These authors reviewed the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identifying 26 patients with iatrogenic nerve injury secondary to shoulder surgery (neurologically intact prior to surgery, treated with an open or arthroscopic shoulder procedure, and with a postoperative nerve injury).
The average age was 43 years (17 - 72). The patients presented to the clinic at an average of 5.4 months after surgery. 7 nerve injuries resulted from open instability procedures, 9 from arthroscopic surgery, 4 from total shoulder arthroplasty, and 6 from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in 13 patients and at a terminal nerve branch in 13. 15 patients (58%) did not recover nerve function after observation. A structural nerve injury (laceration or suture entrapment) occurred in 9 patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus.
Of particular interest to the shoulder arthroplasty surgeon is the observation that 3 of the 4 injuries associated with shoulder arthroplasty involved C5 and C6 nerve roots and/or the upper trunk of the brachial plexus. Two of these patients had regional nerve blocks, raising the possibility of block related nerve injury. There were no structural nerve injuries.
As has been pointed out in the article Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring, the extreme positions necessary to perform a shoulder arthroplasty may put the upper plexus at risk from traction. Of particular concern is the 'barber poling' of the musculocutaneous nerve (C5 and 6) around the humerus when the arm is externally rotated and extended. This seems to be a particular problem in patients having limited external rotation before surgery.
Our current practice is to limit to to 10 seconds the time the humerus is in an extreme position, giving the nerves 'a drink' with the arm in neutral before returning to the extreme position.
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