Orthopaedics & Traumatology: Surgery & Research (2011) 97, 345—348

CLINICAL REPORT

Cranial nerves neuropraxia after shoulder

arthroscopy in beach chair position
A. Cogan a,∗, P. Boyer a, M. Soubeyrand c, F. Ben Hamida a,
J.-L. Vannier b, P. Massin a

a
Department of Orthopaedic Surgery, Bichat Claude Bernard Teaching Hospital Center, Paris-7 University,
46, avenue Henri-Huchard, 75018 Paris, France
b
Intensive Care Department, Bichat Claude Bernard Teaching Hospital Center, Paris-7 University,
46, avenue Henri-Huchard, 75018 Paris, France
c
Department of Orthopaedic Surgery and Anatomy Research Laboratory, Bicêtre Teaching Hospital Center,
Paris 11 University, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France

Accepted: 20 September 2010

KEYWORDS Summary We report a case of neuropraxia of the 9th, 10th and 12th cranial nerve pairs after
Arthroscopy; arthroscopic rotator cuff repair in the beach chair position. The elements in the medical file
Shoulder; seem to exclude an intracranial cause of the lesions and support a mechanical, extracranial
Beach chair position; cause due to intubation and/or the beach chair position. This clinical case report shows the
Complication; neurological risks of the beach chair position during arthroscopic shoulder surgery and presents
Cranial nerve injuries the essential safety measures to prevent these risks.
© 2011 Elsevier Masson SAS. All rights reserved.

Introduction
Arthroscopy is practiced to repair shoulder damage with
patients in the beach chair or the lateral decubitus position.
The choice of position mainly depends upon the surgeon’s
preferences. In the beach chair position joint distraction
can be obtained without traction of the arm thanks to the
weight of the limb, thus avoiding the risk of pulling the
∗ Corresponding author.
E-mail address: cog20002002@yahoo.fr (A. Cogan).
brachial plexus. This position may also reduce the risk of
injury to axillary and/or musculocutaneous nerves when an
anterior portal is used [1]. The arm can be manipulated
and the entire joint can be explored. [2]. If necessary open
surgery is easy to perform [2]. This position is compatible
with locoregional anesthesia, and allows easy access to the
upper airways [3].
Despite all these advantages, complications, includ-
ing thromboembolic or neurological events, may occur
[4—6].
We report a case of palsy of the three cranial nerves
following arthroscopic repair of the rotator cuff with the
patient in the beach chair position. The mechanism of injury

