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The Brachialis Syndrome: A Rare Consequence of Patient Positioning Causing Postoperative Median Neuropathy
Steven M. Koehler, MD; Kristen Meier, MD; Dave R. Shukla, MD; Andrew Lovy, MD; Jaehon Kim, MD; Michael R. Hausman, MD
Mount Sinai Medical Center, New York, NY

Introduction: The purpose of this study is to report a previously unreported condition, that we call “brachialis syndrome”, caused by patient positioning that can result in permanent median nerve damage.
Methods: This is a retrospective series from 2008 to 2014 of five patients. Average age was 33 years (17-49). Each patient was an ASA1. All patients underwent surgical decompression of the median nerve. Two-point discrimination and manual muscle testing assessed neurological function.
Results: Five patients (all men) with six median nerves presented with a brachialis syndrome. Every patient presented with mixed sensory and motor deficit: numbness and paresthesias in the median nerve distribution (including the palmar cutaneous branch) as determined by loss of two point discrimination, pain in the forearm and volar wrist, pain with elbow extension, and motor dysfunction of the AIN innervated muscles. The patients underwent various index surgeries averaging 8.2 hours (3-13 hours). All patients were positioned with their elbows in full extension. The average time to symptoms postoperatively was 1 hour (0-2 hours). Two patients (1 and 2), initially presenting in 2008, had an average time to decompression of 58.5 days (25-92 days). In these patients, CT demonstrated brachialis necrosis adjacent to the trochlea. In the subsequent patients (3-5), the average time to decompression was 19.7 hours (16-22 hours). In these patients, CT demonstrated focal brachialis swelling and neural compression, but no necrosis. During decompression, the median nerve was found to be markedly compressed beneath the fascia and the edge of the lacertus fibrosis extending distally to include the takeoff of the AIN. In all cases the lacertus was abnormally thickened. The brachialis was found to have varying degrees of muscle necrosis. In the patients who presented in 2008, there was only partial neurological recovery up to 1 year. Both continued to have sensory deficits and FPL and FDP weakness, although improved. In patients expediently decompressed (patients 3-5), full neurological recovery occurred in 1 day to 2 weeks.
Discussion and Conclusion: This is the first description of the brachialis syndrome, a postoperative median neuropathy associated with patient positioning. The patients’ arms were placed into full extension, compressing the brachialis against the trochlea during lengthy surgical cases in anesthetized patients and resulting in necrosis, swelling and median nerve compression. The importance of patient positioning can not be overemphasized. Our experience includes patients with delayed presentation, delayed decompression and poor neurological outcomes. Thus, we advocate aggressive surgical management.

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