Inflammatory Brachial Plexitis Mimics Postoperative Iatrogenic Neurological Deficits

Introduction: A potentially common cause of neurosurgical malpractice cases is the misrepresentation of idiopathic brachial neuritis (incidence:1/1000) as an iatrogenic neurological insult caused by a surgeon. To describe our experience of post-procedural brachial neuritis and improve recognition.

Methods: Confirmed postprocedural brachial neuritis patients from a single quaternary care institution were identified and analyzed.

Results: We identified 6 (3 female) postprocedural brachial neuritis patients with mean age 63.7 (range 50-75) years. Procedures included 5 cervical spine surgeries (3 multilevel ACDFs, 2 multilevel posterior fusions with laminectomies, 1 multilevel disc arthroplasty) and 1 intrajugular central venous catheter placement. Average time to symptom onset was 1 week post-procedure (range 1 day-2.5 weeks). Initial symptom was moderate-to-severe shoulder (5), arm (4), and/or neck (1) pain. Subsequently, all developed axillary/shoulder weakness; 3 distal arm/hand weakness, 2 winged scapula, and 2 dyspnea/orthopnea. For diagnosis, two patients had confirmatory EMG, 1 had MR neurography confirming plexus inflammation, and 3 had both (positive EMG findings and inflammation on MR Neurography). (Figure 1). Average time to accurate diagnosis was 3.1 (range 1.5-5) months. Average number of clinicians seen prior to accurate diagnosis: 5. Treatments included opioids (5), steroids (1), and/or physical therapy (6). All experienced partial pain relief by 1-8 weeks; 2 had persistent pain requiring gabapentin past 6 months. All patients continued to experience motor deficits past 6 months: (4 patients had atrophy and 2-4/5 motor strength in proximal the proximal arm, 1 had distal arm 3/5 motor strength, and 1 had scapular winging).

Conclusion : Postoperative idiopathic brachial neuritis mimics iatrogenic nerve damage following neurosurgical procedures. Recognition of this entity is difficult, and 6 patients at our institution saw on average 5 providers over 3 months prior to accurate diagnosis. Brachial plexitis has a prolonged course with typically only partial recovery at 6 months.