A Neglected Cause of Iatrogenic Brachial Plexus Injuries in Psychiatric Patients

A Neglected Cause of Iatrogenic Brachial Plexus Injuries in Psychiatric Patients Abstract BACKGROUND Psychiatric patients are often kept immobilized during hospitalization to avoid self-inflicted injuries and danger to third parties. Inadequate positioning can lead to brachial plexus injuries (BPI). OBJECTIVE To present a series of 5 psychiatric patients with BPI after being left sedated and restrained for prolonged periods of time during hospitalization. METHODS We retrospectively reviewed the charts of 5 psychiatric patients with iatrogenic BPI referred by other institutions to our service. The restraint technique adopted by those institutions consisted of a high-thoracic restraint. All patients underwent complete clinical and neurological examination at our center. Information concerning patient demographics, BPI characteristics, treatment choice, and ultimate outcome was recorded. RESULTS Three patients were male. The age of our patients ranged from 25 to 61 years old (mean: 41.2; median: 43). Three patients had a diagnosis of bipolar disorder while 2 had schizophrenia. Duration of immobilization ranged from 5 to 168 h (mean: 77.8; median: 72). Four patients presented with a unilateral right-sided lesion. Time to presentation ranged from 1 to 9 mo (mean: 4.2; median: 4). All patients also had intense pain and axillary lesions. Four patients received conservative treatment with partial or full functional recovery and complete pain resolution. The remaining patients underwent surgical repair and experienced good functional outcome. CONCLUSION Psychiatric patients who need to be sedated and immobilized must be monitored closely, as BPI can occur from high-thoracic restraints. When such an injury occurs, the patient must be referred to a center specialized in peripheral nerve surgery and rehabilitation. Brachial plexus neuropathies, Iatrogenic disease, Physical restraints, Schizophrenia, Bipolar disorder ABBREVIATIONS ABBREVIATIONS BP brachial plexus BPI brachial plexus injuries EMG electrophysiological MRC Medical Research Council VAS visual analog scale Psychiatric patients are often kept immobilized during hospitalization to reduce the risk that they will sustain self-inflicted injuries or injure others.1 Some will be repeatedly sedated, restrained, and left unsupervised for prolonged periods of time in inappropriate positions that can be harmful, and sometimes even lead to brachial plexus injuries (BPI). Iatrogenic lesions affecting the peripheral nerves and plexuses remain relatively common and underreported, and some of these lesions are associated with severe deficits.2-5 Such injuries have been described for several decades.6,7 They may have either a surgical or nonsurgical cause. Such causes include direct damage to the nerve during surgery; pressure or traction during an anesthetic procedure; pressure caused by external hemorrhaging; ischemia; the injection of caustic materials; direct needle puncture; anticoagulation therapy; prostheses and orthoses; thermal injury; and radiation therapy, among others.2,7,8 According to Sawyer et al,5 ulnar nerve neuropathies are the most frequent iatrogenic nerve injuries caused in patients under anesthesia, followed by injuries involving the brachial plexus (BP) and lumbosacral nerve roots. However, to the best of our knowledge, iatrogenic BPI due to high-thoracic restraints in psychiatric patients has not yet been reported in the English literature. In this paper, we present a small series of 5 psychiatric patients who presented with BPI after being sedated and immobilized for long periods during their hospitalization. They were referred to our center for both evaluation and treatment. All patients consented to publication of his/her image. METHODS We retrospectively reviewed the charts of psychiatric patients with iatrogenic BPI evaluated between January 2007 and January 2014 at our institutions. Consent was obtained, and our study was approved by the ethics committee. In the records from referring institutions, it is clear that patients with severe psychomotor agitation are often sedated and immobilized. The containment technique adopted by those institutions consists of a high-thoracic restraint. With this technique, the patient is immobilized with a bedsheet over his chest and under his armpits that is then tied to the head of the bed (Figure 1). In addition, the patient's upper extremities are both abducted past 90° so that their wrists can be attached to the sides of the bed. FIGURE 1. View largeDownload slide High-thoracic restraint. Due to patient's movement, the arms often do not stay fully abducted. FIGURE 1. View largeDownload slide High-thoracic restraint. Due to patient's movement, the arms often do not stay fully abducted. At our center, all 5 patients underwent a thorough clinical and neurological examination. Each patient's sex, age, psychiatric condition, injury type and side, duration of the immobilization, and time of presentation to our service were recorded. Muscular function was evaluated for each upper limb muscle using the British Medical Research Council (MRC) scale.9 Pain and sensation were assessed by means of a 10-point visual analog scale (VAS) and the 2-point discrimination test,10,11 respectively. The presence of skin and/or vascular lesions was also documented, as well as the duration of follow-up and the patient's final outcome. RESULTS Five patients were included in our series. Patient characteristics related to sex, age, psychiatric condition, duration of immobilization, and BPI type and side are summarized in Table 1. Three patients were male and 2 female. The age of our patients ranged from 25 to 61 years old (mean: 41.2; median: 43). Three patients had a prior diagnosis of bipolar disorder, 1 of which had been admitted to the referring institution in a manic phase. The other 2 patients had the psychiatric diagnosis of schizophrenia. The duration of immobilization ranged from 5 to 168 h (mean: 77.8; median: 72). Two patients presented with high extended BPI, which means a lesion from C5 to C7. One patient presented with high BPI, involving just the C5 and C6 roots. One patient presented with a low lesion, affecting the C8 and T1 roots. The remaining 1 patient presented with a pan-plexopathy, with all 5 nerve roots of the BP involved (C5-T1). Four of our patients presented with a unilateral right-sided lesion, while one had a bilateral BPI. Injuries to the radial nerve caused by wrist restraints were not reported in this patient