Severe spinal injury after shoulder arthroplasty. A rare serious complication

Abstract text (incl. references and figure legends)

Case history. We present a case of an 83-year-old-female with a four-part left proximal humeral fracture treated with reverse shoulder arthroplasty with tuberosity repair and interscalene block plus general anesthesia in a beach chair position. Clinical findings. In first postoperative day, the patient showed plegia and areflexia in the whole left upper limb, global hypoesthesia, in the C5 dermatomal region, gait disorder, right neck deviation and ptosis without myosis. Investigation/results. An MRI of the cervical spine showed ischemic tissue damage, with a hemorrhage component between C1 and C7 limited to left medulla. Diagnosis. Cervical spine cord ischemia with hemorrhagic component in left hemimedulla. Therapy and progressions. She received 4 mg of Dexamethasone every eight hours for a week, 100 mg of acetylsalicylic acid and prompt rehabilitation. One month postoperative, an EMG reported preganglionic motor neurons lesion, between C3-C4 and T1, especially at C5 and C6 levels. All sensory modalities were affected. Follow-up MRI at 2 months showed improvement compared to the previous. EMG at one year reported C5 and C6 proximal muscle reinnervation. Twenty months postoperatively, motor examination showed deltoid 2/5, triceps 4/5, wrist extensors 3/5, volar flexors 3/5, fingers flexors 3/5, extensor pollicis longus 3/5. She maintained global hypoesthesia in the whole left upper limb. Comments. It is necessary to consider all complications related to shoulder surgery like neurological injuries. They may occur as a consequence of acts related to surgery, a result of anesthetic techniques like interscalene block, but above all with patient positioning during surgery in beach chair position. This position has been associated with brain and spinal cord stroke, midcervical quadriplegia, and higher risk of venous and arterial air embolism. References. Ball CM. Neurologic complications of shoulder joint replacement. J Shoulder Elbow Surg. 2017;26(12):2125-2132.

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