be complicated by compression-related peripheral nerve injury. We report the case of a male in his 80s with obesity admitted to the intensive care unit (ICU) with COVID-19 pneumonia who developed brachial plexus disorder in the right upper extremity and musculocutaneous neuropathy in the left. The patient’s cough, dyspnea, and fatigue did not improve; therefore, he was intubated and placed in the prone position for one week. The patient complained of bilateral upper limb weakness on regaining consciousness. We diagnosed left musculocutaneous nerve palsy and right brachial plexus palsy based on physical findings and needle electromyography (EMG). Physical therapy was initiated, including joint range-of-motion exercises focused on preventing contractures in the extremities and active assistive exercises. Motor impairment improved, and the patient was discharged from the rehabilitation center.

Brachial plexopathy as a result of anatomical prone position in COVID‐19 patients—Systematic review

“…A special group of drugs are glucocorticosteroids, which contribute to muscle weakness resulting in neuropathy, regardless of the doses used and the time of administration of the drug ( Álvarez et al, 2021). Genetic and metabolic factors causing brachial plexus palsy during prone position are diabetes (Brugliera et al, 2021;King-Robson et al, 2022;Mano & Fujimura, 2022;Sánchez-Soblechero et al, 2020), and obesity (Brugliera et al, 2021;Le et al, 2020a;Mano & Fujimura, 2022).…”

“…The risk of neuropathy during prone position is greater if risk factors overlap. Some of them are unmodifiable, such as older age (Le et al, 2020b; Mano & Fujimura, 2022), and gender (Le et al, 2020b)—men more often experience compression neuropathies and are invasively ventilated longer in the ICU (Brugliera et al, 2021). General anesthesia used for mechanical ventilation may also increase the incidence of neuropathy due to the loss of normal muscle tone and the patient's inability to report discomfort to medical staff (Brugliera et al, 2021).…”

“…A special group of drugs are glucocorticosteroids, which contribute to muscle weakness resulting in neuropathy, regardless of the doses used and the time of administration of the drug (Álvarez et al, 2021). Genetic and metabolic factors causing brachial plexus palsy during prone position are diabetes (Brugliera et al, 2021; King‐Robson et al, 2022; Mano & Fujimura, 2022; Sánchez‐Soblechero et al, 2020), and obesity (Brugliera et al, 2021; Le et al, 2020a; Mano & Fujimura, 2022). However, even though obesity increases the risk of neuropathy, the decision to disqualify a patient for the prone position should not be made because of the great benefits of better ventilation of the patient (Schavemaker et al, 2021).…”

“…In every case examination evaluating the treatment was performed at least a month after diagnosis. In the last observation, we paid attention to the other complications of the prone position like right musculocutaneous nerve injury and left lumbosacral plexopathy (Brugliera et al, 2021), bilateral anterior ischemic optic neuropathy (Clarke et al, 2021), single musculocutaneous neuropathy on the other side (Mano & Fujimura, 2022), distal right radial neuropathy, and the rotator cuff muscle edema, but related to myopathy (Omar & Garg, 2021).…”

Neuromuscular Disorders Associated With COVID-19

“…52 Complications such as pressure ulcers and neuropathy from traction injury and nerve compression from prolonged immobilization can occur independent of additional risk factors such as obesity and diabetes mellitus. 53 In cases of severe ARDS, prone positioning is commonly used to improve aeration and oxygenation.…”