Hereditary neuropathy with liability to pressure palsies and anaesthesia: peri‐operative nerve injury

Abstract

A 43-year-old female with carcinoma of the left breast underwent wide local excision of the tumour and sentinel lymph node biopsy under general anaesthesia. Three lymph nodes were removed uneventfully during the operation. Postoperatively, the patient complained of weakness and decreased sensation of her left arm. A diagnosis of peri-operative neuropraxia was made. This resolved completely over the following 4 weeks. Genetic testing confirmed a diagnosis of hereditary neuropathy with liability to pressure palsies. Peripheral nerve injury during anaesthesia is one of the most common complications, with a quoted incidence of 0.4% [1]. It may be associated with poor intra-operative positioning and patients most at risk are those with preexisting neuropathy (e.g. diabetes) and certain anatomical and metabolic disorders. We report a case of transient, postoperative high left radial nerve palsy (neuropraxia) due to hereditary neuropathy with liability to pressure palsies (HNPP). There are no published reports of a similar case where a peri-operative peripheral nerve injury has shown to be associated with HNPP. Case historyA 43-year-old female was diagnosed with carcinoma of the left breast. She was admitted for wide local excision of the tumour and axillary sentinel node biopsy using both radionuclide and Patent Blue V dye techniques. The patient was medically well and had been taking tamoxifen 20 mg daily for 2 weeks before the operation. She reported an intolerance to alcohol which caused facial flushing and palpitations. No other anaesthetic risk factors were identified from the history or clinical examination.After insertion of a 22-gauge intravenous cannula on the dorsum of the right hand, anaesthesia was induced using fentanyl citrate 100 lg and propofol 300 mg. A laryngeal mask airway was inserted. Anaesthesia was maintained with a mixture of 50% nitrous oxide in oxygen and a 1-2% inhaled concentration of isoflurane. The patient maintained spontaneous respiration throughout the operation. During the procedure, morphine sulphate 5 mg and granisetron hydrochloride 1 mg were given. The patient was placed in the supine position with her left arm abducted to 90°on an arm board. Gel pads were used judiciously to protect common nerve compression sites. The left arm was wrapped in sterile surgical towels to allow the surgeon to move the arm during the course of the operation. A breast specimen of 76 g was removed from the upper central portion of the left breast and three axillary lymph nodes were removed. No neurological structures were noted by the surgeon during the procedure and there was no direct injury to the brachial plexus. The procedure was completed within 75 min.Immediately after the operation, the patient complained of numbness and generalised weakness of her left arm. She was unable to raise her arm to her face. A good vascular supply was confirmed by strong peripheral pulses.Four days after the operation she continued to complain of residual elbow and forearm numbness with weakness in flexion of her elbo...

Pressure palsy mimicking brachial plexus injury after mastectomy

“…In a recently published report, Wijayasiri et al. reported a case of hereditary neuropathy with liability to pressure palsies (HNPP) after breast surgery [1]. We report a similar case.…”

Hereditary Neuropathy with Liability to Pressure Palsy and Vocal Cord Paralysis After Pulmonary Lobectomy: A Case Report

“…[4][5][6][7][8][9][10][11][12] The condition of 6 patients improved within 2 days to 5 months. 4,5,8,9,11,12 In 2 patients, nerve injury persisted. 7,10 One patient recovered completely; however, no details were described.…”

“…1 In previous cases, anesthesia-related neuropathy in HNPP has mostly involved the peripheral nerves of the extremities. [2][3][4][5][6][7][8][9][10][11][12] It has been recommended that any pressure involving the extremities be minimized during anesthesia to prevent these complications. We report a case that successfully managed to prevent peripheral nerve neuropathy, but the patient manifested with vocal cord paralysis due to recurrent laryngeal nerve (RLN) palsy.…”

Spectrum of peripheral neuropathies associated with surgical interventions; A neurophysiological assessment

“…Apart from direct neural trauma and mechanical factors, other factors may also contribute to the development of post-procedure neuropathy. Nerves may be more susceptible to trauma as a result of pre-existing generalised peripheral neuropathy [9,21], local compression neuropathy (overt or subclinical) [4,22] or as a hereditary predisposition (hereditary neuropathy with liability to pressure palsy/HNPP) [23,24]. HNPP should be considered in patients with post-operative focal neuropathies.…”