Case Report
Idiopathic Brachial Plexus Neuritis After Laparoscopic Treatment of Endometriosis: A Complication That may Mimic Position-Related Brachial Plexus Injury Vasileios Minas, PhD*, and Thomas Aust, MD From Endometriosis Centre, Department of Obstetrics and Gynaecology, Wirral University Teaching Hospital, Upton, United Kingdom (both authors).
ABSTRACT We report the case of a 37-year-old woman who developed idiopathic brachial plexus neuritis, also referred to as ParsonageTurner syndrome, after laparoscopic excision of endometriosis. The differential diagnosis between this non–position-related neuritis and brachial plexus injury is discussed. The aim of this report was to raise awareness on this distressing postoperative complication. Journal of Minimally Invasive Gynecology (2013) 20, 891–893 Ó 2013 AAGL. All rights reserved. Keywords:
DISCUSS
Brachial plexus injury; Endometriosis; Idiopathic brachial neuritis; Laparoscopy; Parsonage-Turner syndrome
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-20-3-JMIG-D-13-00040R1
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Idiopathic brachial plexus neuritis (IBN) was reported in 1948 by Parsonage and Turner [1]. It is a well-recognized syndrome in the orthopedic and neurologic literature, which presents with shoulder girdle pain and weakness [2,3]. It occurs with an overall incidence of 1.64 cases per 100 000 people [4]. The syndrome has been described as a postoperative complication after a number of different surgical procedures including hysteroscopic, orthopedic, and oral surgery [5–11]. In the postoperative patient, the appearance of IBN symptoms may lead to misdiagnosis because they can be attributed to brachial plexus injury (BPI) caused by perioperative patient positioning. Accurate diagnosis, based on clinical presentation and confirmation by electromyography, is essential to counsel and treat the patient appropriately [12]. The syndrome is usually self-limiting. Analgesia during the initial phase of the condition and physical therapy once the painful symptoms have abated represent the mainstay of treatment [13]. The authors declare that they have no conflict of interest. Corresponding author: Vasileios Minas, PhD, Endometriosis Centre, Department of Obstetrics and Gynaecology, Wirral University Teaching Hospital, Upton, CH49 5PE, UK. E-mail: [email protected] Submitted January 17, 2013. Accepted for publication February 8, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.02.003
Case Report A 37-year-old woman who works as a medical practitioner underwent laparoscopic excision of endometriosis. Preoperatively she was well, with no significant medical or family history and a body mass index within normal limits. Her presenting symptom was chronic pelvic pain. During laparoscopy, a left-sided ovarian endometrioma was drained and stripped, left ureterolysis was performed, and endometriosis overlying the left ureter was excised. The operation was performed in the Trendelenburg position under routine general anesthesia. The patient’s head was kept in a neutral position, and her arms were placed straight by her side. The patient had an initially uneventful anesthetic and surgical recovery and was discharged home the same day; however, she was admitted the following day with abdominal pain secondary to urinary retention. These problems resolved with conservative measures. On the third postoperative day, the patient was woken by sudden severe left shoulder pain. The painful symptoms lasted for 3 weeks, during which time she developed associated shoulder weakness. The symptoms were initially interpreted by the patient herself as position-related muscular pain and weakness. She was eventually seen by her general practitioner and referred for an orthopedic assessment 24 days after surgery. Clinical examination revealed wasting and weakness of the
892
Journal of Minimally Invasive Gynecology, Vol 20, No 6, November/December 2013
Fig. 1 MRI of an oblique sagittal section of the patient’s left shoulder. The image shows evidence of supraspinatus (upper box) and infraspinatus (lower box) muscular atrophy. There is a decrease in muscle mass, which is also evident by the increase of the perimuscular fat. Fat is shown in this T2-weighted MRI sequence by increased signal (white tissue).
