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Perioperative peripheral nerve injury (PPNI) is a rare complication that can lead to significant patient disability. PPNI is a substantial cause of medical malpractice claims for anesthesiologists. The etiology of nerve injury is poorly understood making prevention of this complication a challenge. PPNI had been reported despite appropriate padding and positioning practices. Upper extremity nerve injury is the most common form of PPNI encountered in clinical practice and in reviews of closed malpractice claims. In this article, we briefly review the mechanisms of upper extremity PPNI and discuss considerations that may reduce the likelihood of its occurrence.
INTRODUCTION
Perioperative peripheral nerve injury (PPNI)
is an uncommon complication that can lead to significant patient disability and
anesthesiology malpractice claims. The reported incidence of PPNI is 0.03% to
0.1% [1,2]. Upper extremity PPNI comprises 55%-58% of all nerve injury cases
[1,3]. PPNI is the second most common cause of anesthesia malpractice claims
after death [3]. Despite multiple human, cadaveric and animal research models,
we do not have a clear understanding of the exact mechanism of PPNI [4]. This
is primarily because the etiology is multifactorial involving patient
predisposition and a variety of precipitating factors that include
intraoperative patient positioning, physiological parameters, surgery related
factors and postoperative positioning. PPNI often occurs without an
identifiable cause and despite applying standard preventive measures like
proper positioning and padding. The American Society of Anesthesiologists (ASA)
publishes a practice advisory for the prevention of perioperative peripheral
neuropathies [5]. In this article, we will briefly review the mechanisms of
upper extremity PPNI and list considerations to reduce intraoperative upper
extremity peripheral nerve ischemia.
REVIEW
The mechanisms of PPNI include compression,
stretch and inflammation leading to a reduced perfusion pressure in the nerve
fibers [6]. Intraneural hypoperfusion and ischemia is the common final pathway
of the various insults leading to PPNI [7]. Stretching of a peripheral nerve by
5% or more can collapse intraneural capillaries leading to an increase in the
intraneural pressure, a reduction in nerve perfusion pressure and subsequent
ischemia [8]. Compression can lead to increased local tissue pressure,
decreased perfusion pressure and subsequent nerve fiber ischemia [9]. More recently
inflammatory and autoimmune mechanisms have been identified as causes for PPNI.
[10-12]. Nerve biopsies in these cases showed ischemic and inflammatory
injuries to the micro vessel wall and axonal degeneration. Many of these cases
were treated with anti-inflammatory medication with a favorable clinical
response. This type of PPNI, which develops without an identifiable cause and
improves with immunotherapy, is described as postsurgical inflammatory
neuropathy [11].
The ulnar nerve is anatomically susceptible
to compression at the ulnar grove [13]. Men are more susceptible to ulnar
neuropathy than women are because they have relatively less fat content in the
medial aspect of the elbow. Ulnar nerve is susceptible to stretch with higher
degrees of elbow flexion. Risk factors for perioperative ulnar neuropathy
include male gender, extreme body habitus and prolonged hospitalization [14].
The brachial plexus has a superficial
location and passes through two fixed points of anatomy, the intervertebral
foramen and the axillary sheath, making it at risk for stretch
The median nerve courses through the carpal tunnel, making it susceptible to compression with minimal swelling. However, stretch is
the main mechanism of perioperative median nerve injury. Median neuropathy
commonly occurs in men between the ages of 20-40 years of age [16]. Men with
bulky and well-developed biceps have reduced flexibility and an inability to
fully extend the elbow. During general anesthesia, with a relaxed biceps
muscle, the elbow can be stretched to an extent, which is more than in the awake
state, making the median nerve susceptible to stretching, ischemia and injury
[16].
Compression at the spiral groove is the main
mechanism of perioperative radial injury [18]. It may occur due to compression
of the radial nerve by vertical bars of abdominal retractors in the supine arms
out position. In the lateral decubitus position, the vertical bars supporting
the overhead arm board may compress the dependent radial nerve at the radial
groove while the non-dependent radial nerve may be compressed by the edge of
the overhead arm board if it protrudes into the mid humerus. Also, the radial
nerve may be compressed when the arm loses support, slips and the weight of the
upper extremity is supported against the edge of the arm board or operating
room table at mid hummers.
DISCUSSION
Identification of
high-risk patients, optimizing upper extremity position to minimize peripheral
nerve stretch and compression, maintaining physiologic parameters and early
identification of conduction changes are the underpinning principles of all
measures to minimize the occurrence of PPNI.
The following are
considerations to reduce the occurrence of intraoperative upper extremity nerve
ischemia and possibly injury:
·
Perform preoperative evaluation to identify risk
factors. Determine whether the patient can comfortably tolerate the anticipated
operative position
·
Limit arm abduction in a supine patient to 90°
·
In the supine operative position, maintain the
forearm in supination or the neutral positions. Avoid forearm pronation
·
Avoid excessive flexion of the elbow
·
Avoid excessive extension of the wrist
·
Avoid pressure on the spiral groove of the humerus
by metal bars, operating table edge, or the edge of armrest padding if it is
higher than the level of the operating table padding
·
Extend the elbow to the point that was comfortable
during preoperative evaluation
·
Perform periodic perioperative assessments of
intraoperative positioning
·
Apply padding to the arm board and the elbow. Avoid
tight safety straps
·
Apply a chest roll in the lateral decubitus
position. Avoid placing the roll in the axilla
·
Avoid the use of shoulder braces in the steep
head-down position
·
Perform a simple postoperative assessment of
extremity nerve function for early recognition of peripheral neuropathies
·
Document specific perioperative positioning details
·
When available, use neuromonitoring techniques such
as somatosensory evoked potential (SSEP) to identify intraoperative upper
extremity conduction changes. Although intraoperative conduction changes many
not necessary translate to PPNI, reversing intraoperative nerve conduction
changes is prudent and may help reduce PPNI [17]. Intraoperative use of SSEP to
optimize the arm position and the maintenance of intraoperative MAP above 80 mm
Hg while avoiding MAP below 55 mm Hg can significantly reduce the incidence of
abnormal intraoperative conduction changes [17,18].
CONCLUSION
Preventing a multifactorial perioperative
complication such as PPNI remains a challenge for the perioperative team. While
the scientific community had made honorable strides to advance the knowledge of
PPNI, we do not have the complete understanding of PPNI to be able to prevent
it. However, we have enough knowledge to make the attempt at avoiding it a
reality.
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