ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2009;88:1360-1362. doi:10.1016/j.athoracsur.2009.01.076
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Video
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Muhammad I. Aslam
Inger F. Oey
David A. Waller
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Aslam, M. I.
Right arrow Articles by Waller, D. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Aslam, M. I.
Right arrow Articles by Waller, D. A.
Related Collections
Right arrow Chest wall

Case Reports

Latissimus Dorsi Myoclonus After Video Assisted Thoracoscopic Lung Volume Reduction

Muhammad I. Aslam, MRCS, Inger F. Oey, FRCS*, David A. Waller, FRCS (CTh)

Department of Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom

Accepted for publication January 30, 2009.

* Address correspondence to Dr Oey, Department of Thoracic Surgery, Glenfield Hospital, Groby Rd, Leicester, LE3 9QP, United Kingdom (Email: ingeroey{at}hotmail.com).


An accompanying video for this article can be viewed on the Internet at http://ats.ctsnetjournals.org/content/vol88/issue4/images/data/1360/DC1/aslam.mpg.

 

   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Myoclonus as a sequel to thoracotomy has been reported, and its treatment can be challenging to both the patient and the surgeon. We describe a 43-year-old patient with chest wall pain and latissimus dorsi muscle contractions (myoclonus) after video-assisted thoracoscopic lung volume reduction. His symptoms remained refractory to benzodiazepines, nerve blockage, and botulinum toxin injection due to either poor compliance or lack of response to therapy. These symptoms started to resolve spontaneously 18 months after the procedure.

Myoclonus is sudden, brief, involuntary contraction of a muscle or group of muscles. Myoclonus as a sequel to thoracotomy can be challenging to both the patient and the surgeons. We describe a patient with long-lasting myoclonus originating from the latissimus dorsi muscle after a video-assisted thoracoscopic surgical (VATS) lung volume reduction (LVR).

The patient was a 43-year-old man with severe emphysema. His medical history was significant for vertebral disc degeneration, sciatica, and {alpha}1-antitrypsin deficiency with PiZZ phenotype. He underwent unilateral LVR of the lower lobe of the left lung by a VATS procedure performed through three small surgical incisions at fifth and seventh intercostal spaces. Under direct vision, two intercostal chest drains were inserted through the surgical incisions at the fifth and seventh intercostal spaces, as demonstrated in Figures 1 and 2. Go The surgical incisions were closed with Vicryl and Monocryl suture (Ethicon UK, Livingston, United Kingdom) applied to the skin. A paramedian epidural block at the level of T6-T7 was performed for postoperative pain control.


Figure 1
View larger version (30K):
[in this window]
[in a new window]

  		Fig 1. Sites of surgical incisions and chest drains.

 

Figure 2
View larger version (140K):
[in this window]
[in a new window]

  		Fig 2. Chest roentgenogram shows the position of apical and basal chest drains.

 
The patient's immediate postoperative recovery was uneventful for complications. Postoperative pain was effectively controlled by epidural analgesia in the first 48 hours and by oral analgesics after 48 hours. The two intercostal drains remained connected to negative pressure (5 kPa) suction for the initial 48 hours and were removed 4 days after the operation.

The patient was discharged home 5 days after the operation and he continued with pulmonary rehabilitation in the community. He was reviewed in the outpatient clinic 6 weeks after the operation. His surgical wounds were healed and his pulmonary functions had significantly improved.

Three months after the procedure, he started to experience brief arrhythmic contractions of the left latissimus dorsi muscle. The contractions became more frequent, eventually continuous, occurring even during sleep and were associated with spasmodic pain originating from muscle contractions. The muscle contractions gradually increased to such an extent that it appeared as gross fasciculations emanating from the apical drain wound site as shown in the accompanying video, which can be viewed on the Internet (http://ats.ctsnetjournals.org/content/vol88/issue4/images/data/1360/DC1/aslam.mpg).

A detailed neurologic examination of the chest wall, neck, and upper limb revealed no similar activity in any other muscles of the chest, shoulder girdle, or arms. These muscle contractions and pain over the muscle hindered his progress with pulmonary rehabilitation. He was initially prescribed benzodiazepines to relieve the spasm and fasciculations, but he could not comply with this because of the side effects.

