Protecting the brachial plexus during median sternotomy

Injury to the brachial plexus was prospectively assessed in 335 patients undergoing median sternotomy for cardiac operation. All patients were placed in the hand-up position (elbows elevated, arms abducted 90 degrees, and elbows flexed) after right internal jugular vein cannulation (23 cannulation attempts were bilateral). Twenty-eight patients had new upper extremity complaints after the operation, of whom 16 (4.8%) had symptoms considered related to injury of the brachial plexus: one with generalized weakness of the left arm, six with localized weakness, pain, or paresthesia plus objective hypesthesia or weakness, and nine with paresthesias but no objective signs. Four injuries were right sided, four left sided, and eight bilateral. At the time of discharge, 15 of 16 were symptom free and the patient with generalized weakness was rapidly improving. Postoperative plexopathy was not related to degree of sternal retraction, dissection of the internal mammary artery, or cannulation of the internal jugular vein. We believe the low incidence and benign course of brachial plexus problems in these patients resulted from careful sternal retraction and use of the hands-up position. Finally, our data do not support internal jugular cannulation as a major cause of plexus injuries after median sternotomy.