What Actions Can Be Used to Prevent Peripheral Nerve Injury?

INTRODUCTION

Perioperative peripheral nerve injury is a significant source of morbidity for patients, and the second most frequent cause of professional liability for anesthesiologists, accounting for 12% of general anesthesia malpractice claims since 1990 according to the Anesthesia Closed Claims Database, funded by the Anesthesia Quality Institute, the quality wing of the American Society of Anesthesiologists (ASA). ^, The incidence of postoperative peripheral nerve dysfunction is estimated at 0.1% to 0.15%, or 1 in 1000 to 1500 anesthetics. A study by Welch et al. in 2009 of more than 380,000 anesthetics observed an incidence of 0.03% for postoperative nerve injuries. A more recent review in 2018 by Chiu et al. concluded that the overall incidence in the general population of surgical patients is less than 1%, with higher incidences found after cardiac, neurosurgery, and orthopedic procedures.

The etiology of perioperative nerve damage is largely unknown. Injuries to the nerves of the upper or lower extremity may be secondary to stretching and/or compression with malpositioning of the patient. In contrast, ulnar nerve dysfunction may occur despite protective padding and careful positioning. Direct trauma from needles or instruments and chemical toxicity of injected local anesthetics or vasoconstrictors may be implicated in nerve damage after regional anesthetic techniques. Patients with underlying neuronal dysfunction are more susceptible to “double crush syndrome,” which occurs as a result of two distinct subclinical neuronal insults and has been seen with ulnar neuropathy. Nevertheless, there are very few prospective studies on the genesis or prevention of perioperative neuropathy. The relationship between conventional perioperative care and development of postoperative neuropathy is poorly understood.

Because of the absence of randomized controlled trials and a paucity of epidemiologic studies, the evidence on which practice patterns for prevention of perioperative peripheral neuropathy are based is largely consensus opinion. The ASA Task Force on Prevention of Perioperative Peripheral Neuropathies formed a practice advisory regarding perioperative positioning of the patient, use of protective padding, and avoidance of contact with hard surfaces or supports to reduce perioperative neuropathies published in 2018 ( Box 45.1 ). Even with close adherence to these recommendations, however, many peripheral neuropathies, especially those involving the ulnar nerve, may not be preventable.

BOX 45.1

Summary of ASA Practice Advisory Recommendations

(Excerpted from Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology. 2018;128[1]. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, Illinois 60173.)

Preoperative History and Physical Assessment

Review a patient’s preoperative history and perform a physical examination to identify: body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, arthritis, and sex (e.g., male sex and its association with ulnar neuropathy).
When judged appropriate, ascertain whether patients can comfortably tolerate the anticipated operative position.

Positioning Strategies for the Upper Extremities

Positioning Strategies to Reduce Perioperative Brachial Plexus Neuropathy

When possible, limit arm abduction in a supine patient to 90 degrees.
- The prone position may allow patients to comfortably tolerate abduction of their arms to greater than 90 degrees.*

Positioning Strategies to Reduce Perioperative Ulnar Neuropathy

Supine Patient with Arm on an Armboard: Position the upper extremity to decrease pressure on the postcondylar groove of the humerus (ulnar groove).
- Use of either supination or the neutral forearm positions may be used to facilitate this action.
Supine Patient with Arms Tucked at Side: Place the forearm in a neutral position.
Flexion of the Elbow: When possible, avoid flexion of the elbow to decrease the risk for ulnar neuropathy. ^†

Positioning Strategies to Reduce Perioperative Radial Neuropathy

Avoid prolonged pressure on the radial nerve in the spiral groove of the humerus.

Positioning Strategies to Reduce Perioperative Median Neuropathy

Avoid extension of the elbow beyond the range that is comfortable during the preoperative assessment to prevent stretching of the median nerve.

Periodic Assessment of Upper Extremity Position During Procedures

Periodic perioperative assessments may be performed to ensure maintenance of the desired position.

Positioning Strategies for the Lower Extremities

Positioning Strategies to Reduce Perioperative Sciatic Neuropathy

Stretching of the Hamstring Muscle Group: Positions that stretch the hamstring muscle group beyond the range that is comfortable during the preoperative assessment may be avoided to prevent stretching of the sciatic nerve.
Limiting Hip Flexion: Because the sciatic nerve or its branches cross both the hip and the knee joints, assess extension and flexion of these joints when determining the degree of hip flexion.

Positioning Strategies to Reduce Perioperative Femoral Neuropathy

When possible, avoid extension or flexion of the hip to decrease the risk for femoral neuropathy.

Positioning Strategies to Reduce Perioperative Peroneal Neuropathy

Avoid prolonged pressure on the peroneal nerve at the fibular head.

Protective Padding

Padded armboards may be used to decrease the risk for upper extremity neuropathy.
Chest rolls in the laterally positioned patient may be used to decrease the risk for upper extremity neuropathy.
Padding at the elbow may be used to decrease the risk of upper extremity neuropathy.
Specific padding to prevent pressure of a hard surface against the peroneal nerve at the fibular head may be used to decrease the risk of peroneal neuropathy.
Avoid the inappropriate use of padding (e.g., padding too tight) to decrease the risk of perioperative neuropathy.

Equipment

When possible, avoid the improper use of automated blood pressure cuffs on the arm (i.e., placed below the antecubital fossa) to reduce the risk of upper extremity neuropathy.
When possible, avoid the use of shoulder braces in a steep head-down position to decrease the risk of perioperative neuropathies.

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