Disclosures: Jacob Boomgaardt, DO: No financial relationships or conflicts of interest

Case Diagnosis: 64-year old male with persistent left hand pain and weakness status-post coronary artery bypass graft (CABG) subsequently diagnosed with lower trunk brachial plexopathy.

Case Description: 64-year old male with notable past medical history of diabetes mellitus type 2 who presented with persistent hand pain and weakness, including limited use of his left thumb. This began status-post CABG performed in June 2020, and he did not notice any relief of his symptoms status-post carpal tunnel release in October 2020. Given his persistent symptoms, he was referred for electro-diagnostic testing.

Setting: Academic Medical Center.Assessment/

Results: Electro-diagnostic testing was notable for absence of left ulnar and medial antebrachial cutaneous (MAC) sensory nerve action potentials (SNAP), but an intact right MAC SNAP. The left ulnar and median SNAP’s and left ulnar compound muscle action potential amplitudes were reduced. On needle electromyography, there were markedly enlarged, polyphasic motor unit action potentials (evidence of chronic, neurogenic changes) and reduced recruitment in the left first dorsal interosseous, abductor pollicis brevis, flexor digitorum superficialis, and extensor indicis proprius muscles. These findings demonstrated electrophysiologic evidence of a left brachial plexopathy localizing to the lower trunk, consistent with post-median sternotomy plexopathy.

Discussion: Brachial plexus injury is a rare complication following median sternotomy, with some studies reporting incidence as low as 0.5%. During median sternotomy, sternal retractors push the clavicle into the retroclavicular space, thereby increasing tension on the brachial plexus. The main factors associated with post-operative incidence of plexus injury include prolonged operative time, peripheral neuropathy present pre-operatively, and asymmetric sternal tractioning. The prognosis is usually good, with most patients expected to make a complete or near complete recovery within 6 months’ time.

Conclusion: Although incidence of post-median sternotomy plexopathy is rare, it is important to consider in a patient with upper extremity pain, weakness, and sensory loss in the lower trunk distribution following median sternotomy.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-case-of-post-median-sternotomy-plexopathy-following-coronary-artery-bypass-graft/