Elsevier

Surgical Neurology

Volume 63, Issue 1, January 2005, Pages 5-18
Surgical Neurology

Peripheral Nerves
Intraoperative positioning nerve injuries

https://doi.org/10.1016/j.surneu.2004.03.024Get rights and content

Abstract

Intraoperative positioning nerve injuries are regrettable complications of surgery thought to arise from stretch and/or compression of vulnerable peripheral nerves. Generally thought to be preventable, these injuries still occur in patients despite rigorous preventative measures. Sometimes injuries, initially thought to be due to malpositioning, are caused by other factors, such as retraction injury or brachial plexitis. Because of the diversity of nerves susceptible to positioning injury, the clinician must be aware of a variety of presentations and must be able to distinguish them from other postoperative complaints. Prevention remains the mainstay of the management of positioning injuries. Diagnosed and managed appropriately, these lesions typically improve completely over time.

Introduction

The discipline of surgery requires the choreographed manipulation of the patient by the surgical team. Unfortunately, the patient is at risk of sustaining an iatrogenic injury at any step during this process. Nerve injury may occur during placement of intravenous and intra-arterial lines, during injections, during compression of the globes of the eyes, after direct trauma in the operative field, or during the postoperative care of the patient. These forms of nerve injury are reviewed elsewhere [13], [20], [38], [84]. Nerve injuries related to the positioning of the patient on the operating table and the positioning of the equipment vital to the operation were first described in the 1800s [15] and are the subject of this review. Such injuries are usually preventable; however, they unfortunately continue to occur.

Section snippets

Pathophysiology of nerve injury

Intraoperative positioning nerve injuries generally occur when a peripheral nerve is acutely subjected to some combination of stretch, ischemia, and/or compression at the time of surgery. Regardless of the exact mechanism of injury, there is a continuum to the severity of injuries thereby produced. Low-grade stretching of a nerve may cause physical disruption of intraneural blood vessels (vasa nervorum), causing patchy nerve ischemia [31]. More severe stretching may tear the intraneural

Predisposing factors

In an early review [44] of what was then described as “Anaesthesia-paralysis,” several patients were noted to have peripheral nerve injuries after a variety of surgical procedures. Garrigues [44] noted that the selection of anesthetic was unimportant. Both long and short operations resulted in nerve injuries. The most important predisposing factor was thought to be pressure on the nerve. Thin patients were especially at risk. Later reports implicated diabetes as a predisposing factor in the

Injury evaluation

Crucial to the diagnosis of intraoperative positioning nerve injuries is physician awareness of these injuries and their presentation. Often patient complaints are dismissed in the early postoperative period. In the setting of potent postoperative analgesics, residual anesthesia, incisional pain, and other critical care issues, even patients are sometimes unaware of their neurologic deficits. Once a nerve injury is identified, a history with emphasis on predisposing factors should be elicited.

Injury treatment

In the acute phase of intraoperative positioning nerve injury, treatment depends on the nature of the symptoms. Pain is treated with analgesics or other medications efficacious in the treatment of neurogenic pain, such as gabapentin (Neurontin). Motor deficits are treated with physical therapy to maintain joint flexibility and range of motion. Active use of the affected muscles is typically recommended. Splinting may be used to protect an extremity from further injury, assist with activities of

Brachial plexus

Brachial plexus positioning injuries present as a typically painless motor dysfunction referable to the upper and middle trunks [28]. Less commonly, the lower trunk or medial cord may be affected [69]. Injury to the brachial plexus was described in some of the earliest reports of intraoperative positioning nerve injuries. Cadaveric studies were described that implicated compression of the brachial plexus between the ribs and clavicle, at the level of the scalene muscles, or stretched across the

Ulnar nerve

Ulnar nerve injury at the level of the cubital tunnel at the elbow is characterized by numbness and tingling in the fourth and fifth digits, pain along the medial forearm and hand, occasional weakness of the flexor digitorum profundus (fourth and fifth digits), and marked weakness of the lumbricals (fourth and fifth digits), and hand intrinsics. There may be sensitivity to palpation of the nerve at the elbow and Tinel's sign may be present. Flexion of the elbow may worsen symptoms. Ulnar

Radial nerve

The radial nerve innervates the triceps, brachioradialis, supinator, wrist extensors, and finger extensors. Sensory branches supply the lateral upper arm, posterior arm, posterior forearm, and a portion of the dorsal hand. Deficits after injury are variable, depending on the location of injury. Radial nerve injury may occur when the posterior aspect of the arm is pushed against a rigid structure, such as an anesthetic screen [99]. The radial nerve injuries described in the Karolinska Institute

