Risk for Persistent Peripheral Neuropathy after Brachial Artery Injuries
Scott N. Loewenstein, Corianne Rogers, Joshua Adkinson.
Indiana University, Indianapolis, IN, USA.
PURPOSE: Traumatic brachial artery lacerations are rare limb-threatening injuries requiring emergent repair. Concomitant peripheral nerve symptoms are often identified only after surgical repair of the arterial injury. The role for early nerve exploration has not been definitively established, and many peripheral nerve surgeons opt for an initial period of observation, particularly in the setting of gunshot wounds. This study sought to evaluate the risk for persistent peripheral nerve deficits after traumatic brachial artery lacerations.
METHODS: A retrospective review was performed of all patients sustaining a brachial artery injury at one pediatric and two adult urban Midwestern level I trauma centers between Jan 1, 2007 and December 31, 2017. Eligible patients were identified based on Current Procedural Terminology and International Classification of Disease codes using the Indiana Network for Patient Care. We collected patient demographics, comorbidities, alcohol and drug intoxication status, injury mechanism, concomitant injuries, pre-operative nerve examination findings, type of repair, intra-operative nerve exploration findings, short and long-term postoperative nerve examination findings, and mean follow-up.
RESULTS: Thirty-four patients had traumatic brachial artery lacerations requiring operative repair. Eighty-two percent were male and the average age was 25.5 years of age. Injury mechanisms included tidy laceration (32%), gunshot wound (26%), blunt trauma (24%), and untidy laceration (18%). Pre-operatively, 15% had a normal peripheral nerve examination, 26% had localizable nerve symptoms, 38% had non-localizable nerve symptoms, and 21% were urgently taken to the operating room without a formal nerve assessment. Thirty-two percent of patients had intra-operative exploration by a peripheral nerve surgeon, of which 9% had a normal preoperative nerve examination, 9% had a normal nerve exam <7 days post-operatively, and 18% had a normal nerve exam more than 7 days post-operatively. Eighty one percent of patients explored required nerve repair. Among the remaining patients without a formal nerve exploration there was a normal peripheral nerve examination in 17% pre-operatively, 22% within 7 days post-operatively, and 48% after 7 days post-operatively. At an average follow-up of 2.5 years, 26% of patients who did not undergo nerve exploration had localizable peripheral nerve deficits which was similar to 27% of patients who did undergo exploration.
CONCLUSION: A brachial artery laceration requiring repair is associated with a clinically significant risk for long-term peripheral nerve symptoms. Over one-fourth of patients have long-term localizable peripheral nerve deficits. As such, early nerve exploration and repair in patients with peripheral nerve symptoms after a brachial artery injury may be warranted.
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