Does retraction of the sternum during median sternotomy result in brachial plexus injuries?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'does retraction of the sternum during median sternotomy result in brachial plexus injuries or peripheral neuropathies?' Altogether 58 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, date, journal and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Caudal placement of the retractor or relieving the pressure superiorly by removing the upper blades of a retractor (P = 0.02) and use of a caudally placed symmetrical retractor has been shown to reduce neuropathy. Positioning of the patient with 'hands up' positioning showed significant reduction in the incidence of brachial plexus injuries. Furthermore, how wide the retractor is opened and use of an asymmetrical retractor for internal mammary artery (IMA) harvesting are also important factors in quantifying risk of postoperative neuropathy. Wider sternal retraction and longer bypass time did increase the risk of developing postoperative neuropathy. Three asymmetrical retractors were looked at that demonstrates the Delacroix-Chevalier to be the safest (P < 0.05). We conclude that median sternotomy risks brachial plexus injury and where possible the sternum should be opened as small a distance as possible with symmetrical retractor and using a caudally placed retractor.

Sternal force distribution during median sternotomy retraction

“…General suggested methods to minimize rib fractures and brachial plexus injuries are a reduced retraction distance and traction adapted to the patient size and different patient positioning. 3,12,26,29 Further literature 28,[30][31][32] and our results of the SSR measurements suggest a positioning of the SSR blades in a more caudal position, if surgically possible. That would reduce the forces on the cranial thoracic structures with smaller rib curvatures and minimize fractures at the manubrium or the first ribs.…”

Osteopathic treatment in a patient with left-ventricular assist device with left brachialgia: a case report

“…One of the causes of compression is related to the positioning of the shoulder in complete abduction and anterior rotation during surgical sternotomy; this event will cause a persistent elevation of the first rib, compression of the costo-clavicular nervous junction, and a reduction in the posterior space of the pectoralis minor with hypertone, resulting in compression of the brachial plexus 9,15. The case described in this study reports all signs of neurogenic pain of the brachial plexus and, more in detail, of the ulnar nerve for the involvement of the last two fingers of the left hand 7–9…”

Neurovascular Complications of the Upper Extremity Following Cardiovascular Procedures

“…During a median sternotomy, fully opened sternal retractors push the clavicles into the retroclavicular spaces, while the first ribs are rotated superiorly, thereby increasing the tension on the brachial plexus. 22 Direct needle trauma during catheterization of the internal jugular vein may also contribute to brachial plexopathy. Healey et al 22 in their review of 12 studies concluded that the incidence of brachial plexus injury following median sternotomy is as high as 37.7%.…”

“…22 Direct needle trauma during catheterization of the internal jugular vein may also contribute to brachial plexopathy. Healey et al 22 in their review of 12 studies concluded that the incidence of brachial plexus injury following median sternotomy is as high as 37.7%. Other studies have estimated a lower incidence of 5.5 to 10%.…”

“…Notably, caudal placement of a symmetrical sternal retractor, as well as removal of the upper retractor blades, relieves pressure on the superior neurovascular structures and has been shown to reduce brachial plexus injuries. 22 Also, patient positioning using the "hands up" technique, whereby the patient's arms are elevated above the level of the operative table and behind the head, reduces the incidence of brachial plexopathy and compressive ulnar neuropathy when compared with patients whose arms are left at the side during open cardiovascular procedures. 25…”