Intraoperative positioning related injury of superficial radial nerve after shoulder arthroscopy – a rare iatrogenic injury: a case report
© Singh et al; licensee BioMed Central Ltd. 2008
Received: 26 May 2008
Accepted: 18 July 2008
Published: 18 July 2008
Arthroscopy of the shoulder is a well-established and routine procedure. The role is expected to increase further with an ever-increasing list of indications reflecting the gratifying results. Intraoperative injuries of nerves related to positioning are known but, fortunately, rare with shoulder arthroscopy. Appropriate assessment of patient and careful positioning is paramount in prevention of these injuries. Despite robust preventive measures, these injuries continue to occur from time to time. Although there are few reports of position-related intraoperative nerve injuries associated with shoulder arthroscopy, the involvement of superficial radial nerve (SRN) has never been described before. We report a rare case of positioning related injury of SRN in a 35-year-old female after arthroscopic rotator cuff repair and discuss the preventive and legal aspects. To authors' knowledge this is the first reported case of intraoperative positioning related injury of SRN.
Iatrogenic injury to a nerve during perioperative period is a well-known complication [1, 2]. Any surgical procedure requires well-orchestrated handling of the patient by the team in order to avoid these injuries. Adequate patient assessment, preoperative planning and necessary training of staff are imperative . Preexisting medical condition such as diabetes, peripheral vascular disease and malnutrition predispose to the increase risk of injury . Most of these injuries are fortunately reversible and recover completely if diagnosed and managed appropriately . Although mostly reversible, they still cause unnecessary disability and anxiety to the patients and may result in long-term morbidity, as illustrated by this case.
Positioning related nerve injury is well known complication of surgery but fortunately it is rare . It is commonly seen to involve brachial plexus, sciatic, tibial, common peroneal, ulnar, radial, median and axillary nerve . It may also involve musculocutaneous, long thoracic, saphenous, obturator, facial, supraorbital, lingual and lingual nerve . Injury is usually caused when a nerve is subjected to stretch, ischemia or compression at the time of surgery. Stretch or prolonged compression my lead to end-neural edema, Schwann cell damage and/or demyelination, depending upon the duration . In an awake patient poor positioning or compression leads to discomfort prompting to change in position to relieve the symptoms. In an anaesthetized patient this protective mechanism is abolished predisposing patient to nerve injury .
Patient should be assessed preoperatively to search for predisposing factors such as diabetes, peripheral vascular disease, malnutrition, patient built etc. to minimize the risk of injury. Patient with any predisposing risk factors should be recognized and extra precaution should be taken . Thankfully, most of the injuries recover completely over a period of time but is not true in all the cases. In our case patients symptoms markedly improved over period of time but she was left with hypoesthesia in dorsum of first web space.
Positioning nerve injury is known to every surgeon and, despite the robust preventable measures in place, it still continues to occur from time to time. Detailed history taking and thorough preoperative assessment is vital in order identify the high-risk patient to place extra safety measures in the group. When it occurs is it imperative to identify it early, follow the patients up for recovery and refer them to appropriate specialist for necessary treatment.
A fully informed written consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Superficial Radial Nerve.
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