population. TABLE 1. Individual Case Demographic and Baseline Clinical Characteristics Case  Sex  Age (in years)  Psychiatric condition  Duration of immobilization (h)  BPI type  Side of body affected  1  ♀  61  Bipolar disorder  72  Extended High (C5-C6-C7)  Right  2  ♂  41  Schizophrenia  168  High (C5-C6)  Right  3  ♂  36  Schizophrenia  24  Complete (C5-T1)  Bilateral  4  ♀  25  Bipolar disorder (manic phase)  5  Low (C8-T1)  Right  5  ♂  43  Bipolar disorder  120  Extended High (C5-C6-C7)  Right  Case  Sex  Age (in years)  Psychiatric condition  Duration of immobilization (h)  BPI type  Side of body affected  1  ♀  61  Bipolar disorder  72  Extended High (C5-C6-C7)  Right  2  ♂  41  Schizophrenia  168  High (C5-C6)  Right  3  ♂  36  Schizophrenia  24  Complete (C5-T1)  Bilateral  4  ♀  25  Bipolar disorder (manic phase)  5  Low (C8-T1)  Right  5  ♂  43  Bipolar disorder  120  Extended High (C5-C6-C7)  Right  ♂ = male; ♀ = female. View Large Information concerning time to presentation, VAS pain score, axillary skin lesions, vascular lesions, treatment choice, follow-up and final patient outcomes is listed in Table 2. The patients were referred for evaluation by our service after periods ranging between 1 and 9 mo (mean 4.2; median 4) from the time the diagnosis of a plexus lesion was made at the referring institution. This delay in referral to our specialized peripheral nerves unit in all cases occurred due to a first treatment attempt with physical therapy. TABLE 2. Individual Clinical Characteristics and Outcomes Case  Time to presentation (mo)  Pain at presentation (VAS score)  Skin axillary lesions  Vascular lesions  Treatment choice  Follow-up (mo)  Pain at final follow-up (VAS score)  Functional outcome  1  3  8  +  –  Conservative  6  0  Full recovery  2  9  7  +  –  Surgical  12  2  Partial recoverya  3  4  9  +  +  Conservative  30  0  Partial recoverya  4  1  8  +  –  Conservative  12  0  Partial recoverya  5  4  8  +  –  Conservative  24  0  Full recovery  Case  Time to presentation (mo)  Pain at presentation (VAS score)  Skin axillary lesions  Vascular lesions  Treatment choice  Follow-up (mo)  Pain at final follow-up (VAS score)  Functional outcome  1  3  8  +  –  Conservative  6  0  Full recovery  2  9  7  +  –  Surgical  12  2  Partial recoverya  3  4  9  +  +  Conservative  30  0  Partial recoverya  4  1  8  +  –  Conservative  12  0  Partial recoverya  5  4  8  +  –  Conservative  24  0  Full recovery  aMore detailed description in the text. + = present; – = absent. View Large All patients presented with intense pain, which averaged 8 out of 10 on the VAS. They later underwent MRI and electrophysiological testing (EMG). MRI showed changes in signal intensity in the nerve roots and trunks (mostly proximal). EMG identified signs of denervation (fibrillations and positive sharp waves) of the affected muscles. The clinical diagnosis of BPI was therefore confirmed as severe alterations in the neural and muscular elements were observed. All 5 patients had secondary lesions, characterized by abrasive, blunt, or sharp injuries in the armpits. These axillary lesions were bilateral in 1 patient (Figure 2) and unilateral in the other 4. Atrophy of related muscular segments was identified in all patients. The patient (no. 3) with a bilateral lesion also developed thrombosis of the brachial artery on the right side, which was confirmed by color Doppler ultrasound. He was treated medically by the division of vascular surgery with satisfactory results. FIGURE 2. View largeDownload slide Bilateral axillary lesions in a 36-yr-old schizophrenic patient (2). He presented 4 mo after a complete bilateral BPI that had been caused by 24 h of high-thoracic restraint. This patient also had associated vascular lesions. He was treated conservatively and, at last follow-up, exhibited partial recovery 30 mo postinjury. FIGURE 2. View largeDownload slide Bilateral axillary lesions in a 36-yr-old schizophrenic patient (2). He presented 4 mo after a complete bilateral BPI that had been caused by 24 h of high-thoracic restraint. This patient also had associated vascular lesions. He was treated conservatively and, at last follow-up, exhibited partial recovery 30 mo postinjury. Four patients underwent conservative treatment (physical and occupational therapy). Only 1 patient (no. 2) underwent surgical repair. He exhibited a high BPI (C5 and C6) and underwent exploration of the BP, accessory nerve transfer to the suprascapular nerve, and flexor ulnaris carpi muscle motor fascicle transfer from the ulnar nerve to the biceps motor branch (Oberlin's procedure), guided by intraoperative electrical stimulation. Our aim was to diminish his deficits in arm abduction and elbow flexion. This patient was operated upon late, after 9 mo without any clinical or electrophysiological evidence of improvement. Across the 5 patients, the follow-up period ranged from 6 to 30 mo (mean: 16.8; median: 12). The 4 patients treated conservatively experienced complete resolution of pain at follow-up. Two of them experienced full motor function recovery. Patient no. 3 recovered arm abduction at 90° and elbow flexion strength MRC (British Medical Council)9 grade M4+, wrist and finger flexion M4–, finger abduction M3, and finger extension M2, bilaterally. Patient no. 4 reached a M4 for wrist and finger flexion, and finger abduction. After 12 mo, the patient (case no. 2) who underwent surgical treatment reported mild residual pain (VAS: 2) that was successfully controlled with gabapentin. He achieved a muscular force of M3 at 30° arm abduction, without external rotation. His elbow flexion reached M4–, such that he was able to lift a 5 kg weight. DISCUSSION Psychiatric patients are not commonly mentioned in reports describing peripheral nerve lesions. However, bilateral ulnar nerve paralysis has been mentioned as a consequence of drug-induced extrapyramidal side effects in a schizophrenic patient.12 Also, BP palsy in association with subclavian artery false aneurysm has been reported as a complication of parenteral drug addiction.13 Here, we reported a small series of 5 psychiatry patients with BPI caused by the use of physical restraints. Among our patients, 3 presented with a prior diagnosis of bipolar disorder, while 2 had documented schizophrenia. Given its specific anatomical features and proximity to the spinal column and other bone structures, the BP is vulnerable to compressive phenomena and stretch injury.14-17 It is the second most commonly affected nerve structure among iatrogenically caused intraoperative palsy secondary to improper limb