infraspinatus muscle, giving the impression of isolated suprascapular nerve palsy possibly in keeping with IBN. Magnetic resonance imaging (MRI) of her left shoulder showed atrophy of supraspinatus and infraspinatus muscles without any evidence of nerve compression (Fig. 1). Finally, nerve conduction studies confirmed the diagnosis of IBN. The diagnosis was explained to the patient, and recovery was enhanced with physiotherapy. Five months after surgery and by the time this report was written, the patient’s left shoulder weakness had improved slightly with external rotation persisting. Discussion IBN presents with sudden-onset shoulder girdle pain, which is constant and severe. The pain may extend to the trapezius ridge, upper arm, forearm, and hand. Weakness and sensory deficits, including dysesthesias and numbness, are present in the majority of cases and usually follow the acute painful phase [1]. The condition is usually self-limiting, lasting 1 to 2 weeks, but rarely it may persist for much longer [13]. The exact cause of the syndrome is unknown, with immune-mediated inflammation of the brachial plexus believed to be involved in the pathogenesis. The syndrome has been reported in various different clinical situations that involve some kind of physiological insult. Such situations include surgery, anesthesia, infection,
autoimmune conditions, trauma, immunizations, and pregnancy and childbirth. Rarely, IBN may present without an antecedent event [3]. In gynecology, there exists 1 case report of IBN after hysteroscopy and endometrial biopsy [11]. To the best of our knowledge, the case presented here is the first report of such a complication after gynecologic laparoscopic pelvic surgery. In our case, the patient experienced pain approximately 1 week after surgery with a gradual onset of weakness and wasting of the affected muscles. IBN results in significant distress for both the patient and the surgeon. It poses a diagnostic difficulty, and awareness is required to differentiate from BPI, which can complicate laparoscopic gynecologic surgery and presents with similar symptoms. Results of basic laboratory investigations (i.e., full blood count, blood biochemistry including erythrocyte sedimentation rate, immunoglobulin analysis, and urinalysis) are usually normal and therefore unhelpful [2]. The diagnosis of IBN must be based on careful history, which characteristically involves pain followed by profound weakness, and clinical examination. The absence of evidence of nerve compression in MRI may provide further clues toward the diagnosis, which is confirmed by electromyographic studies [14]. Despite the similar presentation of the 2 syndromes, the pathogenesis is notably different. BPI is largely position related. Romanowski et al [15] reviewed 3200 laparoscopies and identified a steep Trendelenburg position, the use of shoulder braces, and the extension of the arms at 90 degrees or more as being associated with BPI. A number of mechanisms that cause either stretching or compression of the brachial plexus are thought to be responsible for the injury [16]. In particular, advanced laparoscopic procedures with high technical complexity, such as excision of extensive endometriosis, require long operating times, which further increases the risk of BPI. Certain measures have been suggested to minimize the risk of BPI such as using the minimal Trendelenburg angle necessary; keeping operating room times to the minimum necessary; avoiding dorsal extension or lateral flexion of the head; avoiding abduction, external rotation, or extension of the upper extremities; and using stabilization techniques other than shoulder braces [16]. The diagnosis of BPI may be made by history and neuromuscular examination. Electromyography can also confirm the diagnosis and differentiate position-related BPI from IBN. In position-related BPI, typical electromyographic changes will be confined to the muscles innervated by the specific nerve or branch at risk for injury and will most commonly be unilateral. However, in IBN, changes will be multifocal and often bilateral [17]. Interestingly, a clinical feature that may help differentiate between IBN and BPI is the timing of the onset of symptomatology. In both conditions, symptoms may occur within the first 2 postoperative days. Often, BPI will manifest clinically immediately after surgery but very rarely later than the second postoperative day [18]. Contrarily, the development of IBN symptoms can be quite variable, occurring up to
Minas and Aust.
Idiopathic Brachial Plexus Neuritis
a week or more after surgery [3]. In our case, the patient’s symptoms presented 3 days after surgery. Although treatment for both IBN and BPI is similar (i.e., nonsteroidal anti-inflammatory analgesia and physical therapy), the implications are different. No measures exist to prevent IBN, whereas BPI may be preventable as discussed earlier. Accurate diagnosis allows the surgeon to offer an accurate explanation to the patient, thus avoiding potential medicolegal implications and negligence claims that may arise as a result of suspected inappropriate perioperative patient positioning and handling [19].
Conclusions IBN (or Parsonage-Turner syndrome) may complicate laparoscopic gynecologic surgery possibly as a result of surgery- or anesthetic-related stress. It is a condition that can be transiently debilitating for the patient and distressing for the surgeon and anesthetic and nursing staff, with potential medicolegal implications. A level of suspicion is required to reach the correct diagnosis and differentiate from positionrelated BPI. To the best of our knowledge, this is the first report of IBN after laparoscopic gynecologic surgery.
References 1. Parsonage MJ, Turner JWA. The shoulder girdle syndrome. Lancet. 1948;1:973–978. 2. Hussey AJ, O’Brien CP, Regan PJ. Parsonage–Turner syndromedcase report and literature review. Hand (N Y). 2007;2:218–221. 3. Feinberg JH, Radecki J. Parsonage-turner syndrome. HSS J. 2010;6: 199–205.
