Patient With Infection Develops Severe Muscle Atrophy

This case involves an otherwise healthy female who initially presented to her pediatrician with a mass in her neck. Given the mass’s persistence over an extended period of time, the patient was referred for an biopsy of the affected lymph node. The biopsy revealed lymphadenitis. After the procedure, the patient lost a significant range of motion in her upper extremities, bone protrusions, as well as severe atrophy of many of her back muscles. She was never referred to a neurologist or an orthopedic for further review. The patient subsequently experienced sharp chest pains and sought the opinion of a cardiologist. She was diagnosed by the cardiologist with precordial catch syndrome.

Question(s) For Expert Witness

1. How frequently do you perform excisional lymph node biopsies in the neck?

2. What are the potential causes of this type of complication? How would it occur?

3. In a patient with new post-op weakness, when should a MRN (MR neurography) of the brachial plexus be ordered and when should the patient be referred to a neurologist for an EMG/NCS?

4. Under what circumstances would you refer this type of patient to a neurosurgeon or peripheral nerve surgeon for brachial plexus exploration and possible neurolysis?

Expert Witness Response E-142719

I am a double board-certified otolaryngologist and facial plastic surgeon. I do plenty of lymph node as well as other mass removals from the neck. I have thankfully never had such a feared complication but have certainly seen and read about such complications. I almost always use a nerve integrity monitor if I will be operating near those neurovascular bundles. My initial thoughts are that there was likely a nerve injury at the base of the neck. I usually do 1-2 excisional biopsies of lymph nodes per month. Generally, the complication described is due to damage of cranial nerve XI, branchial plexus and or the long thoracic nerve. Based on the described location of the lymph node, these nerves are in the anatomic vicinity. I absolutely would get an MRN and EMG done. I would have the patient referred to an appropriate neurologist and possibly an orthopaedic or neurosurgeon. I don't think its really in question that this patient needs a referral to a peripheral nerve surgeon. As for the need for corrective surgery, I would defer to them as this is outside my area of expertise. It sounds like this was being done to diagnose and or rule out a lymphoproliferative disorder. Generally, I will only remove the superficial portion of the lymph node that is easily accessible in order to not endanger the deeper structures underneath.