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Brachial plexus injury

01 February 2006

Mrs J was unhappy with the appearance of her midriff and attended a cosmetic surgery clinic for advice. She was seen by a nurse who told her that she would be a good candidate for abdominal liposuction. After a brief consultation with Dr X, specialist cosmetic surgeon, Mrs J gave her consent to go ahead with the procedure.

After the liposuction, Mrs J experienced severe pain and was unhappy with the appearance of her abdomen. She had fluid leaking from her puncture wounds. She was due to be seen six weeks after her surgery for follow up, but no appointment was sent; she telephoned the clinic to arrange one. When she saw Dr X, Mrs J was told that not enough adipose tissue had been removed and that she would need a repeat procedure.

On waking following the repeat liposuction, Mrs J found that her right arm was weak, such that she couldn’t lift it or hold her husband’s hand. She was told by the clinic staff that she had probably trapped a nerve and was reassured that all would be well by the next day.

Mrs J’s arm was so weak that her husband had to place it under her seatbelt to hold it in place when he drove her home from the clinic. Her arm was no better a week later and she went back to the clinic to see Dr X. He gave Mrs J a collar and cuff and advised her to have physiotherapy.

After several months of physiotherapy treatment Mrs J regained the use of her arm, but never fully recovered her preoperative function in the limb. She had difficulty opening jars, gardening, doing up her bra and had to give up playing badminton.

Mrs J sued the clinic that performed her surgery. The anaesthetist who conducted her sedation for the procedure had placed Mrs J’s hands behind her head as she lay supine; there were no arm boards available to support the weight of the limb in the clinic’s theatre.

Expert opinion

An expert anaesthetist thought that this had caused a traction injury to Mrs J’s brachial plexus. An expert neurologist agreed with the likely mechanism of injury and confirmed its ongoing impairment of Mrs J’s right arm function.

We also had an expert cosmetic surgeon’s opinion that it was inappropriate to carry out liposuction on Mrs J and that she had been inadequately consented for the procedure. An abdominoplasty would have been a more suitable and successful intervention and would have avoided a repeat procedure.

Learning points

  • Preoperative counselling – Cosmetic surgical procedures require a careful preoperative consent process, with meticulous documentation of the risks and expected outcomes as they have been explained to the patient. Patient information leaflets with notes on areas of further discussion are a good way to achieve this. Any leaflets used should be up-to-date, accredited, peer-reviewed and jargon-free.
  • Brachial plexus injuries and anaesthesia – two case-based studies of the phenomenon of brachial plexus injuries occurring in the anaesthetised patient are listed below. The Surgical Tutor Website discusses perioperative nerve injuries briefly and gives advice on how to avoid them. Search for "nerve injuries" here >> 

Further reading

  • Ngamprasertwong P et al., Brachial Plexus Injury Related to Improper Positioning During General Anesthesia, J Anesth, 18(2):132–4 (2004).
  • Ben-David B and Stahl S, Prognosis of Intraoperative Brachial Plexus Injury: A Review of 22 Cases, Br J Anaes, 79(4):440–45 (1997).

Ben-David B and Stahl S, Prognosis of Intraoperative Brachial Plexus Injury: A Review of 22 Cases, Br J Anaes, 79(4):440–45 (1997).