American Society for Peripheral Nerve
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Upper Extremity Neuropathies following Severe COVID-19 Infection: A Multicenter Case Series
Neill Y Li, MD1; Nikhil Murthy, MD2; Franz K Colin, PhD3; Robert J. Spinner, MD?; Bishop Allen, MD5; Murray Peter, MD6; Shin Alexander, MD7
1Mayo Clinic, Rochester, RI; 2Northwestern University, Chicago, IL; 3ShirleyRyan Ability Lab, Chicago, IL; 4Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN; 5Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; 6Department of Orthopedic Surgery/Division of Hand Surgery, The Mayo Clinic, Jacksonville, FL; 7Orthopedics, Mayo Clinic, Rochester, MN

INTRODUCTION: Increasing cases of upper extremity neuropathies following prone positioning for ARDS draws concern as to whether these are related to more patients with ARDS secondary to COVID-19 or a direct effect of the viral infection. The purpose of the study was to examine presentation, injury patterns, and clinical course, for upper extremity neuropathies following mechanical ventilation for COVID-19.
METHODS: A multicenter retrospective study of patients with COVID-19 complicated by ARDS that required mechanical ventilation was undertaken. Demographics, comorbidities, infection, ARDS, and intubation characteristics, prone or lateral decubitus positioning, and onset of neuropathy were queried from outside institutions. Upon evaluation by multicenter peripheral nerve specialists, examination, electrodiagnostic studies, and treatment were collected. Continuous variables were reported with means, standard deviations, medians, and ranges and categorical with frequencies and percentages.
RESULTS: Between September 2020 and January 2022, 11 patients were diagnosed with upper extremity neuropathy. Mean age was 48.7(12.9), 9 were male(81.8%), and mean BMI was 33.8(7.14). Six patients(54.5%) underwent prone positioning for ARDS, one lateral decubitus, and four supine(Table 1). The median length of intubation was 39 days(range 18-60 days). The mean time from infection to neuropathy diagnosis was 2.82 months(2.04). Of the 11 patients, 5 had pan-plexopathies, 2 incomplete plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy (Table 1). Mean follow-up was 10.2 months(6.79). Three patients with pan-plexopathy had resolution starting with shoulder abduction followed by elbow flexion (Table 2, Patient No. 1-3).Patient No. 4 had resolution of bilateral pan-plexopathy to right radial mononeuropathy at 3 months. All other patients demonstrated minimal improvements.
CONCLUSION: Our series demonstrates the presence of peripheral neuropathies and brachial plexopathies following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to COVID-19 studies, only 54.5% of these patients underwent prone positioning. Instead, there may be an interplay of traumatic disturbance to the plexus from positioning alongside physiologic vulnerability of the nerves from COVID-19. Such vulnerability may stem from microthrombotic angiopathy leading to nerve ischemia, direct viral invasion, or auto-antibody targeting of the nervous tissue. Proceeding further in COVID-19 recovery, recognizing long-term complications and optimal treatments will become increasingly necessary.


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