positioning under general anesthesia.6,18 The terminal branches are most often affected via stretching, and the lesions that follow are usually not localized, involving various parts of the plexus.19 Animal studies have shown that the intraneural microcirculation halts whenever there is 15% or more stretching of the nerves relative to their resting length.20 As mentioned previously, all patients evaluated in this study remained immobilized and sedated for a prolonged period of time in an attempt to manage significant psychomotor agitation. The containment technique adopted by the referring institutions consisted of a high-thoracic restraint, using a sheet on the chest, passing it below the 2 armpits and tying it to the head of the bed, while the patient's upper limbs are abducted and the wrists tied to the bed's sides. Although radial nerve injuries were not reported in this patient population, these lesions could be caused by anything wound tightly around the wrist. Because of their agitation, unattended constrained patients had a tendency to slip off the bed, potentially causing forced gradual extension of the upper limbs and prolonged compression of the axillary region, and consequently the BP. Right unilateral involvement in 80% of our patients can be attributed to the patient's all being right-handed, therefore tending to be more active using their right upper extremity. According to our experience, when psychiatric patients need to be immobilized, one should never use twisted linen, which is sharp, has folds, and is not broad and restrictive enough. The restraint vest has also been reported as a cause of BPI; however, there is not enough data to compare the incidence of these lesions following the 2 different techniques.21,22 Alternatively, very broad chest restraints are available that can be attached with magnetic bolts to the bed frame. Iatrogenic injury by stretching and/or compression of the BP is directly related to a patient's physical position, a position in which the arms are abducted at a greater angle than 90°, combined with external rotation, as well as an extended elbow, and a completely supinated forearm.3,4 The prolonged maintenance of 90° abduction on its own also might cause plexus injury. The use of shoulder braces or suspending a patient by the wrists to prevent him from sliding cephalad in a steep head-down position (Trendelenburg's position) and lateral flexion and rotation of the neck have also been linked to this type of injury.4 Any combination of these positions may have a cumulative effect, varying the susceptibility of each individual to a stretch injury.3 A mechanism of injury similar to the aforementioned may have occurred in our patients. Graham et al23 described 5 patients with BPI after sternotomy for cardiac surgery. In the group assessed, the lower roots were the most often affected, sometimes affected bilaterally.23 Pain was an important component of the clinical picture, in addition to a sensorimotor deficit.23 As the roots constituting the plexus nerves are fixed proximally in their spinal canal exit points, while distally the nerves are attached to the axillary fascia, excessive retraction of the halves of the sternum that increases the distance between these points of attachment could thereby stretch the BP.23 Katirji24 described a case of bilateral BPI caused by prolonged excessive stretching of the upper limbs in a patient who underwent a liver transplant.24 This author believed that, in a sizeable proportion of patients with iatrogenic injuries to the BP, there is a history of prolonged anesthesia, central venous catheters for invasive monitoring, or surgical procedures like venous bypass.24 Grunwald et al25 presented a case of bilateral BPI after a unilateral radical mastectomy, with later spontaneous recovery from injury. In this case, the patient's arms were positioned and maintained in 70° to 90° of abduction throughout the roughly 150-min long surgical procedure.25 To the best of our knowledge, no studies in the English literature mention high-thoracic containment as a cause of iatrogenic BPI in patients with psychiatric disorders. In our series, we observed that prolonged immobilization caused BPI in such patients, tending to primarily affect their dominant side. The technique of high-thoracic restraint likely caused the injuries due to both compression and stretching of nerve structures in the upper limbs. CONCLUSION Psychiatric patients with psychomotor agitation may need to be sedated and immobilized. However, such patients must be monitored closely. The use of high-thoracic restraints with twisted linen should be contraindicated, since they can cause iatrogenic BPI and skin abrasion. Other restraint techniques may be considered. Patients who develop such lesions that do not resolve spontaneously in a few months must be referred to tertiary centers with peripheral nerve surgery expertise. BP surgery can be indicated in specific situations. Four of our 5 patients benefited from conservative management (physical and occupational therapy) alone, but 1 ultimately required surgical repair with good functional outcome. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev . 2000;( 2): Cd001163. 2. Antoniadis G, Kretschmer T, Pedro MT, König RW, Heinen CPG, Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treatment. Dtsch Ärztebl Int . 2014; 111( 16): 273- 279. Google Scholar PubMed  3. Coppieters MW, Van de Velde M, Stappaerts KH. Positioning in anesthesiology: toward a better understanding of stretch-induced perioperative neuropathies. Anesthesiology . 2002; 97( 1): 75- 81. Google Scholar CrossRef Search ADS PubMed  4. Ngamprasertwong P, Phupong V, Uerpairojkit K. Brachial plexus injury related to improper positioning during general anesthesia. J Anesth . 2004; 18( 2): 132- 134. Google Scholar CrossRef Search ADS PubMed  5. Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia . 2000; 55( 10): 980- 991. Google Scholar CrossRef Search ADS PubMed  6. Kretschmer T, Heinen CW, Antoniadis G, Richter HP, Konig RW. Iatrogenic nerve injuries. Neurosurg Clin N Am . 2009; 20( 1): 73- 90, vii. Google Scholar CrossRef Search ADS PubMed  7. Wilbourn AJ. Iatrogenic nerve injuries. Neurol Clin . 1998; 16( 1): 55- 82. Google Scholar CrossRef Search ADS PubMed  8. Birch R, Bonney G, Parry CW. Iatropathic injury. In: Birch R, ed. Surgical Disorders of the Peripheral Nerves . Edinburgh, UK: Churchill Livingstone; 1998: 293- 333. 9. Medical Research Council. Aids to Examination of the Peripheral Nervous System . Memorandum nº 45 . London: Her Majesty's stationery office; 1976. 10. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health . 1990; 13( 4): 227- 236. Google Scholar CrossRef Search ADS PubMed  11. Lundborg G, Rosen B. The two-point discrimination test–time for a re-appraisal? J Hand Surg Br . 2004; 29( 5): 418- 422. Google Scholar CrossRef Search ADS PubMed  12. Sampath G, Pandurangi AK. Bilateral ulnar nerve paralysis: an unreported complication of drug-induced extrapyramidal rigidity. Aust N Z J Psychiatry . 1997; 31( 3): 427- 428. Google Scholar CrossRef Search ADS PubMed  13. O’Leary MR. Subclavian artery false aneurysm associated with brachial plexus palsy: a complication of parenteral drug addiction. Am J Emerg Med . 1990; 8( 2): 129- 133. Google Scholar CrossRef Search ADS PubMed  14. Castillo M. Imaging the anatomy of the brachial plexus: review and self-assessment module. AJR Am J Roentgenol.  2005; 185( 6 suppl): S196- S204. Google Scholar CrossRef Search ADS PubMed  15. Mehta MP, Kottamasu SR. Anterior dislocation of the shoulders with bilateral brachial plexus injury. Ann Emerg Med . 1989; 18( 5): 589- 591. Google Scholar CrossRef Search ADS PubMed  16. Bijos PB, Guedes-Corrêa JF. Plexo Braquial . Rio de Janeiro: DiLivros; 2011. 17. Di Lazzaro V, Giambattistelli F, Pravata E, Assenza G. Brachial palsy after deep sleep. J Neurol Neurosurg Psychiatry . 2014; 85( 12): 1409- 1410. Google Scholar CrossRef Search ADS PubMed  18. Trojaborg W. Electrophysiological findings in pressure palsy of the brachial plexus. J Neurol Neurosurg Psychiatry . 1977; 40( 12): 1160- 1167. Google Scholar CrossRef Search ADS PubMed  19. Kim DH, Murovic JA, Tiel RL, Kline DG. Infraclavicular brachial plexus stretch injury. Neurosurg Focus . 2004; 16( 5): 1- 6. 20. Lundborg G, Rydevik B. Effects of stretching the tibial nerve of the rabbit. A preliminary study of the intraneural circulation and the barrier function of the perineurium. J Bone Joint Surg Br.   1973; 55( 2): 390- 401. Google Scholar PubMed  21. Bromberg MB, Vogel CM. Vest restraint palsy. Arch Phys Med Rehabil . 1996; 77( 12): 1316- 1319. Google Scholar CrossRef Search ADS PubMed  22. Scott TF, Gross JA. Brachial plexus injury due to vest restraints. N Engl J Med . 1989; 320( 9): 598. Google Scholar PubMed  23. Graham JG, Pye IF, McQueen IN. Brachial plexus injury after median sternotomy. J Neurol Neurosurg Psychiatry . 1981; 44( 7): 621- 625. Google Scholar CrossRef Search ADS PubMed  24. Katirji MB. Brachial plexus injury following liver transplantation. Neurology . 1989; 39( 5): 736- 738. Google Scholar CrossRef Search ADS PubMed  25. Grunwald Z, Moore JH, Schwartz GF. Bilateral brachial plexus palsy after a right-side modified radical mastectomy with immediate TRAM flap reconstruction. Breast J.  2003; 9( 1): 41- 43. Google Scholar CrossRef Search ADS PubMed  Acknowledgment We are grateful to Prof. Dr. Ricardo de Oliveira-Souza for his helpful comments on an earlier version of the manuscript. COMMENTS This paper presents a small case series that describes 5 patients who suffered brachial plexus injuries (BPI) as a result of prolonged use of high thoracic restraints in the setting of severe psychomotor agitation. The presentation, management, and outcomes of these patients are reported. The discussion includes a survey of other causes of iatrogenic BPI, and also describes the mechanisms believed to be responsible for the injuries. The conclusions of the authors, who urge close monitoring of patients in restraints and recommend against the use of high thoracic restraints, are supported by their observations. Although the injuries appear to be rare (5 cases in 7 years), they are significant and in 1 case sufficiently severe to warrant operative intervention. Restraints are often used in non-psychiatric patients who become agitated in hospitals or nursing facilities, particularly in the elderly who become delirious. This type of neurological injury may be much more common than we appreciate, and this report highlights the importance of observing restrained patients closely. In addition, alternative forms of restraint should be devised. Appropriate referral to a center that can assess and properly manage brachial plexus injuries in a timely fashion is important. Jennifer Hong Eric L. Zager Philadelphia, Pennsylvania Interesting, well-documented iatrogenic lesion mechanism to the brachial plexus with included mini review that raises awareness for meticulous fixation methods in agitated patients. One major conclusion, that can be drawn when viewing the photographs with the restraints (Figure 1) and the scars from the lacerations (Figure 2) has been outlined in the text: If a psychiatric patient needs to be restricted (and in some cases there certainly is a need) one should never use twisted linen, or any device with folds. Broad and even devices that are restrictive enough, yet distribute the pressure evenly are necessary to prevent stretch and pressure lesions. Thomas Kretschmer Niedersachsen, Germany The authors of this article present the clinical circumstance and management of brachial plexus injury in 5 psychiatric patients restrained by a “high-thoracic restraint”. While this relatively low-velocity mechanism of injury is unlikely to cause a neurotomesis, 1 patient was injured severely enough to warrant surgery. This worthy description of a restraint related nerve injury can inform the surgeons’ clinical decision making, the impact of such a description may be greater beyond the borders of our specialty. The use of a “flat” vest restraint should be better tolerated than a twisted sheet. Our surgical undertakings are often preceded by a lengthy risk-benefit preamble, but non-surgical and non-invasive interventions often fall into a category for which physicians are more willing to settle for an inferred consent, rather than an informed consent. This might be more likely in vulnerable populations. In cases of aggressive psychiatric patients that put themselves or others at risk, the physicians’ responsibility to protect both the patient and the staff can lead to tough choices. It isn’t hard to see how this could spiral into an ethical/professional/legal dilemma. This article appropriately focuses on prevention. I applaud the thoughtful guidance provided by the authors for improving the safety of the restraints described based on their observations from these iatrogenic brachial plexus injuries. This stands to make the tough choices easier and to make patients safer. Christopher Baggott Amgad Hanna Madison, Wisconsin Copyright © 2017 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

