Nerve Damage During Surgery: Brachial Plexus and Peripheral Injuries

How Nerves Are Injured During Surgery

Nerves can be injured during surgery through several mechanisms:

• Direct cutting or transection: The surgeon's scalpel, scissors, or electrocautery cuts the nerve. This is the most severe type of injury and typically requires immediate repair. Complete transection causes total loss of function in the distribution of the nerve.
• Crush injury: The nerve is compressed or crushed by surgical instruments, clamps, or retractors. Crush injuries can cause partial or complete loss of function, depending on the force and duration of compression.
• Stretch injury: Excessive traction or stretching of the nerve during retraction or manipulation. Stretch injuries are particularly common in orthopedic and cardiac surgeries.
• Thermal injury: Electrocautery or laser burns damage the nerve. Thermal injuries may not be immediately apparent but develop over hours to days as the burned tissue degenerates.
• Ischemic injury: The nerve's blood supply is compromised during surgery, causing damage from oxygen deprivation. This can occur from prolonged retraction, excessive compression, or injury to the vasa nervorum (the small blood vessels that supply the nerve).
• Positioning injury: The patient's position during surgery compresses or stretches a nerve. This is particularly common in the brachial plexus (shoulder/upper arm) during procedures requiring the arms to be extended or tucked, and in the common peroneal nerve (lower leg) during lithotomy (legs in stirrups) position.
• Tourniquet injury: Prolonged or excessively tight tourniquet use during limb surgery can cause nerve damage from compression and ischemia.
• Hematoma compression: Postoperative bleeding creates a hematoma that compresses a nerve. If not promptly evacuated, this can cause permanent nerve damage.

Common Surgeries Associated with Nerve Damage

Nerve damage can occur during any surgery, but certain procedures carry higher risks:

• Spine surgery: The spinal cord and nerve roots are at risk during any spinal procedure. Nerve root injury can cause weakness, numbness, or pain in the distribution of the affected nerve.
• Cardiac surgery: The phrenic nerve (controlling the diaphragm) and the brachial plexus are at risk, particularly during coronary artery bypass and valve surgery. Phrenic nerve injury can cause diaphragm paralysis and breathing difficulty.
• Thyroid surgery: The recurrent laryngeal nerve (controlling the vocal cords) is at risk. Injury causes hoarseness, breathing difficulty, or aspiration. The external branch of the superior laryngeal nerve is also at risk, affecting voice pitch.
• Cholecystectomy (gallbladder surgery): During laparoscopic gallbladder surgery, clipping or cutting can injure nerves, and trocar placement can cause abdominal wall nerve injuries. [Link to: /surgical-errors/gallbladder-surgery-malpractice]
• Hernia repair: The ilioinguinal, iliohypogastric, and genitofemoral nerves are at risk during inguinal hernia repair. Injury causes chronic groin pain, a common and debilitating complication.
• Hip and knee replacement: The sciatic, femoral, and peroneal nerves are at risk. Injury can cause foot drop, weakness, or loss of sensation in the leg.
• Shoulder surgery: The axillary nerve and brachial plexus are at risk during arthroscopic and open shoulder procedures.
• Abdominal surgery: The intercostal nerves and abdominal wall nerves can be injured during trocar placement, incisions, or dissection.
• Cesarean section: The bladder, bowel, and lower abdominal nerves can be injured. [Link to: /medical-malpractice/delayed-c-section]
• Mastectomy and breast surgery: The intercostobrachial nerve and long thoracic nerve are at risk, causing numbness, pain, and shoulder winging.

Brachial Plexus Injuries

The brachial plexus is a network of nerves that originates in the neck and supplies the arm and hand. Brachial plexus injuries during surgery are particularly devastating because they affect the entire upper extremity.

Brachial plexus injuries during adult surgery are most commonly caused by: - Positioning during surgery: The arms are placed in an extended or abducted position for cardiac surgery, thoracic surgery, or other procedures requiring chest access. The stretch on the brachial plexus can cause injury — particularly if the position is maintained for a long time or if the patient has anatomical variations that increase susceptibility. - Direct surgical injury: During neck, shoulder, or chest surgery, the surgeon may cut, crush, or burn the brachial plexus directly. - Compression from hematoma or hardware: Postoperative bleeding or surgical hardware can compress the brachial plexus.

Symptoms of brachial plexus injury include: - Weakness or paralysis of the shoulder, arm, or hand - Numbness or tingling in the arm or hand - Severe pain (neuropathic pain) - Loss of grip strength - Inability to raise the arm

[Link to: /birth-injury/erbs-palsy-lawyer]

Peripheral Nerve Injuries

In addition to the brachial plexus, many peripheral nerves can be injured during surgery:

• Recurrent laryngeal nerve: During thyroid or parathyroid surgery. Injury causes hoarseness, breathing difficulty, or aspiration. Bilateral injury can cause life-threatening airway obstruction.
• Phrenic nerve: During cardiac or thoracic surgery. Injury causes diaphragm paralysis and breathing difficulty.
• Sciatic nerve: During hip replacement or pelvic surgery. Injury causes weakness, numbness, or pain in the leg and foot.
• Common peroneal nerve: During knee surgery or procedures requiring lithotomy position. Injury causes foot drop — inability to lift the foot, causing a steppage gait.
• Femoral nerve: During abdominal surgery, pelvic surgery, or hip replacement. Injury causes weakness in hip flexion and knee extension.
• Ilioinguinal/iliohypogastric nerves: During hernia repair. Injury causes chronic groin pain, numbness, or burning.
• Intercostobrachial nerve: During mastectomy or axillary surgery. Injury causes numbness, pain, or burning in the inner arm.
• Facial nerve: During parotid surgery or facelift. Injury causes facial weakness or paralysis. [Link to: /surgical-errors/plastic-surgery-malpractice]
• Optic nerve: During spinal surgery (from prolonged prone position and hypotension) or sinus surgery. Injury causes vision loss — a devastating, often permanent complication.

