Recovery of brachial plexus injury after bronchopleural fistula closure surgery based on electrodiagnostic study: A case report and review of literature

BACKGROUND: Axillary thoracotomy and muscle flap are muscle- and nerve-sparing methods among the surgical approaches to bronchopleural fistula (BPF). However, in patients who are vulnerable to a nerve compression injury, nerve injury may occur. In this report, we present a unique case in which the brachial plexus (division level), suprascapular, and long thoracic nerve injury occurred after BPF closure surgery in a patient with ankylosing spondylitis and concomitant multiple joint contractures. CASE SUMMARY: A 52-year-old man with a history of ankylosing spondylitis with shoulder joint contractures presented with right arm weakness and sensory impairment immediately after axillary thoracotomy and latissimus dorsi muscle flap surgery for BPF closure. During the surgery, the patient was positioned in a lateral decubitus position with the right arm hyper-abducted for approximately 6 h. Magnetic resonance imaging and ultrasound revealed subclavius muscle injury or myositis with brachial plexus (BP) compression and related neuropathy. An electrodiagnostic study confirmed the presence of BP injury involving the whole-division level, long thoracic, and suprascapular nerve injuries. He was treated with medication, physical therapy, and ultrasound-guided injections. Ultrasound-guided steroid injection at the BP, hydrodissection with 5% dextrose water at the BP and suprascapular nerve, and intra-articular steroid and hyaluronidase injection at the glenohumeral joint were performed. On postoperative day 194, the pain and arm weakness were resolved, and a follow-up electrodiagnostic study showed marked improvement. CONCLUSION: Clinicians should consider the possibilities of multiple nerve injuries in patients with joint contracture, and treat each specific therapeutic target.