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10 1016@j Wneu 2019 01 093 PDF
10 1016@j Wneu 2019 01 093 PDF
Bilateral brachial plexus injury after MiraDry® procedure for axillary hyperhidrosis: a
case report
Ross C. Puffer, MD, Allen T. Bishop, MD, Robert J. Spinner, MD, Alexander Y. Shin,
MD
PII: S1878-8750(19)30191-3
DOI: https://doi.org/10.1016/j.wneu.2019.01.093
Reference: WNEU 11266
Please cite this article as: Puffer RC, Bishop AT, Spinner RJ, Shin AY, Bilateral brachial plexus injury
after MiraDry® procedure for axillary hyperhidrosis: a case report, World Neurosurgery (2019), doi:
https://doi.org/10.1016/j.wneu.2019.01.093.
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Bilateral brachial plexus injury after MiraDry® procedure for axillary hyperhidrosis: a
case report
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Allen T. Bishop MD2
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Robert J. Spinner MD1
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From: Department of Orthopedic Surgery, Mayo Clinic, Rochester MN
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Department of Neurosurgery
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Department of Orthopedic Surgery
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Financial Disclosures: None of the authors has a financial interest in any of the products,
devices, or drugs mentioned in this manuscript.
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Corresponding Author:
Alexander Y. Shin, MD
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Ph: 507-284-3689
Fax: 507-266-2533
Shin.alexander@mayo.edu
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Bilateral BPI after MiraDry® Procedure
Abstract
Multiple treatments are available for primary axillary hyperhidrosis, including non-invasive,
microwave based thermal treatments designed to destroy sweat glands in the axilla. Often these
procedures involve local anesthetic injection to the axilla, followed by placement of the
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microwave emitter onto the skin and applying the heat treatment to varying depths of the
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subcutaneous tissues.
Case Report
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A 49-year old, thin and active woman (BMI 19.6) underwent microwave based treatment to the
bilateral axillary regions. She experienced an electric sensation into the ulnar digits of the right
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hand during anesthetic injection, and then underwent the microwave thermal treatment. She
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suffered a bilateral brachial plexus injury with imaging evidence of severe, subcutaneous edema
surrounding the nerves of the plexus in the axilla, as well as denervation atrophy of the arm and
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forearm muscles bilaterally. At the time of evaluation and EMG, 8 months after treatment, she
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had recovered significant strength in the left upper extremity, but continued to have evidence of a
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severe radial nerve injury on the right. EMG demonstrated some recovery and observation was
sustained thermal injury to the nerves in the axilla bilaterally, given the close proximity to the
Conclusion
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given to the distal brachial plexus which may be at risk of damage with high powered
microwave-based therapy.
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Introduction
1.4%. 7 Multiple treatments are available, but many are not considered a long-term solution
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outside of invasive surgical procedures. Non-invasive, microwave-based treatments have been
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developed and have shown efficacy in treatment of this condition. 2,4
MiraDry® (Sientra, Santa Clara, CA) is a Food and Drug Administration approved
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device that uses microwave technology to heat the sweat glands in the dermal/hypodermal
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placed in a supine position with arms abducted over the head, exposing the axilla bilaterally. A
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grid with targets for local anesthetic is applied to the skin of the axilla, and 31 separate injections
of local anesthetic (1% lidocaine with 1:100,000 epinephrine) are applied to each axilla. Next,
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the microwave emitter is positioned over the grid, and heat treatment is applied. There are five
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settings that adjust the degree of microwave power applied, but the authors could not readily find
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any information guiding which power settings to use in specific patient scenarios. The maximum
depth of field on the highest setting has not been reported. The device received initial FDA
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clearance in 2011 and underwent a Class II medical device recall in April 2011 (recall number z-
2591-2011) after reports of skin burns in patients treated with the MiraDry® system. The recall
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occurred in Japan and was completed after 8 devices underwent “field correction.”
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Several studies evaluating the MiraDry® system have demonstrated efficacy for
treatment of hyperhidrosis with minimal, local skin side effects in the area of treatment including
edema, erythema, hair loss, skin markings and discomfort. 3,5No long-term complications were
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Bilateral BPI after MiraDry® Procedure
reported. 3,5 We present a case of bilateral brachial plexus injury after microwave-based
Case Report
A 49-year-old, bilateral hand dominant, thin and active female (BMI 19.6) was offered a
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percutaneous microwave treatment designed to treat primary axillary hyperhidrosis in the
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waiting room of her dermatologist. During local anesthetic injection of (1% lidocaine with
1:100,000 epinephrine), she noted an electrical shock sensation traveling to the ulnar digits of the
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right hand. She notified the provider and was informed that this was normal. The procedure
continued and the microwave treatment was completed bilaterally at the highest energy level
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(5/5). Immediately after the completion of the procedure, the patient experienced profound
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weakness and numbness in bilateral upper extremities. She was informed that this would resolve.
The following morning she noted severe right triceps weakness which resulted in a laceration on
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her face after reaching for a mug from a top cupboard. There was also loss of wrist and finger
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extension of the right hand, and diffuse median/ulnar nerve distribution weakness of the left
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hand.