When Nerve Damage Constitutes Medical Malpractice

Not all nerve damage during surgery is malpractice. Some nerves are small, variable in location, or directly in the surgical field, making injury a known risk. However, nerve damage constitutes medical malpractice when:

• The nerve was not in the surgical field and should not have been injured: For example, injuring the recurrent laryngeal nerve during a gallbladder surgery, or injuring the brachial plexus during an abdominal procedure.
• Improper surgical technique: The surgeon used excessive force, improper dissection technique, or improper use of electrocautery near nerves.
• Failure to identify and protect nerves: In surgeries where nerves are known to be at risk (e.g., recurrent laryngeal nerve in thyroid surgery), the standard of care requires identifying and protecting the nerve. Failure to do so may constitute negligence.
• Improper patient positioning: The patient was positioned in a way that stretched or compressed a nerve, and the positioning was not corrected or monitored.
• Excessive tourniquet time or pressure: During limb surgery, tourniquet use was prolonged or excessively tight, causing nerve damage.
• Failure to recognize and treat nerve injury intraoperatively: If a nerve is injured during surgery, it should be recognized and, if possible, repaired immediately. Failure to recognize the injury allows ongoing damage and worsens outcomes.
• Failure to recognize and treat postoperative nerve compression: If a postoperative hematoma compresses a nerve, it must be promptly evacuated. Delays in diagnosis and treatment can cause permanent nerve damage.
• Failure to obtain informed consent: The surgeon did not adequately explain the risk of nerve damage for the specific procedure.

Recognizing Signs of Surgical Nerve Damage

If you experience any of the following after surgery, seek immediate medical attention — and consider consulting a malpractice attorney:

• Numbness or tingling: New or worsening numbness or tingling in any part of the body after surgery.
• Weakness: Inability to move a limb, grip objects, lift the arm, or walk normally.
• Severe pain: Burning, shooting, or electric shock-like pain — particularly in the distribution of a nerve.
• Foot drop: Inability to lift the foot when walking, causing it to drag.
• Hoarseness: After neck or chest surgery, may indicate recurrent laryngeal nerve injury.
• Breathing difficulty: After cardiac or thoracic surgery, may indicate phrenic nerve injury.
• Vision changes: After spinal surgery, may indicate optic nerve injury.
• Muscle atrophy: Wasting of muscles in the distribution of an injured nerve, which develops over weeks to months.

Treatment and Prognosis

The treatment and prognosis of surgical nerve damage depend on the type and severity of the injury:

Neuropraxia (mild injury): The nerve is bruised but not cut. Recovery typically occurs within weeks to months as the nerve heals. Most neuropraxic injuries recover fully, though some may cause residual symptoms.

Axonotmesis (moderate injury): The nerve fibers (axons) are damaged but the nerve sheath is intact. Recovery is possible but slow — nerves regrow at approximately 1 inch per month. Full recovery may take 6-18 months and may be incomplete.

Neurotmesis (severe injury): The nerve is completely cut or destroyed. Spontaneous recovery is not possible. Surgical repair (direct repair, nerve grafting, or nerve transfer) may be attempted, but outcomes are often disappointing. Many patients are left with permanent disability.

Treatment options include: - Observation: For mild injuries, monitoring for spontaneous recovery over weeks to months. - Surgical repair: Direct nerve repair, nerve grafting (using a nerve from elsewhere in the body to bridge a gap), or nerve transfer (rerouting a functioning nerve to restore function). - Tendon transfer: Transferring a functioning tendon to restore a lost function. - Pain management: Neuropathic pain is difficult to treat and may require medications (gabapentin, pregabalin), nerve blocks, spinal cord stimulators, or pain pumps. - Physical and occupational therapy: To maintain joint mobility, prevent contractures, and maximize remaining function. - Assistive devices: Braces (e.g., ankle-foot orthosis for foot drop), splints, and mobility aids.

New York Malpractice Law

Nerve damage malpractice cases in New York are governed by CPLR § 214-a (2.5-year statute of limitations) and CPLR § 3012-a (certificate of merit requirement). New York does not cap non-economic damages — significant for nerve damage cases where chronic pain and loss of function are primary damages. Expert witnesses must be board-certified in the same or a related specialty as the defendant surgeon, and may include neurologists, neurosurgeons, and orthopedic surgeons. [Link to: /cerebral-palsy-lawyer/statute-of-limitations]

Frequently Asked Questions

The value of a medical malpractice case in New York depends on several factors, including the severity of the injury, the strength of liability evidence, and the economic and non-economic damages involved. New York is one of the few states with no caps on medical malpractice damages, meaning there is no artificial limit on what you can recover. Below are typical settlement ranges based on injury severity.