513 - Upper Extremity Brachial Plexopathy during Transtibial Amputation

Case Diagnosis: Brachial Plexopathy

Case Description: 52-year-old male with BMI 34 who developed a brachial plexopathy from improper positioning during transtibial amputation.

After left transtibial amputation for osteomyelitis, patient experienced total paralysis and numbness of bilateral upper extremities. The right recovered acutely, but left remained paralyzed and numb. MRI brachial plexus demonstrated intramuscular edema in left supraspinatus, trapezius, pectoralis major, and left axillary edema surrounding brachial plexus. Nerve conduction study revealed median: absent sensory nerve action potential (SNAP), prolonged compound muscle action potential (CMAP), ulnar: absent SNAP, extremely low amplitude CMAP. Electromyography (EMG) demonstrated neurogenic findings in left biceps, triceps, pronator teres, infraspinatus, and cervical paraspinals. Diagnosis of severe subacute brachial plexopathy was established

Discussions: Brachial plexus injury from position or anesthesia related injuries is not uncommon. The second most injured site of nerve damage related to anesthesia and surgical interventions is the brachial plexus.

Despite careful positioning and awareness, brachial plexus injury occurs in approximately 0.2% of patients who receive general anesthesia. Brachial plexus injuries that occur secondary to mispositioning of patients during general anesthesia are well known to the surgical world, and are a uniquely difficult injury to prevent.

EMG/NCS interpretation, and multimodal treatment plans are pivotal in managing these patients to have successful outcomes.

Conclusions: It is important to understand surgery is not without risks, and something as seemingly niche as positioning can have devastating effects on a patient. Ensuring adequate follow up, education, and support remains paramount in aiding our patients to find a new normal in their lives.

Anatomy of the individual is important in understanding where manifestations of injury can occur, and as physiatrists, allow us to navigate their rehabilitation in a successful way. Through this, we can set realistic expectations and facilitate functional improvements in a patients physical, mental, and emotional well-being.