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Posterior Interosseous Neuropathy during Appendicectomy.

Byline: Zaheer A Gill, Farooq A Rathore (Email: farooqrathore@gmail.com) and Amal Iftikhar

Abstract

Intraoperative and anesthesia related radial nerve injuries have been reported in different surgical procedures and various mechanisms proposed for its occurrence The present case resulted from a procedure of a short duration of 45 minutes. Understanding the pathophysiology of these events and correction of the patient's posture during surgery can prevent such complications.

Introduction

Intra operative peripheral nerve injuries were described as early as 1894.1 However, their incidence remains vague and is probably underestimated.2 Radial nerve injury has been reported following cardiac surgery,3 pyelolithotomy,4 laparoscopic adrenalectomy,4 laprotomy5 and orthopaedic surgery.6 A case of radial nerve palsy following appendectomy under general anaesthesia is presented.

Case Report

A 14 years male was referred, to electrodiagnostic laboratory, for evaluation of weakness in the right hand. He had a past history of undergoing appendectomy under general anaesthesia two weeks back and developed weakness in grip and difficulty in extending right wrist post operatively. On examination there were no sensory symptoms. Medical record did not reveal any documented neurological deficit pre operatively and he denied having any difficulty in gripping before surgery. There was no history of any systemic illness or traumatic injury to the upper limbs. During the 45 minutes surgery, he was operated in a supine position with a blood pressure cuff applied on left arm, while the right arm was placed in an abducted position on a padded arm board. No complication occurred during anaesthesia administration and surgery and the recovery was uneventful.

In the immediate post operative period he reported weakness in right wrist. Physical examination showed mild to moderate right wrist drop but no mass, swelling or redness was observed. He had weakness of extensor digitorum communis and extensor pollicis longus and was able to completely extend the wrist resulting in some radial deviation. Finger and wrist flexion were normal, as was intrinsic hand function. Reflexes and sensations were intact in all four limbs. Plain x-ray of right elbow was normal.

A provisional diagnosis of radial nerve injury, distal to elbow was made and he was referred for electrodiagnostic evaluation. Detailed testing of both upper limbs using surface electrodes was performed. On nerve conduction test, the radial motor on affected side showed a very low compound muscle action potential when recording the Extensor Indices Proprius. No potential was elicitable with stimulation at elbow or above. In contrast, the left side had normal distal compound muscle action potential amplitude, and no drop in amplitude was seen with proximal stimulation. Median and ulnar motor and sensory studies were also performed subsequently to rule out wide spread lesion, but these were normal.

The radial superficial sensory tests were normal and symmetrical on both sides. This pattern was consistent with an injury to posterior interosseous nerve, which is a motor nerve with no cutaneous distribution. The needle electromyography tests revealed fibrillation potentials in Extensor Indices Proprius with modeate to severely reduced recruitment. Motor unit morphology was normal indicating a recent injury, so were the findings in extensor digitorum communis and extensor carpi ulnaris. Brachioradialis, extensor carpi radialis longis and triceps were normal excluding the higher lesion.

All the above findings were consistent with posterior interosseous neuropathy. Patient was managed conservatively with oral vit B12, physiotherapy and home based exercise program. Complete recovery was achieved in 8 weeks with no neurological deficit. Repeat nerve conduction studies / extensor indices proprius showed normalization of radial compound muscle action potential amplitude.

Discussion

Intraoperative and anesthesia related radial nerve injuries have been reported following various surgical procedures3-6 and different mechanisms have been proposed.3,5,7,8 for its occurrence. It can occur due to direct injury by needles, thermal injury by diathermy,7 stretching of arm during positioning ,compression by blood pressure cuff8 or retractor3,9 ultimately leading to nerve ischemia. The most common site and mechanism of radial nerve injury is the compression in the spiral groove, in close contact with the Humerus. The nerve can be compressed easily when the humerus is malpositioned posteriorly, for example on the edge of an operating table or a hard surface.

The possible causes of wrist drop in the present case could be compression injury by blood pressure cuff or by malpositioning of the arm or direct injury to the posterior cord in the axilla and severe C7-8 radiculopathy

Since the blood pressure cuff was applied on the asymptomatic left side, therefore this possibility is ruled out. Appendectomy does not involve use of large retractors that may compress the radial nerve; therefore this possibility is also discarded. A partial brachial plexus nerve injury due to excessive abduction was also not likely because the right arm was abducted only 80-85 degrees. Moreover, absence of sensory symptoms and normal extensor indices proprius findings in brachioradialis and triceps excluded radial nerve injury at spiral groove or involvement of posterior cord respectively. Normal electromyography of C7-8 innervated non radial muscles, further ruled out the possibility of radiculopathy. The possibility of neuropathy liable to pressure palsies as reported by Wijayyasiri10 was considered as a possible etiology.

Most probable reason for radial neuropathy in this case was compression of posterior interosseous nerve due to faulty positioning either during surgery or in the recovery room. This was supported by relatively minor neurological deficit at presentation, electrophysiological findings and complete recovery within eight weeks.

Authors' contributions

* 1st author performed the electrodiagnostic evaluation of the patient and did the literature search and revised the manuscript.

* 2nd author did the literature review and was a major contributor in writing the manuscript"

* 3rd author did the final revision of the manuscript

* All authors read and approved the final manuscript.

References

1. Bqdinger K. Ueber L7 hmungen nach chloroformnarkosen. Arch Klin Chir 1894; 47:121-45.

2. Sawyer RJ, Richmond MN, Hickey JD, Jarratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000; 55: 980-91.

3. Papadopoulou M, Spengos K, Papapostolou A, Tsivgoulis G, Karandreas N. Intraoperative radial nerve injury during coronary artery surgery-report of two cases. J brachial plex peripher Nerve Inj. 2006 5; 1:7 doi:10.1186/1749-7221-1-7.

4. Tuncali BE, Tuncali B, Kuvaki B, Cinar O, Dogan A, Elar Z. Radial nerve injury after general anaesthesia in the lateral decubitus position. Anaesthesia. 2005 ;60:602-4.

5. Maeda R, Koinuma T, Seo N. Posterior interosseous nerve palsy in a man in a lateral position for laparoscopic adrenalectomy-a case report Masui. 2005 ;54:909-11.

6. Eipe N, Padhi NR. Tourniquet palsy or residual block. Anesth Analg 2005; 100: 903-4.

7. Cheney FW, Domino KB, Caplan RA, Pasner KL. Nerve injury associated with anesthesia. Anesthesiology 1999; 90: 1062-9.

8. Lin CC, Jawan B, de Villa MV, Chen FC, Liu PP. Blood pressure cuff compression injury of the radial nerve. J Clin Anesth 2001;13:306-8.

9. Lee HC, Kim HD, Park WK, Rhee HD, Kim KJ: Radial nerve paralysis due to Kent retractor during upper abdominal operation. Yonsei Med J 2003, 44:1106-9.

10. Wijayyasiri L, Batas D, Quiney N. Hereditary neuropathy with liability to pressure palsies and anaesthesia: peri-operative nerve injury. Anaesthesia 2006 ;61:1004-6.

Zaheer A Gill and Farooq A Rathore, Armed Forces Institute of Rehabilitation Medicine, Abid Majeed Road, Rawalpindi, 46000, Pakistan,

Amal Iftikhar, Lousiana State University,1501 Kings Hwy, Shreveport, LA 71103, USA.
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Article Details
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Publication:Pakistan Journal of Medical Research
Article Type:Case study
Geographic Code:9PAKI
Date:Sep 30, 2010
Words:1216
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