Perioperative Complications Associated with Brachial Plexus Repair in Infants

INTRODUCTION

Over the past decade, early operative intervention has become the treatment of choice for infants with brachial plexus birth injuries who fail to demonstrate appropriate spontaneous recovery during the first 3–8 months of life (Gilbert, 2001; Kay, 1998; Sherburn et al., 1997; Sloof, 1995). In spite of the rapidly increasing number of surgical cases performed, little attention has been given to perioperative management, including anaesthetic techniques and associated surgical risks (Birch, 2000; Borrero, 2001; Hazama et al., 1999; La Scala et al., 2001; Seveso et al., 1983). This report analyses the perioperative complications in a series of operative cases.

PATIENTS AND METHODS

The hospital, surgical, and anaesthetic records of 100 consecutive cases (1998–2000) of brachial plexus repair in infants who sustained brachial plexus birth trauma were retrospectively reviewed. A single surgeon performed all of the procedures. Anaesthesia was administered by senior members of a paediatric anaesthesia department at a large, dedicated children’s hospital. The patient population consisted of 51 male infants and 49 female infants. The average age at surgery was 41 weeks and the average weight at surgery was 9.50 kg. The average surgical time was 7.3 h. Seventy-five cases were upper/middle (C5, C6, ±C7) plexus lesions and 25 cases were total lesions. Ninety-six patients underwent nerve-grafting procedures. No intercostal transfers were used. One patient (Case 1) had a phrenic nerve injury. Twenty infants underwent simultaneous shoulder reconstruction (posterior capsuloplasty and/or subscapularis slide).

RESULTS

Eight perioperative complications were noted. Five complications were intraoperative and involved wheezing, increased rhonchi, and transient CO₂ changes while under anaesthesia. These may have been related to bronchospasm since relaxing agents were not used. All patients were treated with intraoperative albuterol and their postoperative courses were all uneventful. Three immediate postoperative complications were noted as follows.

DISCUSSION

Previous reports in the anaesthesia literature have described a variety of potential postoperative complications associated with brachial plexus surgery in neonates (Hazama et al., 1999; Seveso et al., 1983). In addition to respiratory abnormalities including atelectasis, PCO₂ elevation, and increased bronchial secretions; problems with body temperature control have also been noted. More recently additional complications such as phrenic nerve injury (Birch, 2000; Borrero, 2001), pneumothorax, chylothorax, fluid overload, and pulmonary oedema have been noted (La Scala et al., 2001).

In this retrospective report we have carefully reviewed a consecutive series of 100 cases from both surgical and anaesthetic perspectives. Certain features are associated with the low incidence of perioperative complications. First, all procedures were performed by the same surgical team. Second, all patients are evaluated by a paediatrician 24–48 h before surgery. Third, our anaesthetic technique utilised a continuous narcotic infusion which not only permitted consistent and reproducible intraoperative neurophysiologic studies, but also, when compared to a smaller series using inhalation agents, appeared to allow for a smoother postanaesthetic course with decreased agitation. This technique limits the need for significant or prolonged postoperative sedation or analgesia. Temperature monitoring with a nasopharyngeal probe and precise fluid management further reduce morbidity. Careful intraoperative dissection using the operating microscope and intraoperative neurophysiology aids in preventing iatrogenic injury.

These data further support the relatively safe nature of these lengthy and complex operative procedures when performed by experienced personnel in an appropriate paediatric surgical environment. With the exception of Case 1, we have not found any factors in the patients with intra- or postoperative problems that would distinguish them from the uneventful cases. As with any long operative procedure, especially in infants, the potential for serious morbidity and even mortality exists. However, parents should not be discouraged from treatment of their child’s brachial plexus injury due to fear of surgical complications.