Bilateral Hand Wasting After Coronary Artery Bypass Graft Surgery

Key words: brachial plexopathy, coronary artery bypass graft, small muscle wasting, sternotomy

A 63-year old man underwent successful coronary artery bypass graft (CABG) surgery with left internal mammary artery (LIMA) harvest. He required urgent resternotomy 2 days after CABG due to postoperative mediastinal bleeding. Upon recovery from anesthesia, he complained of weakness of both hands. Neurological examination revealed weakness of extensors of the wrists as well as weak hand grip on both sides. Electrodiagnostic tests performed on day 6 were suggestive of bilateral brachial plexus lesions involving C7-T1 nerve roots. Magnetic resonance imaging of the spine was unremarkable. Rehabilitative physiotherapy was initiated.

He continued to have progressive thinning of both forearms and hands. When seen 4 months later, neurological examination revealed marked wasting of bilateral dorsal interossei (Figure 1A), extensor digitorum communis (Figure 1B), and abductor digiti minimi (Figure 1C). Our case demonstrates the effects of bilateral brachial plexus injury secondary to traction and compression of nerve roots during sternotomy for CABG. Open surgical harvesting of LIMA is believed to increase the risk of injury to the brachial plexus. We believe that this approach probably aggravated the neurological damage in our patient. Proper positioning, thoracoscopic harvesting of LIMA, and avoiding prolonged and excessive traction on the rib cage could have reduced the risk of this injury.

From the ¹Division of Neurology, Department of Medicine, and ²the Yong Loo Lin School of Medicine, National University Hospital, Singapore.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted May 24, 2019.

Address for correspondence: Vijay K. Sharma, MD, Yong Loo Lin School of Medicine, National University of Singapore, Division of Neurology, Department of Medicine, National University Hospital, Singapore, 1E Lower Kent Ridge Road, Singapore 119228. Email: mdcvks@nus.edu.sg