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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 4
| Issue : 2 | Page : 86-87 |
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Saturday night palsy
Vijay Adabala, Nishith Govil, Revanth Challa
Department of Anesthesiology, AIIMS, Rishikesh, Uttarakhand, India
| Date of Submission | 13-Feb-2020 |
| Date of Decision | 02-Mar-2020 |
| Date of Acceptance | 18-Mar-2020 |
| Date of Web Publication | 11-May-2020 |
Correspondence Address:
Dr, Vijay Adabala
Department of Anesthesiology, AIIMS, Rishikesh - 249 201, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/BJOA.BJOA_11_20
How to cite this article:
Adabala V, Govil N, Challa R. Saturday night palsy. Bali J Anaesthesiol 2020;4:86-7 |
Dear Editor,
Perioperative peripheral nerve injury (PPNI) is not a well-recognized complication with an incidence of 0.4%. It has been increasingly recognized over the past few decades.[1] PPNIs complicate both general and regional anesthesia. Studies have revealed that anesthesia-related nerve injury (ulnar nerve 28%, brachial plexus 20%, lumbosacral nerve roots 16%, and spinal cord 13%) has become the third most common cause of anesthesia-related litigation.[2],[3]
Recently, we managed a 24-year-old female admitted to the hospital for excision of glomus jugular tumor of the right ear. Blood investigations and physical examination results were normal, and there was no history of any other chronic disease or familial peripheral neuropathy. The patient was laid in a supine position on the operating table with a soft cloth under the pressure points. The right arm and the left arm were parallel next to the body. Except for invasive blood pressure monitoring on the right hand throughout the procedure, no intervention such as intravenous or intramuscular injection was made.
The automatic blood pressure device cuff was attached to the left arm. The surgery lasted for approximately 13 h. Throughout the surgery, nitrous oxide, isoflurane, propofol, and vecuronium were administered. Due to prolonged surgery time and the extent of surgery, the patient was kept on mechanical ventilation for the whole night. The next day, the patient was extubated and was shifted to the ward.
Later, she started complaining of pain in the right arm. On examination, ecchymosis was noted in the right arm with a dropped hand. A diagnosis of acute radial nerve palsy was made. No pathology was determined on computed tomography brain imaging. Physical therapy such as range of motion exercises and occupational therapy were started immediately and were continued after discharge. A splint was applied to prevent contractures.
The first electromyography (EMG) test and nerve conduction velocity test were done 2 weeks postoperatively. The EMG findings of the triceps muscle and ulnar, median, and musculocutaneous nerve conduction velocities were normal. Conduction was blocked in the radial nerve in the middle part of the right arm. After 2 months, there was no movement, not even minimal, in the wrist and fingers, and the sensory loss in the thumb had recovered and was confirmed by EMG. Compared with the previous EMG, a partial recovery was seen toward the distal of the nerve after 3 months. After 5 months, minimal movements started to be observed in the extensor muscles of the wrist and fingers, and at 8 months, there was full recovery.
Peripheral nerve injuries can cause a range of morbidity from transient and clinically minor injury to severe permanent injury, sometimes leading to loss of employment. Of peripheral nerve injuries during general anesthesia, ulnar nerve injuries are most often seen due to topography. Radial nerve injuries due to compression are seen less frequently compared to the ulnar nerve because the radial nerve passes through a deeper area.[4]
While causative factors in PPNI can be multifactorial such as compression, stretch, and ischemia of nerves, hypertension, tobacco use, and diabetes mellitus, however, are also associated with the development of PPNI.[5] In the current case, standard pads were used under the extremities, the patient position was checked at intervals, and there were no local causes such as cyst or tumor or any predisposing systemic causes such as hypotension or hypoxia. The probable mechanism in this patient could be a double-crush syndrome (DCS).
This indicates that compressive lesion occurring along a nerve in the past renders the nerve to be less tolerant of compression at the same or a second locus.[6] It was first described in 1973 by Upton and McComas. Disruption of axonal transport along the nerve increases the vulnerability of distal axons to compression syndromes and symptomatology. This phenomenon can be associated with cervicothoracic nerve root pathology. The value of the concept of DCS is still a debate because there is no way to verify that symptoms are attributed to this particular phenomenon objectively.[7]
Radial nerve paralysis can be due to compression from the cuff of the automatic blood pressure device used to measure blood pressure during general anesthesia.[8] Radial nerve paralysis has been reported to be associated with compression of the triceps, brachialis muscle, and brachioradialis muscle with hypertrophy, resulting from muscular effort or excessive use of the arm muscles.[9] In paralysis, due to the mechanical effect of the blood pressure device cuff, the patient generally has complaints of pain in the arm and the physical examination, hyperemia, and edema.
Physical therapy must be applied carefully for lengthy periods to prevent muscle atrophy and contractures. Tests such as nerve conduction velocity and EMG provide an understanding of the integrity of the nerve and location of the lesion, respectively.[10] Understanding the topography of peripheral nerves enables precautions to be taken to prevent injury in the perioperative period.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: A closed claims analysis. Anesthesiology 1999;90:1062-9.  |
| 2. | Wijayasiri L, Batas D, Quiney N. Hereditary neuropathy with liability to pressure palsies and anaesthesia: Peri-operative nerve injury. Anaesthesia 2006;61:1004-6. |
| 3. | 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. |
| 4. | Winfree CJ, Kline DG. Intraoperative positioning nerve injuries. Surg Neurol 2005;63:5-18. |
| 5. | Lee YK, Kim YI, Choy WS. Radial nerve compression between the brachialis and brachioradialis muscles in a manual worker: A case report. J Hand Surg Am 2006;31:744-6. |
| 6. | Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973;2:359-62. |
| 7. | Dellon AL, Mackinnon SE. Chronic nerve compression model for the double crush hypothesis. Ann Plast Surg 1991;26:259-64. |
| 8. | Lotem M, Fried A, Levy M, Solzi P, Najenson T, Nathan H. Radial palsy following muscular effort. A nerve compression syndrome possibly related to a fibrous arch of the lateral head of the triceps. J Bone Joint Surg Br 1971;53:500-6. |
| 9. | Bickler PE, Schapera A, Bainton CR. Acute radial nerve injury from use of an automatic blood pressure monitor. Anesthesiology 1990;73:186-8. |
| 10. | Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician 2010;81:147-55. |
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