Nerve injury associated with shoulder surgery

Introduction Progress in shoulder surgery is associated with improved operating rooms equipment, advanced surgical products and minimally invasive techniques. There are rare injuries to nerves and vessels being intersected or pulled into the sutures. However, marginal tears, compression and nerve entrapment of trunks during access retraction, catheterization, inadequate correct of the patient on the operating table and errors in rehabilitation can be common.

The purpose was to identify factors predisposing to peripheral nerve injury to the upper limb during shoulder surgery and offer prevention options.

Material and methods Major studies in the field of shoulder anatomy and surgery published between 1984 and 2023 were reviewed to identify anatomical, biomechanical and perioperative factors leading to peripheral nerve injuries. The original literature search was conducted on key resources including GoogleScholar, PubMed, ScienceDirect, RSCI, Scopus. Four approaches were used for structuring and informative presentation of the data to include types of the peripheral nerve injury in the upper limb.

Results and discussion Factors predisposing to the peripheral nerve injury in the upper limb during shoulder surgery were identified in the review. Prevention measures include the patient positioned on the operating table with adequate fixation of the head and torso, regardless of the chosen position; traction of the involved upper limb with a load of not greater than 9 kg using a specialized clamp; preoperative marks of the surgical field and staining of bone landmarks; the arthroscopic ports 1–2 cm to be shifted more distally minimizing the fluid flow into the joint during a long operation. Postoperative consultation with rehabilitation specialists is essential to develop an early activation program and assess the risks of neurological disorders.

Conclusion The shoulder anatomy and the localization of unsafe zones of the shoulder, the risks associated with a particular manipulation were explored for effective preoperative planning and prevention of neurological complications in the treatment of surgical pathology of the shoulder joint.

1. Carofino BC, Brogan DM, Kircher MF, et al. Iatrogenic nerve injuries during shoulder surgery. J Bone Joint Surg Am. 2013;95(18):1667-1674. doi: 10.2106/JBJS.L.00238

2. Lafosse T, Lafosse L. Neurological Complications in Shoulder Arthroscopy. In: Lafosse L, Agneskirchner J, Lafosse T. (eds) Complications in Arthroscopic Shoulder Surgery. Springe: Cham Publ.; 2020:139-148. doi: 10.1007/978-3-030-24574-0_14

3. Rashid A., Abdul-Jabar H., Lam F. Nerve injury associated with shoulder surgery. Current Orthopaedics. 2008;22(4):284-288. doi: 10.1016/j.cuor.2008.04.009

4. Andrews JR, Carson WG Jr, Ortega K. Arthroscopy of the shoulder: technique and normal anatomy. Am J Sports Med. 1984;12(1):1-7. doi: 10.1177/036354658401200101

5. Murphy GS, Greenberg SB, Szokol JW. Safety of Beach Chair Position Shoulder Surgery: A Review of the Current Literature. Anesth Analg. 2019;129(1):101-118. doi: 10.1213/ANE.0000000000004133

6. Park TS, Kim YS. Neuropraxia of the cutaneous nerve of the cervical plexus after shoulder arthroscopy. Arthroscopy. 2005;21(5):631. doi: 10.1016/j.arthro.2005.02.003

7. Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy. 2011;27(4):532-541. doi: 10.1016/j.arthro.2010.09.008

8. Hung NK, Lee CH, Chan SM, et al. Transient unilateral hypoglossal nerve palsy after orotracheal intubation for general anesthesia. Acta Anaesthesiol Taiwan. 2009;47(1):48-50. doi: 10.1016/S1875-4597(09)60022-9

9. Cogan A, Boyer P, Soubeyrand M, et al. Cranial nerves neuropraxia after shoulder arthroscopy in beach chair position. Orthop Traumatol Surg Res. 2011;97(3):345-348. doi: 10.1016/j.otsr.2010.09.020

10. Higgins JD, Frank RM, Hamamoto JT, et al. Shoulder Arthroscopy in the Beach Chair Position. Arthrosc Tech. 2017;6(4):e1153-e1158. doi: 10.1016/j.eats.2017.04.002

11. Li X, Eichinger JK, Hartshorn T, et al. A comparison of the lateral decubitus and beach-chair positions for shoulder surgery: advantages and complications. J Am Acad Orthop Surg. 2015;23(1):18-28. doi: 10.5435/JAAOS-23-01-18

12. Hamamoto JT, Frank RM, Higgins JD, et al. Shoulder Arthroscopy in the Lateral Decubitus Position. Arthrosc Tech. 2017;6(4):e1169-e1175. doi: 10.1016/j.eats.2017.04.004

13. Cate G, Barnes J, Cherney S, et al. Current status of virtual reality simulation education for orthopedic residents: the need for a change in focus. Global Surg Educ. 2023;2(1):46. doi: 10.1007/s44186-023-00120-w

14. Burkhart SS. Shoulder arthroscopy: a bridge from the past to the future. J Shoulder Elbow Surg. 2020;29(8):e287-e296. doi: 10.1016/j.jse.2020.04.011