893 4. Beghi E, Kurland LT, Mulder DW, Nicolosi A. Brachial plexus neuropathy in the population of Rochester, Minnesota. Ann Neurol. 1985;18: 320–323. 5. Anderton JM, Schady W, Markham DE. An unusual case of postoperative brachial palsy. B J Anaesth. 1994;72:605. 6. Dawson DM, Karup C. Perioperative nerve lesions. Arch Neurol. 1989; 46:1355–1360. 7. Eggers KA, Asai T. Post-operative brachial plexus neuropathy after total knee replacement under spinal anaesthesia. Br J Anaesth. 1995;75: 642–644. 8. Huang YC, Wang HC, Tsai YF, et al. Postsurgical brachial neuritis after orthognathic surgery. A case report. J Oral Maxillofac Surg. 2005;63: 1387–1390. 9. Malamut RI, Marques W, England JD, et al. Post-surgical idiopathic brachial neuritis. Muscle Nerve. 1994;17:320–324. 10. Savader SJ, Omdal DG, Venbrux AC. Brachial plexus neuropathy: A rare complication of patient positioning during interventional radiological procedures. J Vasc Interv Radiol. 1999;10:579–582. 11. Fibuch EE, Mertz J, Geller B. Postoperative onset of idiopathic brachial neuritis. Anesthesiology. 1996;84:455–458. 12. Misamore GW, Lehman DE. Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am. 1996;78:1405–1408. 13. Tsairis P, Dyck PJ, Mulder DW. Natural history of brachial plexus neuropathy. Report on 99 patients. Arch Neurol. 1972;27:109–117. 14. McCarty EC, Tsairis P, Warren RF. Brachial neuritis. Clin Orthop Relat Res. 1999;368:37–43. 15. Romanowski L, Reich H, McGlynn F, et al. Brachial plexus neuropathies after advanced laparoscopic surgery. Fertil Steril. 1993;60: 729–732. 16. Shveiky D, Aseff JN, Iglesia CB. Brachial plexus injury after laparoscopic and robotic surgery. J Minim Invasive Gynecol. 2010;17: 414–420. 17. Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol. 2005;63:5–18. 18. Ben-David B, Stahl S. Prognosis of intraoperative brachial plexus injury: a review of 22 cases. Br J Anaesth. 1997;79:440–445. 19. Dornette WHL. Compression neuropathies. Medical aspects and legal implications. Int Anaesthesiol Clin. 1986;24:201–229.
Idiopathic Brachial Plexus Neuritis After Laparoscopic Treatment of Endometriosis: A Complication That may Mimic Position-Related Brachial Plexus Injury Vasileios Minas, PhD*, and Thomas Aust, MD From Endometriosis Centre, Department of Obstetrics and Gynaecology, Wirral University Teaching Hospital, Upton, United Kingdom (both authors).
ABSTRACT We report the case of a 37-year-old woman who developed idiopathic brachial plexus neuritis, also referred to as ParsonageTurner syndrome, after laparoscopic excision of endometriosis. The differential diagnosis between this non–position-related neuritis and brachial plexus injury is discussed. The aim of this report was to raise awareness on this distressing postoperative complication. Journal of Minimally Invasive Gynecology (2013) 20, 891–893 Ó 2013 AAGL. All rights reserved. Keywords:
DISCUSS
Brachial plexus injury; Endometriosis; Idiopathic brachial neuritis; Laparoscopy; Parsonage-Turner syndrome
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-20-3-JMIG-D-13-00040R1
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace.