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Abstract

Abstract BACKGROUND Psychiatric patients are often kept immobilized during hospitalization to avoid self-inflicted injuries and danger to third parties. Inadequate positioning can lead to brachial plexus injuries (BPI). OBJECTIVE To present a series of 5 psychiatric patients with BPI after being left sedated and restrained for prolonged periods of time during hospitalization. METHODS We retrospectively reviewed the charts of 5 psychiatric patients with iatrogenic BPI referred by other institutions to our service. The restraint technique adopted by those institutions consisted of a high-thoracic restraint. All patients underwent complete clinical and neurological examination at our center. Information concerning patient demographics, BPI characteristics, treatment choice, and ultimate outcome was recorded. RESULTS Three patients were male. The age of our patients ranged from 25 to 61 years old (mean: 41.2; median: 43). Three patients had a diagnosis of bipolar disorder while 2 had schizophrenia. Duration of immobilization ranged from 5 to 168 h (mean: 77.8; median: 72). Four patients presented with a unilateral right-sided lesion. Time to presentation ranged from 1 to 9 mo (mean: 4.2; median: 4). All patients also had intense pain and axillary lesions. Four patients received conservative treatment with partial or full functional recovery and complete pain resolution. The remaining patients underwent surgical repair and experienced good functional outcome. CONCLUSION Psychiatric patients who need to be sedated and immobilized must be monitored closely, as BPI can occur from high-thoracic restraints. When such an injury occurs, the patient must be referred to a center specialized in peripheral nerve surgery and rehabilitation. Brachial plexus neuropathies, Iatrogenic disease, Physical restraints, Schizophrenia, Bipolar disorder ABBREVIATIONS ABBREVIATIONS BP brachial plexus BPI brachial plexus injuries EMG electrophysiological MRC Medical Research Council VAS visual analog scale Psychiatric patients are often kept immobilized during hospitalization to reduce the risk that they will sustain self-inflicted injuries or injure others.1 Some will be repeatedly sedated, restrained, and left unsupervised for prolonged periods of time in inappropriate positions that can be harmful, and sometimes even lead to brachial plexus injuries (BPI). Iatrogenic lesions affecting the peripheral nerves and plexuses remain relatively common and underreported, and some of these lesions are associated with severe deficits.2-5 Such injuries have been described for several decades.6,7 They may have either a surgical or nonsurgical cause. Such causes include direct damage to the nerve during surgery; pressure or traction during an anesthetic procedure; pressure caused by external hemorrhaging; ischemia; the injection of caustic materials; direct needle puncture; anticoagulation therapy; prostheses and orthoses; thermal injury; and radiation therapy, among others.2,7,8 According to Sawyer et al,5 ulnar nerve neuropathies are the most frequent iatrogenic nerve injuries caused in patients under anesthesia, followed by injuries involving the brachial plexus (BP) and lumbosacral nerve roots. However, to the best of our knowledge, iatrogenic BPI due to high-thoracic restraints in psychiatric patients has not yet been reported in the English literature. In this paper, we present a small series of 5 psychiatric patients who presented with BPI after being sedated and immobilized for long periods during their hospitalization. They were referred to our center for both evaluation and treatment. All patients consented to publication of his/her image. METHODS We retrospectively reviewed the charts of psychiatric patients with iatrogenic BPI evaluated between January 2007 and January 2014 at our institutions. Consent was obtained, and our study was approved by the ethics committee. In the records from referring institutions, it is clear that patients with severe psychomotor agitation are often sedated and immobilized. The containment technique adopted by those institutions consists of a high-thoracic restraint. With this technique, the patient is immobilized with a bedsheet over his chest and under his armpits that is then tied to the head of the bed (Figure 1). In addition, the patient's upper extremities are both abducted past 90° so that their wrists can be attached to the sides of the bed. FIGURE 1. View largeDownload slide High-thoracic restraint. Due to patient's movement, the arms often do not stay fully abducted. FIGURE 1. View largeDownload slide High-thoracic restraint. Due to patient's movement, the arms often do not stay fully abducted. At our center, all 5 patients underwent a thorough clinical and neurological examination. Each patient's sex, age, psychiatric condition, injury type and side, duration of the immobilization, and time of presentation to our service were recorded. Muscular function was evaluated for each upper limb muscle using the British Medical Research Council (MRC) scale.9 Pain and sensation were assessed by means of a 10-point visual analog scale (VAS) and the 2-point discrimination test,10,11 respectively. The presence of skin and/or vascular lesions was also documented, as well as the duration of follow-up and the patient's final outcome. RESULTS Five patients were included in our series. Patient characteristics related to sex, age, psychiatric condition, duration of immobilization, and BPI type and side are summarized in Table 1. Three patients were male and 2 female. The age of our patients ranged from 25 to 61 years old (mean: 41.2; median: 43). Three patients had a prior diagnosis of bipolar disorder, 1 of which had been admitted to the referring institution in a manic phase. The other 2 patients had the psychiatric diagnosis of schizophrenia. The duration of immobilization ranged from 5 to 168 h (mean: 77.8; median: 72). Two patients presented with high extended BPI, which means a lesion from C5 to C7. One patient presented with high BPI, involving just the C5 and C6 roots. One patient presented with a low lesion, affecting the C8 and T1 roots. The remaining 1 patient presented with a pan-plexopathy, with all 5 nerve roots of the BP involved (C5-T1). Four of our patients presented with a unilateral right-sided lesion, while one had a bilateral BPI. Injuries to the radial nerve caused by wrist restraints were not reported in this patient population. TABLE 1. Individual Case Demographic and Baseline Clinical Characteristics Case  Sex  Age (in years)  