Expert: JM Starkman, MD - 7/16/2009

Question
QUESTION: Are you aware of any instances where placing a patient with Hydrocephalus/VP Shunt in the Trendelenburg position for a 10+ hour surgery has caused permanent Hypertension, Mental Status deficiencies and Irregular Heartbeat possibly requiring a pacemaker?  I don't know the exact degree the head was below the heart, only that it was greater than 10 degrees.  There was no previous history of Hypertension or irregular heartbeat prior to the surgery.  Bilateral Brachial Plexus Injury was confirmed by EMG, but other issues have never been explained.

Thank you.

ANSWER: The short answer is: "No, I'm not aware of a syndrome like the one you describe".  However, there is nothing innocuous about placing a patient in trendelenberg for the long period of time you describe--the literature is virtually saturated with all sorts of mild and serious complications from having one's head lower than the central circulation.  

One could easily imagine a patient in the described position having a period of hypotension and/or fluid overload causing a decrease in cerebral perfusion pressure and therefore a relative lack of oxygen delivery to the Cb cortex....and the patient described is ALREADY at risk for an increase in intracranial pressure [ICP] based on the history of VP shunt, etc.  ?Did the shunt occlude?  Was there a period of cerebral anoxia?

It's possible that a relative increase in ICP has occurred due to malfunction of the shunt causing the body to up-regulate the blood pressure.  This same phenomena is associated with cardiac bradyarrhythmias---which might need a pacemaker if they cannot be adequately managed with drugs.

I hope a neurosurgeon has had an opportunity to evaluate this patient.

---------- FOLLOW-UP ----------

QUESTION: Thank you so much for responding and providing the info above.  Our son's shunt was tested and it was operating properly and still is today.  It is now 5 years since the surgery above and he still has all the same issues, bilateral brachial plexus damage, mental status change, Hypo/Hypertension, irregular heartbeat, etc.  We are not aware of any cerebral anoxia occurring.

Our son's neurosurgeon was called in immediately and he questioned the other surgeon if our son had been dropped during the surgery.  The answer was no.

Is Brachial Plexus Injury a form of Spinal Cord Injury?

Do you know how long it would take for symptoms to show after a surgery of that length which involves positioning issues?  Wouldn't it be immediately upon awaking from the Anesthesia?  Naturally, a person cannot complain of the pain, etc. while they are still under the influence of anestesia and morphine.  What is your opinion of this?

Thank you and we look forward to hearing back from you.

Answer
The brachial plexus is the complex grouping of nerve roots and their branches that subserve the upper extremity.  They are located distal/beyond the spinal cord near the shoulder joint and the armpit, so they are not a spinal cord (central nervous system) injury, but a nerve injury (peripheral nervous system).  The symptoms should show up right away, as in the recovery room, as you've mentioned.  Nervous tissue when damaged is slow to heal and in many cases is an irreversible injury.