Idiopathic brachial plexus neuritis (IBN) was reported in 1948 by Parsonage and Turner [1]. It is a well-recognized syndrome in the orthopedic and neurologic literature, which presents with shoulder girdle pain and weakness [2,3]. It occurs with an overall incidence of 1.64 cases per 100 000 people [4]. The syndrome has been described as a postoperative complication after a number of different surgical procedures including hysteroscopic, orthopedic, and oral surgery [5–11]. In the postoperative patient, the appearance of IBN symptoms may lead to misdiagnosis because they can be attributed to brachial plexus injury (BPI) caused by perioperative patient positioning. Accurate diagnosis, based on clinical presentation and confirmation by electromyography, is essential to counsel and treat the patient appropriately [12]. The syndrome is usually self-limiting. Analgesia during the initial phase of the condition and physical therapy once the painful symptoms have abated represent the mainstay of treatment [13]. The authors declare that they have no conflict of interest. Corresponding author: Vasileios Minas, PhD, Endometriosis Centre, Department of Obstetrics and Gynaecology, Wirral University Teaching Hospital, Upton, CH49 5PE, UK. E-mail: [email protected] Submitted January 17, 2013. Accepted for publication February 8, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.02.003
Case Report A 37-year-old woman who works as a medical practitioner underwent laparoscopic excision of endometriosis. Preoperatively she was well, with no significant medical or family history and a body mass index within normal limits. Her presenting symptom was chronic pelvic pain. During laparoscopy, a left-sided ovarian endometrioma was drained and stripped, left ureterolysis was performed, and endometriosis overlying the left ureter was excised. The operation was performed in the Trendelenburg position under routine general anesthesia. The patient’s head was kept in a neutral position, and her arms were placed straight by her side. The patient had an initially uneventful anesthetic and surgical recovery and was discharged home the same day; however, she was admitted the following day with abdominal pain secondary to urinary retention. These problems resolved with conservative measures. On the third postoperative day, the patient was woken by sudden severe left shoulder pain. The painful symptoms lasted for 3 weeks, during which time she developed associated shoulder weakness. The symptoms were initially interpreted by the patient herself as position-related muscular pain and weakness. She was eventually seen by her general practitioner and referred for an orthopedic assessment 24 days after surgery. Clinical examination revealed wasting and weakness of the
892
Journal of Minimally Invasive Gynecology, Vol 20, No 6, November/December 2013
Fig. 1 MRI of an oblique sagittal section of the patient’s left shoulder. The image shows evidence of supraspinatus (upper box) and infraspinatus (lower box) muscular atrophy. There is a decrease in muscle mass, which is also evident by the increase of the perimuscular fat. Fat is shown in this T2-weighted MRI sequence by increased signal (white tissue).
infraspinatus muscle, giving the impression of isolated suprascapular nerve palsy possibly in keeping with IBN. Magnetic resonance imaging (MRI) of her left shoulder showed atrophy of supraspinatus and infraspinatus muscles without any evidence of nerve compression (Fig. 1). Finally, nerve conduction studies confirmed the diagnosis of IBN. The diagnosis was explained to the patient, and recovery was enhanced with physiotherapy. Five months after surgery and by the time this report was written, the patient’s left shoulder weakness had improved slightly with external rotation persisting. Discussion IBN presents with sudden-onset shoulder girdle pain, which is constant and severe. The pain may extend to the trapezius ridge, upper arm, forearm, and hand. Weakness and sensory deficits, including dysesthesias and numbness, are present in the majority of cases and usually follow the acute painful phase [1]. The condition is usually self-limiting, lasting 1 to 2 weeks, but rarely it may persist for much longer [13]. The exact cause of the syndrome is unknown, with immune-mediated inflammation of the brachial plexus believed to be involved in the pathogenesis. The syndrome has been reported in various different clinical situations that involve some kind of physiological insult. Such situations include surgery, anesthesia, infection,
autoimmune conditions, trauma, immunizations, and pregnancy and childbirth. Rarely, IBN may present without an antecedent event [3]. In gynecology, there exists 1 case report of IBN after hysteroscopy and endometrial biopsy [11]. To the best of our knowledge, the case presented here is the first report of such a complication after gynecologic laparoscopic pelvic surgery. In our case, the patient experienced pain approximately 1 week after surgery with a gradual onset of weakness and wasting of the affected muscles. IBN results in significant distress for both the patient and the surgeon. It poses a diagnostic difficulty, and awareness is required to differentiate from BPI, which can complicate laparoscopic gynecologic surgery and presents with similar symptoms. Results of basic laboratory investigations (i.e., full blood count, blood biochemistry including erythrocyte sedimentation rate, immunoglobulin analysis, and urinalysis) are usually normal and therefore unhelpful [2]. The diagnosis of IBN must be based on careful history, which characteristically involves pain followed by profound weakness, and clinical examination. The absence of evidence of nerve compression in MRI may provide further clues toward the diagnosis, which is confirmed by electromyographic studies [14]. Despite the similar presentation of the 2 syndromes, the pathogenesis is notably different. BPI is largely position related. Romanowski et al [15] reviewed 3200 laparoscopies and identified a steep Trendelenburg position, the use of shoulder braces, and the extension of the arms at 90 degrees or more as being associated with BPI. A number of mechanisms that cause either stretching or compression of the brachial plexus are thought to be responsible for the injury [16]. In particular, advanced laparoscopic procedures with high technical complexity, such as excision of extensive endometriosis, require long operating times, which further increases the risk of BPI. Certain measures have been suggested to minimize the risk of BPI such as using the minimal Trendelenburg angle necessary; keeping operating room times to the minimum necessary; avoiding dorsal extension or lateral flexion of the head; avoiding abduction, external rotation, or extension of the upper extremities; and using stabilization techniques other than shoulder braces [16]. The diagnosis of BPI may be made by history and neuromuscular examination. Electromyography can also confirm the diagnosis and differentiate position-related BPI from IBN. In position-related BPI, typical electromyographic changes will be confined to the muscles innervated by the specific nerve or branch at risk for injury and will most commonly be unilateral. However, in IBN, changes will be multifocal and often bilateral [17]. Interestingly, a clinical feature that may help differentiate between IBN and BPI is the timing of the onset of symptomatology. In both conditions, symptoms may occur within the first 2 postoperative days. Often, BPI will manifest clinically immediately after surgery but very rarely later than the second postoperative day [18]. Contrarily, the development of IBN symptoms can be quite variable, occurring up to
Minas and Aust.