Psychiatric condition  Duration of immobilization (h)  BPI type  Side of body affected  1  ♀  61  Bipolar disorder  72  Extended High (C5-C6-C7)  Right  2  ♂  41  Schizophrenia  168  High (C5-C6)  Right  3  ♂  36  Schizophrenia  24  Complete (C5-T1)  Bilateral  4  ♀  25  Bipolar disorder (manic phase)  5  Low (C8-T1)  Right  5  ♂  43  Bipolar disorder  120  Extended High (C5-C6-C7)  Right  Case  Sex  Age (in years)  Psychiatric condition  Duration of immobilization (h)  BPI type  Side of body affected  1  ♀  61  Bipolar disorder  72  Extended High (C5-C6-C7)  Right  2  ♂  41  Schizophrenia  168  High (C5-C6)  Right  3  ♂  36  Schizophrenia  24  Complete (C5-T1)  Bilateral  4  ♀  25  Bipolar disorder (manic phase)  5  Low (C8-T1)  Right  5  ♂  43  Bipolar disorder  120  Extended High (C5-C6-C7)  Right  ♂ = male; ♀ = female. View Large Information concerning time to presentation, VAS pain score, axillary skin lesions, vascular lesions, treatment choice, follow-up and final patient outcomes is listed in Table 2. The patients were referred for evaluation by our service after periods ranging between 1 and 9 mo (mean 4.2; median 4) from the time the diagnosis of a plexus lesion was made at the referring institution. This delay in referral to our specialized peripheral nerves unit in all cases occurred due to a first treatment attempt with physical therapy. TABLE 2. Individual Clinical Characteristics and Outcomes Case  Time to presentation (mo)  Pain at presentation (VAS score)  Skin axillary lesions  Vascular lesions  Treatment choice  Follow-up (mo)  Pain at final follow-up (VAS score)  Functional outcome  1  3  8  +  –  Conservative  6  0  Full recovery  2  9  7  +  –  Surgical  12  2  Partial recoverya  3  4  9  +  +  Conservative  30  0  Partial recoverya  4  1  8  +  –  Conservative  12  0  Partial recoverya  5  4  8  +  –  Conservative  24  0  Full recovery  Case  Time to presentation (mo)  Pain at presentation (VAS score)  Skin axillary lesions  Vascular lesions  Treatment choice  Follow-up (mo)  Pain at final follow-up (VAS score)  Functional outcome  1  3  8  +  –  Conservative  6  0  Full recovery  2  9  7  +  –  Surgical  12  2  Partial recoverya  3  4  9  +  +  Conservative  30  0  Partial recoverya  4  1  8  +  –  Conservative  12  0  Partial recoverya  5  4  8  +  –  Conservative  24  0  Full recovery  aMore detailed description in the text. + = present; – = absent. View Large All patients presented with intense pain, which averaged 8 out of 10 on the VAS. They later underwent MRI and electrophysiological testing (EMG). MRI showed changes in signal intensity in the nerve roots and trunks (mostly proximal). EMG identified signs of denervation (fibrillations and positive sharp waves) of the affected muscles. The clinical diagnosis of BPI was therefore confirmed as severe alterations in the neural and muscular elements were observed. All 5 patients had secondary lesions, characterized by abrasive, blunt, or sharp injuries in the armpits. These axillary lesions were bilateral in 1 patient (Figure 2) and unilateral in the other 4. Atrophy of related muscular segments was identified in all patients. The patient (no. 3) with a bilateral lesion also developed thrombosis of the brachial artery on the right side, which was confirmed by color Doppler ultrasound. He was treated medically by the division of vascular surgery with satisfactory results. FIGURE 2. View largeDownload slide Bilateral axillary lesions in a 36-yr-old schizophrenic patient (2). He presented 4 mo after a complete bilateral BPI that had been caused by 24 h of high-thoracic restraint. This patient also had associated vascular lesions. He was treated conservatively and, at last follow-up, exhibited partial recovery 30 mo postinjury. FIGURE 2. View largeDownload slide Bilateral axillary lesions in a 36-yr-old schizophrenic patient (2). He presented 4 mo after a complete bilateral BPI that had been caused by 24 h of high-thoracic restraint. This patient also had associated vascular lesions. He was treated conservatively and, at last follow-up, exhibited partial recovery 30 mo postinjury. Four patients underwent conservative treatment (physical and occupational therapy). Only 1 patient (no. 2) underwent surgical repair. He exhibited a high BPI (C5 and C6) and underwent exploration of the BP, accessory nerve transfer to the suprascapular nerve, and flexor ulnaris carpi muscle motor fascicle transfer from the ulnar nerve to the biceps motor branch (Oberlin's procedure), guided by intraoperative electrical stimulation. Our aim was to diminish his deficits in arm abduction and elbow flexion. This patient was operated upon late, after 9 mo without any clinical or electrophysiological evidence of improvement. Across the 5 patients, the follow-up period ranged from 6 to 30 mo (mean: 16.8; median: 12). The 4 patients treated conservatively experienced complete resolution of pain at follow-up. Two of them experienced full motor function recovery. Patient no. 3 recovered arm abduction at 90° and elbow flexion strength MRC (British Medical Council)9 grade M4+, wrist and finger flexion M4–, finger abduction M3, and finger extension M2, bilaterally. Patient no. 4 reached a M4 for wrist and finger flexion, and finger abduction. After 12 mo, the patient (case no. 2) who underwent surgical treatment reported mild residual pain (VAS: 2) that was successfully controlled with gabapentin. He achieved a muscular force of M3 at 30° arm abduction, without external rotation. His elbow flexion reached M4–, such that he was able to lift a 5 kg weight. DISCUSSION Psychiatric patients are not commonly mentioned in reports describing peripheral nerve lesions. However, bilateral ulnar nerve paralysis has been mentioned as a consequence of drug-induced extrapyramidal side effects in a schizophrenic patient.12 Also, BP palsy in association with subclavian artery false aneurysm has been reported as a complication of parenteral drug addiction.13 Here, we reported a small series of 5 psychiatry patients with BPI caused by the use of physical restraints. Among our patients, 3 presented with a prior diagnosis of bipolar disorder, while 2 had documented schizophrenia. Given its specific anatomical features and proximity to the spinal column and other bone structures, the BP is vulnerable to compressive phenomena and stretch injury.14-17 It is the second most commonly affected nerve structure among iatrogenically caused intraoperative palsy secondary to improper limb positioning under general anesthesia.6,18 The terminal branches are most often affected via stretching, and the