Thursday, April 10, 2014

Shoulder arthroplasty and nerve monitoring

Intraoperative nerve monitoring during total shoulder arthroplasty surgery

The authors quote a published incidence of postoperative neurological deficit after shoulder arthroplasty between 1% and 16%. They conducted a prospective study of nerve conduction in 21 patients who underwent primary or revision total shoulders using intraoperative sensory evoked potentials.

Seven (33%) patients had a signal change. The only significant risk factor identified for signal change was male sex.The median nerve was the most affected nerve in the operated arm. All but one signal change returned to normal before completion of the operation and no patient had a persisting postoperative clinical neurological deficit.

Changes in the neurophysiological signal could not be attributed to a particular position of the limb, stage during surgery or physiological parameter (e.g. blood pressure).

Comment: It is our experience that the median and the musculocutaneous nerves are at greatest risk for traction injury and that the position of greatest risk is when the arm is externally rotated and extended (positions it which these nerves are wrapped around the humerus). The injury most commonly presents as dysethesia in the hand (median nerve) or lateral forearm (musculocutaneous nerve) or as weakness of the biceps. Traction injuries are best avoided by minimizing the amount of time the arm is held in this 'danger position'.
Nerves are at increased risk if (1) the arm lacks external rotation preoperatively and (2) if the patient is on Methotrexate.


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