Idiopathic Brachial Plexus Neuritis
a week or more after surgery [3]. In our case, the patient’s symptoms presented 3 days after surgery. Although treatment for both IBN and BPI is similar (i.e., nonsteroidal anti-inflammatory analgesia and physical therapy), the implications are different. No measures exist to prevent IBN, whereas BPI may be preventable as discussed earlier. Accurate diagnosis allows the surgeon to offer an accurate explanation to the patient, thus avoiding potential medicolegal implications and negligence claims that may arise as a result of suspected inappropriate perioperative patient positioning and handling [19].
Conclusions IBN (or Parsonage-Turner syndrome) may complicate laparoscopic gynecologic surgery possibly as a result of surgery- or anesthetic-related stress. It is a condition that can be transiently debilitating for the patient and distressing for the surgeon and anesthetic and nursing staff, with potential medicolegal implications. A level of suspicion is required to reach the correct diagnosis and differentiate from positionrelated BPI. To the best of our knowledge, this is the first report of IBN after laparoscopic gynecologic surgery.
References 1. Parsonage MJ, Turner JWA. The shoulder girdle syndrome. Lancet. 1948;1:973–978. 2. Hussey AJ, O’Brien CP, Regan PJ. Parsonage–Turner syndromedcase report and literature review. Hand (N Y). 2007;2:218–221. 3. Feinberg JH, Radecki J. Parsonage-turner syndrome. HSS J. 2010;6: 199–205.
893 4. Beghi E, Kurland LT, Mulder DW, Nicolosi A. Brachial plexus neuropathy in the population of Rochester, Minnesota. Ann Neurol. 1985;18: 320–323. 5. Anderton JM, Schady W, Markham DE. An unusual case of postoperative brachial palsy. B J Anaesth. 1994;72:605. 6. Dawson DM, Karup C. Perioperative nerve lesions. Arch Neurol. 1989; 46:1355–1360. 7. Eggers KA, Asai T. Post-operative brachial plexus neuropathy after total knee replacement under spinal anaesthesia. Br J Anaesth. 1995;75: 642–644. 8. Huang YC, Wang HC, Tsai YF, et al. Postsurgical brachial neuritis after orthognathic surgery. A case report. J Oral Maxillofac Surg. 2005;63: 1387–1390. 9. Malamut RI, Marques W, England JD, et al. Post-surgical idiopathic brachial neuritis. Muscle Nerve. 1994;17:320–324. 10. Savader SJ, Omdal DG, Venbrux AC. Brachial plexus neuropathy: A rare complication of patient positioning during interventional radiological procedures. J Vasc Interv Radiol. 1999;10:579–582. 11. Fibuch EE, Mertz J, Geller B. Postoperative onset of idiopathic brachial neuritis. Anesthesiology. 1996;84:455–458. 12. Misamore GW, Lehman DE. Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am. 1996;78:1405–1408. 13. Tsairis P, Dyck PJ, Mulder DW. Natural history of brachial plexus neuropathy. Report on 99 patients. Arch Neurol. 1972;27:109–117. 14. McCarty EC, Tsairis P, Warren RF. Brachial neuritis. Clin Orthop Relat Res. 1999;368:37–43. 15. Romanowski L, Reich H, McGlynn F, et al. Brachial plexus neuropathies after advanced laparoscopic surgery. Fertil Steril. 1993;60: 729–732. 16. Shveiky D, Aseff JN, Iglesia CB. Brachial plexus injury after laparoscopic and robotic surgery. J Minim Invasive Gynecol. 2010;17: 414–420. 17. Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol. 2005;63:5–18. 18. Ben-David B, Stahl S. Prognosis of intraoperative brachial plexus injury: a review of 22 cases. Br J Anaesth. 1997;79:440–445. 19. Dornette WHL. Compression neuropathies. Medical aspects and legal implications. Int Anaesthesiol Clin. 1986;24:201–229.