15. Park J, Kim JY, Kim D, et al. Single-Portal Arthroscopic Posterior Shoulder Stabilization. Arthrosc Tech. 2021;10(12):e2813-e2817. doi: 10.1016/j.eats.2021.08.031

16. Dunn ASM, Petterson SC, Plancher KD. The Shoulder Trans-pectoralis Arthroscopic Portal Is a Safe Approach to the Arthroscopic Latarjet Procedure: A Cadaveric Analysis. Arthroscopy. 2021;37(2):470-476. doi: 10.1016/j.arthro.2020.09.044

17. Bharati S, Karmakar M, Ghosh S. Ipsilateral paralysis of hypoglossal nerve following interscalene brachial plexus block. J Anaesthesiol Clin Pharmacol. 2014;30(3):446-447. doi: 10.4103/0970-9185.137304

18. Shah AC, Barnes C, Spiekerman CF, Bollag LA. Hypoglossal nerve palsy after airway management for general anesthesia: an analysis of 69 patients. Anesth Analg. 2015;120(1):105-120. doi: 10.1213/ANE.0000000000000495

19. Meyer M, Graveleau N, Hardy P, Landreau P. Anatomic risks of shoulder arthroscopy portals: anatomic cadaveric study of 12 portals. Arthroscopy. 2007;23(5):529-536. doi: 10.1016/j.arthro.2006.12.022

20. Leechavengvongs S, Teerawutthichaikit T, Witoonchart K, et al. Surgical anatomy of the axillary nerve branches to the deltoid muscle. Clin Anat. 2015;28(1):118-122. doi: 10.1002/ca.22352

21. Segmüller HE, Alfred SP, Zilio G, et al. Cutaneous nerve lesions of the shoulder and arm after arthroscopic shoulder surgery. J Shoulder Elbow Surg. 1995;4(4):254-258. doi: 10.1016/s1058-2746(05)80017-5

22. Kim SH, Koh YG, Sung CH, et al. Iatrogenic suprascapular nerve injury after repair of type II SLAP lesion. Arthroscopy. 2010;26(7):1005-1008. doi: 10.1016/j.arthro.2010.01.005

23. Chan H, Beaupre LA, Bouliane MJ. Injury of the suprascapular nerve during arthroscopic repair of superior labral tears: an anatomic study. J Shoulder Elbow Surg. 2010;19(5):709-715. doi: 10.1016/j.jse.2009.12.007

24. Memon M, Kay J, Gholami A, Simunovic N, Ayeni OR. Fluid Extravasation in Shoulder Arthroscopic Surgery: A Systematic Review. Orthop J Sports Med. 2018;6(5):2325967118771616. doi: 10.1177/2325967118771616

25. McFarland EG, Caicedo JC, Guitterez MI, et al. The anatomic relationship of the brachial plexus and axillary artery to the glenoid. Implications for anterior shoulder surgery. Am J Sports Med. 2001;29(6):729-733. doi: 10.1177/03635465010290061001

26. Fu MC, Hendel MD, Chen X, et al. Surgical anatomy of the radial nerve in the deltopectoral approach for revision shoulder arthroplasty and periprosthetic fracture fixation: a cadaveric study. J Shoulder Elbow Surg. 2017;26(12):2173-2176. doi: 10.1016/j.jse.2017.07.021

27. Patel MS, Daher M, Fuller DA, Abboud JA. Incidence, Risk Factors, Prevention, and Management of Peripheral Nerve Injuries Following Shoulder Arthroplasty. Orthop Clin North Am. 2022;53(2):205-213. doi: 10.1016/j.ocl.2021.11.006

28. Provencher MT, Bhatia S, Ghodadra NS, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92 Suppl 2:133-151. doi: 10.2106/JBJS.J.00906

29. Hovelius L, Körner L, Lundberg B, et al. The coracoid transfer for recurrent dislocation of the shoulder. Technical aspects of the Bristow-Latarjet procedure. J Bone Joint Surg Am. 1983;65(7):926-934.

30. Lädermann A, Denard PJ, Burkhart SS. Injury of the suprascapular nerve during latarjet procedure: an anatomic study. Arthroscopy. 2012;28(3):316-321. doi: 10.1016/j.arthro.2011.08.307

31. Hoyen H, Papendrea R. Exposures of the shoulder and upper humerus. Hand Clin. 2014;30(4):391-399. doi: 10.1016/j.hcl.2014.08.003

32. Chawla H, Gamradt S. Reverse Total Shoulder Arthroplasty: Technique, Decision-Making and Exposure Tips. Curr Rev Musculoskelet Med. 2020;13(2):180-185. doi: 10.1007/s12178-020-09613-3

33. Knežević J, Mihalj M, Čukelj F, Ivanišević A. MIPO of proximal humerus fractures through an anterolateral acromial approach. Is the axillary nerve at risk? Injury. 2017;48 Suppl 5:S15-S20. doi: 10.1016/S0020-1383(17)30733-7

34. Yildirim C, Demirel M, Bayram E, et al. Acromion-axillary nerve distance and its relation to the arm length in the prediction of the axillary nerve position: a clinical study. J Orthop Surg Res. 2022;17(1):248. doi: 10.1186/s13018-022-03085-6