lesions that follow are usually not localized, involving various parts of the plexus.19 Animal studies have shown that the intraneural microcirculation halts whenever there is 15% or more stretching of the nerves relative to their resting length.20 As mentioned previously, all patients evaluated in this study remained immobilized and sedated for a prolonged period of time in an attempt to manage significant psychomotor agitation. The containment technique adopted by the referring institutions consisted of a high-thoracic restraint, using a sheet on the chest, passing it below the 2 armpits and tying it to the head of the bed, while the patient's upper limbs are abducted and the wrists tied to the bed's sides. Although radial nerve injuries were not reported in this patient population, these lesions could be caused by anything wound tightly around the wrist. Because of their agitation, unattended constrained patients had a tendency to slip off the bed, potentially causing forced gradual extension of the upper limbs and prolonged compression of the axillary region, and consequently the BP. Right unilateral involvement in 80% of our patients can be attributed to the patient's all being right-handed, therefore tending to be more active using their right upper extremity. According to our experience, when psychiatric patients need to be immobilized, one should never use twisted linen, which is sharp, has folds, and is not broad and restrictive enough. The restraint vest has also been reported as a cause of BPI; however, there is not enough data to compare the incidence of these lesions following the 2 different techniques.21,22 Alternatively, very broad chest restraints are available that can be attached with magnetic bolts to the bed frame. Iatrogenic injury by stretching and/or compression of the BP is directly related to a patient's physical position, a position in which the arms are abducted at a greater angle than 90°, combined with external rotation, as well as an extended elbow, and a completely supinated forearm.3,4 The prolonged maintenance of 90° abduction on its own also might cause plexus injury. The use of shoulder braces or suspending a patient by the wrists to prevent him from sliding cephalad in a steep head-down position (Trendelenburg's position) and lateral flexion and rotation of the neck have also been linked to this type of injury.4 Any combination of these positions may have a cumulative effect, varying the susceptibility of each individual to a stretch injury.3 A mechanism of injury similar to the aforementioned may have occurred in our patients. Graham et al23 described 5 patients with BPI after sternotomy for cardiac surgery. In the group assessed, the lower roots were the most often affected, sometimes affected bilaterally.23 Pain was an important component of the clinical picture, in addition to a sensorimotor deficit.23 As the roots constituting the plexus nerves are fixed proximally in their spinal canal exit points, while distally the nerves are attached to the axillary fascia, excessive retraction of the halves of the sternum that increases the distance between these points of attachment could thereby stretch the BP.23 Katirji24 described a case of bilateral BPI caused by prolonged excessive stretching of the upper limbs in a patient who underwent a liver transplant.24 This author believed that, in a sizeable proportion of patients with iatrogenic injuries to the BP, there is a history of prolonged anesthesia, central venous catheters for invasive monitoring, or surgical procedures like venous bypass.24 Grunwald et al25 presented a case of bilateral BPI after a unilateral radical mastectomy, with later spontaneous recovery from injury. In this case, the patient's arms were positioned and maintained in 70° to 90° of abduction throughout the roughly 150-min long surgical procedure.25 To the best of our knowledge, no studies in the English literature mention high-thoracic containment as a cause of iatrogenic BPI in patients with psychiatric disorders. In our series, we observed that prolonged immobilization caused BPI in such patients, tending to primarily affect their dominant side. The technique of high-thoracic restraint likely caused the injuries due to both compression and stretching of nerve structures in the upper limbs. CONCLUSION Psychiatric patients with psychomotor agitation may need to be sedated and immobilized. However, such patients must be monitored closely. The use of high-thoracic restraints with twisted linen should be contraindicated, since they can cause iatrogenic BPI and skin abrasion. Other restraint techniques may be considered. Patients who develop such lesions that do not resolve spontaneously in a few months must be referred to tertiary centers with peripheral nerve surgery expertise. BP surgery can be indicated in specific situations. Four of our 5 patients benefited from conservative management (physical and occupational therapy) alone, but 1 ultimately required surgical repair with good functional outcome. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev . 2000;( 2): Cd001163. 2. Antoniadis G, Kretschmer T, Pedro MT, König RW, Heinen CPG, Richter HP. Iatrogenic nerve injuries: prevalence, diagnosis and treatment. Dtsch Ärztebl Int . 2014; 111( 16): 273- 279. Google Scholar PubMed  3. Coppieters MW, Van de Velde M, Stappaerts KH. Positioning in anesthesiology: toward a better understanding of stretch-induced perioperative neuropathies. Anesthesiology . 2002; 97( 1): 75- 81. Google Scholar CrossRef Search ADS PubMed  4. Ngamprasertwong P, Phupong V, Uerpairojkit K. Brachial plexus injury related to improper positioning during general anesthesia. J Anesth . 2004; 18( 2): 132- 134. Google Scholar CrossRef Search ADS PubMed  5. Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia . 2000; 55( 10): 980- 991. Google Scholar CrossRef Search ADS PubMed  6. Kretschmer T, Heinen CW, Antoniadis G, Richter HP, Konig RW. Iatrogenic nerve injuries. Neurosurg Clin N Am . 2009; 20( 1): 73- 90, vii. Google Scholar CrossRef Search ADS PubMed  7. Wilbourn AJ. Iatrogenic nerve injuries. Neurol Clin . 1998; 16( 1): 55- 82. Google Scholar CrossRef Search ADS PubMed  8. Birch R, Bonney G, Parry CW. Iatropathic injury. In: Birch R, ed. Surgical Disorders of the Peripheral Nerves . Edinburgh, UK: Churchill Livingstone; 1998: 293- 333. 9. Medical Research Council. Aids to Examination of the Peripheral Nervous System . Memorandum nº 45 . London: Her Majesty's stationery office; 1976. 10. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health . 