1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2010.09.020
346
is discussed as well as the precautions to be taken to avoid
this complication.
Clinical case
An active, retired, right hand dominant 66 year old patient
(78 kg, 1 m 79), presented with a transfixing rupture of the
right supraspinatus tendon without retraction or muscular
degeneration, resulting in pain which had not responded to
long term medical treatment. In addition to the cuff injury,
arthroscan also revealed an acromioclavicular arthropathy
compressing the myotendinous junction.
The patient underwent arthroscopy in the beach chair
position under general anesthesia without complementary
interscalenic nerve block (Fig. 1) for reinsertion of the
supraspinatus tendon. During surgery subacromial debride-
ment was performed in association with acromioclavicular
resection and repair of the tear, by the double row suture
anchor technique (Ancre Swive Lock, Arthrex, Naples, EU).
Two arthroscopic canulla were used: one in the anterolat-
eral position and one in the lateral position. Pump pressure
was adjusted to 50 mmHg. A total of 12 litres of draining was
necessary.
During anesthesia, oxygen saturation ranged between 99
à 100%, blood pressure between 19/5 and 13/7 and heart
rate between 50 and 70. Anesthesia lasted 170 minutes and
surgery 120 minutes.
When the patient awoke, he had difficulty chewing and
speaking and his voice had changed. Facial asymmetry and
a deviated tongue were observed. Consultation with an ENT
confirmed complete palsy of the 9th and 12th cranial nerve
pairs and partial palsy of the 10th. (insensitivity of the
Figure 1 Installation in the beach chair position for arthro-
scopic shoulder surgery.
A. Cogan et al.
hemi-soft palate, homolateral hemi-ageusia). The cardiol-
ogist concluded that there was no emboliogenic disease.
The presence of vascular lesions in the medulla oblongata
was excluded by CT scan and MRI. The patient gradually and
completely recovered after 6 months.
Discussion
The rate of neurological complications after shoulder
surgery in particular by arthroscopy is very low Rodeo S.A
[7]. In a series of 14000 shoulder arthroscopies Small identi-
fied 4 cases or a rate of 0.03% (three in the brachial plexus
and one in the axillary nerve). The lateral decubitus posi-
tion seems to present a higher risk of complications because
of the traction to the arm, with a rate of 6—30% of perma-
nent or temporary palsy involving the brachial plexus or the
nerves of the forearm [8,9].
Neuropraxia of the three hypoglossal nerves (cranial
nerve XII), glosso-pharyngeal (cranial nerve IX) and vagus
nerves (cranial nerve X), has never been reported following
shoulder arthroscopy in the beach chair position. Only iso-
lated injuries have been reported. Isolated neuropraxia of
the large hypoglossal nerve for example, may occur during
numerous interventions such as tooth extractions, during an
anterior surgical approach of the cervical spine, or carotid
endarterectomies [10,11]. Mullins et al. were the first to
report nerve injury during shoulder arthroscopy in the beach
chair position [12]. Two other cases of isolated unilateral
palsy of the hypoglossal nerve have been published [13].
The first in a 41-year old man after open Bankart repair in
the beach chair position, and the second in a 71-year old
man after arthroscopic acromioplasty associated with mini-
open repair of the rotator cuff. All of these cases resolved
spontaneously.
Multiple injury to the cranial nerves in the present case
could be explained by several mechanisms. An intracranial
cause is suggested because the three nerves originate in the
medulla oblongata on the medial side of the jugular bulb.
This suggests cerebral hypoperfusion or a thromboembolic
event [5,6,14]. Insufficient perfusion of the vertebral artery
may also be the cause due to the hyperextension associated
with rotation and lateral direction of the head, or even gas
embolisms. However, none of the perioperative data support
this hypothesis, such as the results of perioperative pressure
monitoring of the arm, the negative results of brain imaging
or postoperative cardiological tests.
Thus a mechanical, extracranial cause is more proba-
ble. The hypoglossal nerve emerges from the skull by the
hypoglossal canal, which is very close to the jugular fora-
men where the other nerves pass (Figs. 2 and 3). They are
at risk of being pulled, especially during anesthesia [15,16].
During intubation the patient’s tongue is pushed forward and
the head is pushed back which can cause pulling. [17]. The
pressure on the cricoid cartilage during intubation has also
been described as a cause of traction to the hypoglossal
nerve, which is fixed in this area [18]. When the patient
is positioned with the head rotated to the left for surgery of
the right shoulder, positional injury can occur due to nerve
compression and pulling, or ‘‘rack’’ type effects caused by
various anatomical structures (Fig. 2).
Cranial nerves neuropraxia after shoulder arthroscopy in beach chair position 347

Figure 2 Physipopathology of nerve damage on the transversal plan with an inferior view of the base of the skull, and the
aerodigestive track of the three nerves. When the head is rotated to the left for surgery of the right shoulder, the hypothesis of
positional injury can be explained by compression-pulling of the nerve or rack type effects caused by different anatomical structures.
For clarity, we only show the angle of the jaw, which could compress the 12th pair of cranial nerves.

Figure 3 Physiopathology of nerve damage in the saggital plane with a left lateral view of the neck. The projection of the angle
and the ascending branch of the jaw are presented as dotted lines with shading of subjacent structures. A zoom centered on the
angle of the jaw is represented in the inset. This emphasizes the close relationship between this angle and the 12th pair of cranial
nerves thus emphasizing the ‘‘chopping block’ type effect, which could explain nerve compression.

During surgery any change in position which modifies the
angle of the trunk in relation to the headrest, can cause
nerve compression under the angle of the jaw, which can
become a block. This chopping block effect (Fig. 3) of
the angle of the jaw can also occur if there is too much
flexion of the headrest during initial installation. The cran-
iospinal axis should be respected and manipulated with
care during this type of surgery. The head should be firmly
attached to the headrest with no ocular or jugular compres-
sion. The patient’s position should be checked frequently
during surgery by the members of the surgical and anesthe-
sia team especially if the angle of the operating table is
changed.
Conclusion
This clinical report describes a neurological complication
involving neuropraxia of 3 cranial nerves. The medical file
seems to exclude an intracranial cause for the lesions and
support a mechanical extracranial cause due to intubation
and/or set-up. This clinical report is a reminder of the neu-
348
rological risks of the beach chair position during arthroscopic
shoulder surgery, and the essential safety precautions that
should be taken to avoid these complications
Disclosure of interest
The authors have not supplied their declaration of conflict
of interest.
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