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Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads.

ABSTRACT: A 64-year-old male patient underwent cardiac resynchronization therapy (CRT) device implantation via the axillary venous approach. Two weeks later, the patient started complaining of "electric shock-like" pain in the left axillary area. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. Fluoroscopic examination showed that the left ventricle (LV) and right atrium (RA) leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient's shoulder was passively abducted. Brachial plexus irritation by the angulated CRT leads was strongly suspected. To relieve the acute angulation, we had to adjust the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method. After successful lead repositioning, the neuropathic pain improved rapidly. Although transvenous pacing lead-induced nerve injury is not a frequent complication, this possibility should be kept in mind by the operators.

SUBMITTER: Kim SY

PROVIDER: S-EPMC4580703 | biostudies-other | 2015 Sep

REPOSITORIES: biostudies-other

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Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads.

Kim So Yeon SY Park Jong Sung JS Bang Jung Hee JH Kang Eun Ju EJ

Korean circulation journal 20150625 5

A 64-year-old male patient underwent cardiac resynchronization therapy (CRT) device implantation via the axillary venous approach. Two weeks later, the patient started complaining of "electric shock-like" pain in the left axillary area. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. Fluoroscopic examination showed that the left ventricle (LV) and right atrium (RA) leads were positioned at ...[more]

PMID: 26413112

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Project description:Background and purposeBrachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury.Materials and methodsThis prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings.ResultsForty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001).ConclusionsHigh-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.

Project description:OBJECTIVE: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis. CLINICAL PRESENTATION: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department. INTERVENTION: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion. CONCLUSION: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.

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Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads.

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Brachial Plexus Injury Caused by Indwelling Axillary Venous Pacing Leads.

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