The consultant anesthetist, who had a special interest in pain management, attempted a nerve block with 0.5% bupivacaine, but the patient failed to show any improvement in pain and muscle contractions. Ultimately, he was referred for injection of botulinum toxin to paralyze the latissimus dorsi muscle. The patient was unable to tolerate the procedure because of pain at the needle insertion site. This procedure was attempted thrice during a 6-month period, but he failed to comply with the procedure even when attempted under sedation.

The patient continued to experience the muscle contractions, but the pain began to subside over time. By 18 months after the LVR, the frequency and strength of the contractions had reduced remarkably without any intervention. The patient is now actively participating in his pulmonary rehabilitation program and is anticipating the second operation of his staged lung volume reduction.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Myoclonus is sudden, brief, involuntary movement of a muscle or group of muscles that is caused by sudden muscle contraction and relaxation of muscle. The contraction phase is denoted as positive myoclonus and the relaxation phase is called negative myoclonus [1]. Myoclonus may originate from a lesion of the nerve supplying the affected muscle or muscle group. Nerve conduction studies and electromyography (EMG) may be helpful in identifying the cause of myoclonus. Antispasmodic medications such as benzodiazepines and barbiturates may help to relieve the symptoms, and if these fail, then nerve resection or paralysis of muscle with botulinum toxin type A injection may be used to relieve the symptoms [2].

This report describing myoclonus of the latissimus dorsi muscle after VATS joins other reports of myoclonus of this muscle after thoracoscopy [3, 4]. The latissimus dorsi muscle is innervated by the thoracodorsal nerve (C5, C6, C7), which arises from the posterior cord of the brachial plexus. Any injury to this nerve can lead to paralysis of the latissimus dorsi muscle, whereas compression or entrapment of the thoracodorsal nerve may lead to persistent involuntary contractions [4]. Cases have been reported where surgical exploration of the thoracotomy wound revealed fibrous tissue around the nerve at the old surgical incision site. The absence of any neurologic deficit or similar activity in other muscles supplied by the same nerve roots or by more proximal or distal branches of the posterior cord of the brachial plexus strongly suggested that the latissimus dorsi contractions were the result of abnormal activity in the nerve supplying this muscle.

Nerve blocks with long-acting local anaesthetics might not relieve the symptoms, as demonstrated in our patient. In refractory cases, patients had to undergo serial injections of botulinum toxin type A to paralyze the muscle [5]. Botulinum toxin acts to reduce the activity of overactive muscles by blocking the release of acetylcholine at the neuromuscular junction, thereby rendering the muscle unable to contract for a period of 3 to 4 months [2]. Surgical exploration and release of the thoracodorsal nerve/posterior cord of the brachial plexus may result in cessation of muscle contractions in some cases. In very refractory cases, nerve section [6] and even resection of muscle may be the only cure for this condition. In our patient, the nerve compression or irritation subsided spontaneously.

Although muscle-sparing thoracotomy and VATS offer less damage to the neurovascular structures of the chest wall, careful selection of sites of surgical incisions may prevent nerve compression and subsequent intolerable muscle contractions.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Shibasaki H. Overview and classification of myoclonus Clin Neurosci 1995–96;3:189-192.
  2. Jankovic J, Brin M. Therapeutic uses of botulinum toxin N Engl J Med 1991;324:1186-1194.[Medline]
  3. Chung SJ, Lee E, Lee MC. Myoclonus of the latissimus dorsi muscle after thoracotomy Mov Disord 2008;23:1949-195015.[Medline]
  4. Hao L, Clarke CP. Persistent twitching of the latissimus dorsi muscle after a posterolateral thoracotomy ANZ J Surg 2002;72:680-681.[Medline]
  5. Figus A, Mazzocchi M, Dessy LA, Curinga G, Scuderi N. Treatment of muscular contraction deformities with botulinum toxin type A after latissimus dorsi flap and sub-pectoral implant breast reconstruction J Plast Reconstr Aesthet Surg 2008[E-pub ahead of print; doi: 10.1016/j.bjps.2007.07.025].
  6. Kuwabara S, Fukutake T, Kasahata N, Shimoe Y, Yamanaka I, Hirayama K. Associated movement as a sequel to thoracotomy: aberrant regeneration to the latissimus dorsi muscle Mov Disord 1995;10:788-790.[Medline]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Video
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Muhammad I. Aslam
Inger F. Oey
David A. Waller
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Aslam, M. I.
Right arrow Articles by Waller, D. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Aslam, M. I.
Right arrow Articles by Waller, D. A.
Related Collections
Right arrow Chest wall

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS