Ann Thorac Surg 2008;86:1350-1351. doi:10.1016/j.athoracsur.2008.02.039
© 2008 The Society of Thoracic Surgeons
Case Reports
Quadrilateral Space Syndrome: A Rare Complication of Thoracic Surgery
Motohiro Nishimura, MD, PhDa,*,
Masao Kobayashi, MD, PhDa,
Kenichiro Hamagashira, MDa,
Shinpachiro Noumi, MDa,
Kazuhiro Ito, MD, PhDb,
Daishiro Kato, MD, PhDb,
Junichi Shimada, MD, PhDb
a Department of Surgery, Social Insurance Kyoto Hospital, Kyoto, Japan
b Department of Thoracic Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
Accepted for publication February 13, 2008.
* Address correspondence to Dr Nishimura, Department of Thoracic Surgery, Nantan General Hospital, Yagiueno 25, Yagi-cho, Nantan, Kyoto, 629-0197, Japan (Email: fs2m-nsmr{at}asahi-net.or.jp).
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Abstract
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We report a case of quadrilateral space syndrome related to thoracic surgery. A 21-year-old man underwent video-assisted thoracic surgery for a left-sided pneumothorax. After the operation, he presented with difficulties in left arm abduction and paresthesia over the lateral aspect of the shoulder and upper arm. Deltoid muscle atrophy and tenderness over the quadrilateral space were also observed. On further examination, he was diagnosed with isolated paralysis of the axillary nerve, the so-called quadrilateral space syndrome. This is a rare complication, but it interferes with the activities of daily living, and thus one should pay attention to this syndrome.
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Introduction
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Quadrilateral space syndrome is an unusual syndrome caused by compression of the axillary nerve and the posterior humeral circumflex artery, or by a traction force acting on the axillary nerve. This syndrome is almost always found in the dominant arm, and it is not usually associated with any history of trauma. We report a case related to body position during surgical procedures.
A 21-year-old man was admitted to our hospital for a left-sided pneumothorax. He underwent blebs resection by conventional video-assisted thoracic surgery under general anesthesia. The patient was placed in a right decubitus position with his left arm in 90 degrees of abduction and flexion. His elbow was placed at approximately 45 degrees of flexion, and the forearm was on an armrest beside his head. His head lay on a headrest so that it could not lean to either side. He was left in this position for 1.5 hours during the operation. After the left lung was deflated, three 12-mm ports were made in the third and seventh intercostal spaces at the midaxillary line and in the fifth intercostal space at the midclavicular line. Blebs at the apex were then excised with a 60-mm endoscopic stapler. A chest tube (18-French) was placed in the apex though the seventh intercostal space wound. Pleurodesis was not performed. The anesthesia time was 2.5 hours. The chest tube was removed, and he was discharged on postoperative day 2. By postoperative day 7, he became aware of the difficulties with left arm abduction (Fig 1A), and paresthesia over the lateral aspect of his shoulder and upper arm (Fig 1B). Deltoid muscle atrophy and tenderness over the quadrilateral space were also present (Fig 1C). Electrodiagnostic studies demonstrated decreased motor conduction in the axillary nerve. He was diagnosed with isolated paralysis of the axillary nerve, or quadrilateral space syndrome. He was treated conservatively with physical therapy and symptomatic care. Three months later, the symptoms were almost resolved.
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Fig 1. (A) Active range of motion showing markedly decreased abduction. (B) Paresthesia in the axillary nerve distribution (dotted line area). Point tenderness with compression over the quadrilateral space (looped line area) and deltoid atrophy. (C) One of the wounds from the operation (third intercostal space midaxillary line) is seen.
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Comment
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Quadrilateral space syndrome was first described by Bateman [1] in 1972, but few cases have been reported. All patients had their diagnoses made based on: (1) tenderness over the quadrilateral space, (2) paresthesia over the lateral shoulder and upper posterior arm, and (3) deltoid weakness associated with decreased shoulder abduction. This uncommon syndrome is caused by compression of the posterior humeral circumflex artery and axillary nerve, or both, or one of its major branches, in the quadrilateral space that is bounded by the teres minor, teres major, long head of the triceps, and neck of the humerus bone [2]. The axillary nerve and posterior humeral circumflex artery pass through this space below the shoulder capsule. The muscles supplied by the axillary nerve are the teres minor and the deltoid. A positive arteriogram reveals occlusion of the posterior humeral circumflex artery with the arm in extreme (greater than 90 degrees) abduction and external rotation. If further objective diagnostic data are required, electrodiagnostic studies show a decreased amplitude or slowing along the axillary nerve, or both, or abnormal electromyogram findings for the deltoid. When these muscles become completely paralyzed, there is an inability to elevate the arm or possibly only partial abduction, but some patients retain a full range of motion of the shoulder by the action of supplementary muscles. Therefore, the symptoms of axillary nerve palsy may be overlooked. This syndrome developed insidiously in a majority of the cases previously reported [2, 3]. In this case, we hypothesized that his body position during video-assisted thoracic surgery, the right decubitus position with his left arm in 90 degrees of abduction and flexion, caused compression or traction, or both, of the axillary nerve. Retrospectively, we also recalled the possibility of some mild external rotation. After the diagnosis is made, most patients (75%) are treated conservatively with symptomatic care, physical therapy, and reassurance [4]. Nevertheless, surgical decompression of the quadrilateral space and lysis of the abnormal fibrous strands should be considered if conservative therapy fails. Cahill and Palmer [2] reported that in a series of 18 patients who underwent surgery, 8 had dramatic and complete relief of their symptoms, 8 had some improvement, and 2 showed no improvement. In the field of thoracic surgery, although there have been no reports on this syndrome, there may be many unrecognized cases of this syndrome. Brachial plexus palsy is the most common of all nerve injuries associated with lateral thoracotomies. It can occur from stretching or compression of the nerves, and it is usually caused by a combination of the two [5]. Mild stretching of a nerve beyond its normal elasticity may rupture the epineural vessels, thus causing patches of ischemia within the nerve. More forceful stretching will rupture the perineurium, creating hematomas in the nerve bundle and even necrosis of the nerve fibers [6]. Extension and lateral flexion of the head to one side with the patient in a lateral decubitus or supine position increases the angle between the head and the acromion of the opposite shoulder, thus stretching the brachial plexus [5]. Suspension of the arm from either a screen or a crossbar with the patient in the lateral decubitus position also stretches the nerve, especially if the arm is in extreme abduction. Although common clinical practice permits maximum abduction of the arm to ninety degrees, injuries have occurred with as little as sixty degrees of abduction when accompanied by rotation [6]. Furthermore, in this position, the clavicle can be forced against the first rib, and compression of the plexus is anatomically possible, resulting in increased tension distal to the point of compression. When the arm and shoulder lie between the thorax and the table in the lateral decubitus position, the plexus is compressed against the thorax by the humeral head. There are systematically-developed practical advisories intended to assist in decision-making in areas of patient care when scientific evidence is insufficient, although they are not intended as standards, guidelines, or absolute requirements [7]. Complete prevention of nerve injury to the upper extremities due to operative position may not be achievable, but an awareness of the susceptibility of these nervous structures to stress and the application of obvious precautions will minimize their incidence. We recommend preventive measures as follows: (1) a neutral position for the head; (2) the shoulder joint should be placed in no more than 90 degrees of abduction, and the abduction should be limited to 60 degrees when accompanied by external rotation; (3) the elbow should be placed in mild flexion; (4) the forearm should be resting on the armrest beside the head; and (5) a roll should be placed under the axilla to avoid compression of the brachial plexus.
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References
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- Bateman JE. The Shoulder and NeckPhiladelphia, PA: W. B. Saunders Co; 1972.
- Cahill BR, Palmer RE. Quadrilateral space syndrome J Hand Surg 1983;8:65-69.[Medline]
- McKowen HC, Voorhies RM. Axillary nerve entrapment in the quadrilateral space: a case report J Neurosurg 1987;66:932-934.[Medline]
- Cormier PJ, Matalon TA, Wolin PM. Quadrilateral space syndrome: a rare cause of shoulder pain Radiology 1988;167:797-798.[Abstract/Free Full Text]
- Cooper DE, Jenkins RS, Bready L, et al. The prevention of injuries of the brachial plexus secondary to malposition of the patient during surgery Clin Orthop Relat Res 1988;228:33-41.[Medline]
- Lincoln JR, Sawyer HP. Complications related to body positions during surgical procedures Anesthesiology 1961;22:800-809.[Medline]
- American Society of Anesthesiologists Task Force on prevention of postoperative peripheral neuropathies Practice advisory for the prevention of perioperative peripheral neuropathies Anesthesiology 2000;92:1168-1182.[Medline]
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Abstract
Introduction