1990; 13( 4): 227- 236. Google Scholar CrossRef Search ADS PubMed  11. Lundborg G, Rosen B. The two-point discrimination test–time for a re-appraisal? J Hand Surg Br . 2004; 29( 5): 418- 422. Google Scholar CrossRef Search ADS PubMed  12. Sampath G, Pandurangi AK. Bilateral ulnar nerve paralysis: an unreported complication of drug-induced extrapyramidal rigidity. Aust N Z J Psychiatry . 1997; 31( 3): 427- 428. Google Scholar CrossRef Search ADS PubMed  13. O’Leary MR. Subclavian artery false aneurysm associated with brachial plexus palsy: a complication of parenteral drug addiction. Am J Emerg Med . 1990; 8( 2): 129- 133. Google Scholar CrossRef Search ADS PubMed  14. Castillo M. Imaging the anatomy of the brachial plexus: review and self-assessment module. AJR Am J Roentgenol.  2005; 185( 6 suppl): S196- S204. Google Scholar CrossRef Search ADS PubMed  15. Mehta MP, Kottamasu SR. Anterior dislocation of the shoulders with bilateral brachial plexus injury. Ann Emerg Med . 1989; 18( 5): 589- 591. Google Scholar CrossRef Search ADS PubMed  16. Bijos PB, Guedes-Corrêa JF. Plexo Braquial . Rio de Janeiro: DiLivros; 2011. 17. Di Lazzaro V, Giambattistelli F, Pravata E, Assenza G. Brachial palsy after deep sleep. J Neurol Neurosurg Psychiatry . 2014; 85( 12): 1409- 1410. Google Scholar CrossRef Search ADS PubMed  18. Trojaborg W. Electrophysiological findings in pressure palsy of the brachial plexus. J Neurol Neurosurg Psychiatry . 1977; 40( 12): 1160- 1167. Google Scholar CrossRef Search ADS PubMed  19. Kim DH, Murovic JA, Tiel RL, Kline DG. Infraclavicular brachial plexus stretch injury. Neurosurg Focus . 2004; 16( 5): 1- 6. 20. Lundborg G, Rydevik B. Effects of stretching the tibial nerve of the rabbit. A preliminary study of the intraneural circulation and the barrier function of the perineurium. J Bone Joint Surg Br.   1973; 55( 2): 390- 401. Google Scholar PubMed  21. Bromberg MB, Vogel CM. Vest restraint palsy. Arch Phys Med Rehabil . 1996; 77( 12): 1316- 1319. Google Scholar CrossRef Search ADS PubMed  22. Scott TF, Gross JA. Brachial plexus injury due to vest restraints. N Engl J Med . 1989; 320( 9): 598. Google Scholar PubMed  23. Graham JG, Pye IF, McQueen IN. Brachial plexus injury after median sternotomy. J Neurol Neurosurg Psychiatry . 1981; 44( 7): 621- 625. Google Scholar CrossRef Search ADS PubMed  24. Katirji MB. Brachial plexus injury following liver transplantation. Neurology . 1989; 39( 5): 736- 738. Google Scholar CrossRef Search ADS PubMed  25. Grunwald Z, Moore JH, Schwartz GF. Bilateral brachial plexus palsy after a right-side modified radical mastectomy with immediate TRAM flap reconstruction. Breast J.  2003; 9( 1): 41- 43. Google Scholar CrossRef Search ADS PubMed  Acknowledgment We are grateful to Prof. Dr. Ricardo de Oliveira-Souza for his helpful comments on an earlier version of the manuscript. COMMENTS This paper presents a small case series that describes 5 patients who suffered brachial plexus injuries (BPI) as a result of prolonged use of high thoracic restraints in the setting of severe psychomotor agitation. The presentation, management, and outcomes of these patients are reported. The discussion includes a survey of other causes of iatrogenic BPI, and also describes the mechanisms believed to be responsible for the injuries. The conclusions of the authors, who urge close monitoring of patients in restraints and recommend against the use of high thoracic restraints, are supported by their observations. Although the injuries appear to be rare (5 cases in 7 years), they are significant and in 1 case sufficiently severe to warrant operative intervention. Restraints are often used in non-psychiatric patients who become agitated in hospitals or nursing facilities, particularly in the elderly who become delirious. This type of neurological injury may be much more common than we appreciate, and this report highlights the importance of observing restrained patients closely. In addition, alternative forms of restraint should be devised. Appropriate referral to a center that can assess and properly manage brachial plexus injuries in a timely fashion is important. Jennifer Hong Eric L. Zager Philadelphia, Pennsylvania Interesting, well-documented iatrogenic lesion mechanism to the brachial plexus with included mini review that raises awareness for meticulous fixation methods in agitated patients. One major conclusion, that can be drawn when viewing the photographs with the restraints (Figure 1) and the scars from the lacerations (Figure 2) has been outlined in the text: If a psychiatric patient needs to be restricted (and in some cases there certainly is a need) one should never use twisted linen, or any device with folds. Broad and even devices that are restrictive enough, yet distribute the pressure evenly are necessary to prevent stretch and pressure lesions. Thomas Kretschmer Niedersachsen, Germany The authors of this article present the clinical circumstance and management of brachial plexus injury in 5 psychiatric patients restrained by a “high-thoracic restraint”. While this relatively low-velocity mechanism of injury is unlikely to cause a neurotomesis, 1 patient was injured severely enough to warrant surgery. This worthy description of a restraint related nerve injury can inform the surgeons’ clinical decision making, the impact of such a description may be greater beyond the borders of our specialty. The use of a “flat” vest restraint should be better tolerated than a twisted sheet. Our surgical undertakings are often preceded by a lengthy risk-benefit preamble, but non-surgical and non-invasive interventions often fall into a category for which physicians are more willing to settle for an inferred consent, rather than an informed consent. This might be more likely in vulnerable populations. In cases of aggressive psychiatric patients that put themselves or others at risk, the physicians’ responsibility to protect both the patient and the staff can lead to tough choices. It isn’t hard to see how this could spiral into an ethical/professional/legal dilemma. This article appropriately focuses on prevention. I applaud the thoughtful guidance provided by the authors for improving the safety of the restraints described based on their observations from these iatrogenic brachial plexus injuries. This stands to make the tough choices easier and to make patients safer. Christopher Baggott Amgad Hanna Madison, Wisconsin Copyright © 2017 by the Congress of Neurological Surgeons

Journal

NeurosurgeryOxford University Press

Published: Mar 1, 2018

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