35. Cheung S, Fitzpatrick M, Lee TQ. Effects of shoulder position on axillary nerve positions during the split lateral deltoid approach. J Shoulder Elbow Surg. 2009;18(5):748-755. doi: 10.1016/j.jse.2008.12.001

36. Chuaychoosakoon C, Suwannaphisit S. The Relationship Between Arm Abduction Position and the Risk of Iatrogenic Anterior Branch of the Axillary Nerve Injuries: A Cadaveric Study. Orthop J Sports Med. 2021;9(5):23259671211008834. doi: 10.1177/23259671211008834

37. Wilkinson EB, Williams JF, Paul KD, et al. MRI evaluation of axillary neurovascular bundle: Implications for minimally invasive proximal humerus fracture fixation. JSES Int. 2021;5(2):205-211. doi: 10.1016/j.jseint.2020.11.002

38. Wirth MA, Butters KP, Rockwood CA Jr. The posterior deltoid-splitting approach to the shoulder. Clin Orthop Relat Res. 1993;(296):92-98.

39. Thomasson BG, Matzon JL, Pepe M, et al. Distal peripheral neuropathy after open and arthroscopic shoulder surgery: an under-recognized complication. J Shoulder Elbow Surg. 2015;24(1):60-66. doi: 10.1016/j.jse.2014.08.007

40. Walch G, Bacle G, Lädermann A, et al. Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon's experience? J Shoulder Elbow Surg. 2012;21(11):1470-1477. doi: 10.1016/j.jse.2011.11.010

41. Lenters TR, Davies J, Matsen FA 3rd. The types and severity of complications associated with interscalene brachial plexus block anesthesia: local and national evidence. J Shoulder Elbow Surg. 2007;16(4):379-387. doi: 10.1016/j.jse.2006.10.007

42. Hogan QH. Pathophysiology of peripheral nerve injury during regional anesthesia. Reg Anesth Pain Med. 2008;33(5):435- 441. doi: 10.1016/j.rapm.2008.03.002

43. Anderson DM, White RA. Ischemic bandage injuries: a case series and review of the literature. Vet Surg. 2000;29(6):488- 498. doi: 10.1053/jvet.2000.17847

44. Murphy EP, Fenelon C, Alexander M, Quinlan J. Anterior interosseous nerve palsy as a result of prolonged shoulder immobilisation. BMJ Case Rep. 2019;12(5):e229010. doi: 10.1136/bcr-2018-229010

45. Scully WF, Wilson DJ, Parada SA, Arrington ED. Iatrogenic nerve injuries in shoulder surgery. J Am Acad Orthop Surg. 2013;21(12):717-726. doi: 10.5435/JAAOS-21-12-717

46. Esmail AN, Getz CL, Schwartz DM, et al. Axillary nerve monitoring during arthroscopic shoulder stabilization. Arthroscopy. 2005;21(6):665-671. doi: 10.1016/j.arthro.2005.03.013

47. Nagda SH, Rogers KJ, Sestokas AK, et al. Neer Award 2005: Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring. J Shoulder Elbow Surg. 2007;16(3 Suppl):S2-S8. doi: 10.1016/j.jse.2006.01.016

48. Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve. 2022;66(6):661-670. doi: 10.1002/mus.27706

49. Pripotnev S, Bucelli RC, Patterson JMM, et al. Interpreting Electrodiagnostic Studies for the Management of Nerve Injury. J Hand Surg Am. 2022;47(9):881-889. doi: 10.1016/j.jhsa.2022.04.008

50. Gupta R, Patel NA, Mazzocca AD, Romeo A. Understanding and Treating Iatrogenic Nerve Injuries in Shoulder Surgery. J Am Acad Orthop Surg. 2020;28(5):e185-e192. doi: 10.5435/JAAOS-D-18-00608

51. Kamble N, Shukla D, Bhat D. Peripheral Nerve Injuries: Electrophysiology for the Neurosurgeon. Neurol India. 2019;67(6):1419-1422. doi: 10.4103/0028-3886.273626

52. Tuturov AO. The role of peripheral nerve surgery in a tissue reinnervation. Chin Neurosurg J. 2019;5:5. doi: 10.1186/s41016-019-0151-1

53. Petrosyan AS, Egiazaryan KA, Panin MA, Ratyev AA, Al-bawareed OA. Evolution of shoulder arthroplasty. RUDN Journal of Medicine. 2022;26(2):117-128. (In Russ.) doi: 10.22363/2313-0245-2022-26-2-117-128

54. Giyasova N., Alilov Kh., Sadullaev O. et al. Visualization of traumatic injuries of the shoulder girdle. Innovation Scientific Journal. 2022;1(11):59-75. (In Russ.)

55. Shershnev AM, Dokolin SY, Kuzmina VI, et al. Options in Tendon Transfers for Anterior-Superior Rotator Cuff Tears: Review. Traumatology and Orthopedics of Russia. 2023;29(1):135-142. doi: 10.17816/2311-2905-2017