Pam Westwood, a specialist clinical negligence Associate in our Birmingham Medical Negligence team, is acting on behalf of a client who suffered nerve injury to the nerves in her shoulder during what was meant to be minimally invasive keyhole surgery in the abdominal area.
The injury was to the brachial plexus, which is a network of nerves in the shoulder that carries movement and sensory signals from the spinal cord to the arms and hands. Brachial plexus injuries can cause pain, weakness and numbness in the arm and hand. The long thoracic nerve is a motor nerve which helps to pull the shoulder blade forward.
Details of the Case
The procedure our client had was to her kidney area, nowhere near her arm or shoulder, but as a result of that procedure, she has been left with lack of feeling affecting her right index and middle finger, pain, limited movement and ‘winging’ or protrusion of her shoulder blade, all of which restrict her in her day to day life.
What caused the nerve injury
The damage was caused by lying on her side during the procedure due to an alleged failure to protect the nerves from compression (pressing or squashing) under her chest for the duration of the procedure which took a few hours.
Our client went into surgery thinking her kidney and urine problems would be resolved, but has been left instead with a permanent nerve injury.
How can nerve damage occur during surgery?
Whilst said to be uncommon, nerve damage can occur during surgery, particularly under general anaesthetic, due to compression/stretching related to positioning or from direct injury by the surgeon. If a nerve is stretched or compressed (pressed on or squashed), this can damage the nerve. That is because every nerve is supplied by blood vessels which keep it healthy and if these blood vessels are damaged during the operation, or if the blood supply is reduced due to pressure or stretching, the nerve can be starved of oxygen.
When you are awake, you would feel this compression or stretching and move to relieve the discomfort. During an anaesthetic, you cannot do this and you are reliant on the medical staff to make sure you are positioned properly and that steps have been taken to minimise the risk of any nerve damage.
Other surgical factors that may cause nerve damage can include injury from the retractors which are surgical instruments that are used to hold structures in the body out of the way so that the surgeon can see more deeply into the body. They are often used with care, aiming to avoid pressure on nerves, but sometimes these can cause nerve damage. Other nerve injuries can occur where the surgeon directly damages a nerve as he/she operates. Surgical instruments can also compress and/or stretch a nerve. During some operations, this may be difficult or impossible to avoid, but is some cases, it is down to a lack of care being taken to avoid damaging delicate nerves.
Nerve damage due to compression or stretching is higher risk if a patient already has narrowing of their blood vessels generally or nerves that are already compromised by co-existing diseases, such as rheumatoid arthritis and diabetes.
You are more likely to get nerve damage if you have been placed in certain positions. That is why it is so important that the medical team take the specific risks of that surgery into account and you are carefully positioned for your operation, with appropriate steps taken to protect vulnerable nerves and minimise the risk of damage to the blood supply.
What steps should be taken to prevent nerve damage?
The anaesthetist, surgeon and theatre staff have a duty to take care to try and prevent nerve damage. They share the responsibility of minimising the risks by:
- careful padding of vulnerable areas;
- positioning the patient in a way which avoids stretching or compressing the nerves as much as possible;
- being aware of the risk of damaging nerves;
- avoiding or minimising undue pressure on a body part;
- ensuring proper positioning of the arms, hands, shoulders, legs, or feet as improper positioning may cause serious injury
Possible injuries that can be caused by nerve damage
If sensory nerves are damaged, this can result in numbness, tingling, inappropriate warm or cold sensations or pain, which can be a continuous aching pain or a sharp shooting pain. Symptoms can start immediately after injury to a nerve or sometimes may not appear until several weeks after the initial injury. If motor nerves are damaged, there may be weakness or paralysis (loss of movement) of muscles in the area supplied by that nerve. If mixed nerves are damaged, there will be a mixture of symptoms. The area affected varies according to which nerves have been damaged. There could be anything between a very small patch of numbness, to most of a limb being affected.
Damage to the spinal cord is rare, but usually affects both muscle power and sensation, depending on where the damage has happened. Unfortunately, spinal cord damage is often extensive and permanent. The bowels and the bladder can also be affected, with devastating consequences.
In most cases, the nerve damage may repair itself within a few days, or can take up to a year or more. However, in some unfortunate cases, (around 1 in 1,000 anaesthetics) the nerve damage is permanent. Unfortunately, damage caused by an injury to the nerves in the spinal cord is usually permanent as these nerves cannot generally repair themselves. The people most at risk of spinal cord damage are those having cardiac, major vascular or spinal surgery. It is usually the result of the surgery itself or because of poor blood supply to the spinal cord.
What to do if you have suffered nerve damage following surgery?
If you have suffered a nerve injury following surgery and are concerned as to whether the correct protective steps were taken, please contact Pam Westwood in our clinical negligence team.