After three months of outpatient evaluation and no improvement, she underwent bilateral
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brachial plexus (Figure 1) and upper extremity MRI which demonstrated substantial
subcutaneous and perineural edema in the axilla bilaterally as well as atrophy and signal changes
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within the distal musculature (Figure 2). She was referred for physical therapy and began to
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notice improvement in the left hand approximately 7 months after her MiraDry® procedure. At 8
months she underwent evaluation at our institution with EMG demonstrating a chronic, inactive
left brachial plexopathy involving proximal radial, ulnar and median nerves in the region of the
axilla, as well as a chronic right posterior cord plexopathy, with reinnervation features present in
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Bilateral BPI after MiraDry® Procedure
all examined muscles. Clinically, the patient had recovered modified British Medical Research
Council (BMRC) grade 4 strength in median and ulnar innervated muscles of the left hand, but
had persistent BMRC grade 0 strength in the wrist and finger extensors on the right. Given the
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secondary reconstruction of the right radial nerve deficit via tendon transfers if no further
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recovery occurred.
Discussion
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This case highlights the propensity for brachial plexus injury in patients undergoing procedures
targeting the axillary region. It is unclear whether any of the 31 injections of local anesthetic in
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each axilla caused the brachial plexus injury or if unintended field effects of the microwave
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emitter led to nerve irritation and damage. The persistence of the deficit, as well as the depth of
edema evident on MRI may suggest that the microwave heating played a more significant role in
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the nerve damage than the local anesthetic. All local anesthetics can be neurotoxic at high-
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enough levels, however lidocaine has a lower toxicity than the local anesthetic bupivacaine. 6
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The patient described an electric shock sensation into the right hand during injection of the local
anesthetic, which may suggest an injury was sustained during needle insertion, however the
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patient also experienced a deficit of the left hand, and did not report any shooting pains into the
hand during left-sided injection, suggesting a microwave heat damage etiology. It is also
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plausible that the combination of local anesthetic and tissue heating lead to an increased degree
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of nerve injury. There has been significant recovery over time, suggesting a possible
neurapraxic-type injury on the left side, but the presence of fibrillation potentials in the extensor
musculature of the right forearm suggest a more substantial nerve injury, such as an
A literature search was performed, and several cases of brachial plexus injury after
microwave-based treatment were found. Three separate patients developed a deficit after the
procedure, and all three had persistent deficits at 6 months, with evidence of incomplete, but
ongoing recovery. In one of the reports, the injury occurred even with the device on the lowest
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1,3,8
power setting. Complication rates in the currently published series suggest no long term side
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effects reported in any of the original 31 patients at 2 years of follow-up. 3,5 Given the proximity
of the distal brachial plexus to the skin edge within the axilla, especially in thin, active patients,
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hydrodissection after local anesthetic administration to buffer the brachial plexus, or decreased
Conclusion
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In thin patients undergoing treatment of primary axillary hyperhidrosis, consideration should be
given to the distal brachial plexus which may be at risk of damage with high powered
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microwave-based therapy.
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References
1. Chang CK, Chen CY, Hsu KF, Chiu HT, Chu TS, Liu HH, et al: Brachial plexus injury
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2. Glaser DA, Coleman WP, 3rd, Fan LK, Kaminer MS, Kilmer SL, Nossa R, et al: A
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randomized, blinded clinical evaluation of a novel microwave device for treating axillary
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Surg. 2012;38:185-191. https://doi.org/10.1111/j.1524-4725.2011.02250.x
3. Hong HC, Lupin M, O'Shaughnessy KF: Clinical evaluation of a microwave device for
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treating axillary hyperhidrosis. Dermatol Surg. 2012;38:728-735.
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https://doi.org/10.1111/j.1524-4725.2012.02375.x
4. Johnson JE, O'Shaughnessy KF, Kim S: Microwave thermolysis of sweat glands. Lasers
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5. Lupin M, Hong HC, O'Shaughnessy KF: Long-term efficacy and quality of life
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Surg. 2014;40:805-807.
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cytotoxic effects of different local anesthetics on a human neuroblastoma cell line. Anesth
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7. Strutton DR, Kowalski JW, Glaser DA, Stang PE: US prevalence of hyperhidrosis and
8. Suh DH, Lee SJ, Kim K, Ryu JH: Transient median and ulnar neuropathy associated with
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Legends:
subcutaneous and soft tissue edema in both axillae extending proximally within the subpectoral
regions along the distal brachial plexus bilaterally (arrows). This edema and fluid signal encases
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the distal brachial plexus and the terminal branches bilaterally.
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Figure 2: (A) Axial T2-weighted MRI of the right arm demonstrates denervation atrophy of the
triceps (asterisk). (B) Radial-innervated muscle atrophy (asterisk) is present in the distal forearm
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on T2-weighted MRI on the right. (C) Muscle atrophy (asterisks) is present in both the flexor and
extensor compartments of the distal left forearm, suggesting radial, median and ulnar nerve
injury.
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BMI – Body mass index
EMG – Electromyogram
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