Median nerve

The median nerve supplies the upper extremity pronators, flexor carpi radialis, flexor digitorum superficialis, flexor digitorum profundus 1 and 2, flexor pollicis, opponens pollicis, and the abductor pollicis brevis muscles. Sensory supply is to the first 3 digits of the hand, splitting the fourth digit with the ulnar nerve. Hanging the unpadded, pronated arm off the table may compress the median nerve as it traverses the upper arm on the table edge [25]. This may be exacerbated if the surgeon

Long thoracic nerve

The long thoracic nerve supplies the serratus anterior muscle. Weakness in this distribution permits winging of the scapula. First reported in 1926 as an intraoperative positioning nerve injury [108], this case was likely brachial plexitis, given apparent painful prodrome and delay of onset from the time of surgery. In fact, a review of postoperative long thoracic nerve palsies including a series of new patients suggests the possibility that many cases in the literature have been falsely

Musculocutaneous nerve

Isolated musculocutaneous nerve palsy may occur because of intraoperative malpositioning. This lesion is characterized by weakness in arm flexion and numbness along the distribution of the lateral cutaneous nerve of the forearm, the sensory continuation of the musculocutaneous nerve. In one reported case, the patient was positioned with the arm abducted, extended, and internally rotated [40]. The patient improved completely over several months.

One case report details a 10-hour intra-abdominal

Axillary nerve

The axillary nerve supplies motor innervation to the deltoid muscle and sensory innervation to a portion of the deltoid muscle's overlying skin. When paralyzed, shoulder abduction from 30° to 90° is compromised. Isolated injury to this nerve from positioning is rare but has been reported in the prone position [50]. Axillary nerve injury has also been reported in 1 (0.014%) of 7,150 patients in a series of total hip arthroplasties in the lateral position, resolving completely within 1 year [92].

Peroneal nerve

Common peroneal nerve injury results in weakness of ankle extensors and foot dorsiflexors from involvement of the deep peroneal division, and weakness of ankle eversion from involvement of the superficial peroneal division. Because of overlap from surrounding nerves, sensory loss may variably involve the dorsum of the foot and the lateral leg and ankle. Compressive straps used to restrain the legs, presumably in a lithotomy position, were thought to be responsible for the peroneal nerve

Tibial nerve

Injury to the sciatic nerve may paralyze or weaken foot and toe plantar flexors, foot inverters, and foot intrinsics. Numbness occurs along the posterior leg and sole of the foot. Unlike the peroneal nerve at the fibular head, the tibial nerve occupies a position in the leg largely protected by adjacent soft tissue and muscle. Injuries to the tibial nerve in isolation are uncommon but may occur when the nerve is compressed against the femur at the level of the popliteal space by support behind

Femoral nerve

Femoral nerve injury at the level of the inguinal ligament typically results in weakness of the quadriceps muscles, loss of the knee jerk reflex, and variable sensory loss over the anterior and medial thigh and medial leg to the ankle. Femoral nerve injury has occurred after gynecologic surgery in the lithotomy position [53], [109]. The authors proposed that the nerve be subjected to angulation and compression beneath the inguinal ligament when the thighs are severely abducted and the hips

Lateral femoral cutaneous nerve

Injury to the lateral femoral cutaneous nerve typically manifests as lateral thigh pain, commonly known as meralgia paresthetica. It may become injured by the laterally placed support bar for the stirrups used to maintain the legs elevated in the lithotomy position [33]. In addition, the nerve may also be injured by inadequately padded bolsters in the prone position, compressing the nerve in the thigh just distal to the inguinal ligament, or injured at the level of the inguinal nerve during

Sciatic nerve

Sciatic nerve injury at or near to the sciatic notch may involve one or both of the peroneal and tibial divisions. The peroneal division is more posteriorly and laterally placed, and thus is usually more susceptible to injury. Loss of the sciatic nerve at this proximal location usually involves the biceps femoris muscle, in addition to the peroneal and/or tibial innervated muscles. More distal injury may spare function in the hamstrings. Sciatic nerve compression between the operating table and

Saphenous nerve

Injury to this sensory nerve results in pain, paresthesias, or numbness along the anteromedial leg. Saphenous nerve injury has occurred from compression due to medially placed stirrup holders in the lithotomy position [99]. The Bierhoff leg holders used in the lithotomy position, when insufficiently padded, may compress the saphenous nerve against the medial tibial condyle [43]. Recovery after injury to this nerve may take many months because of its long course.

Obturator nerve

Injury to the obturator nerve may weaken the thigh adductors. Rarely described, intraoperative injury may occur as the nerve is compressed against the inferior aspect of the pubic ramus of the pelvis at the level of the obturator foramen during dorsal lithotomy procedures [45]. There are few or no data describing recovery after injury to this nerve from malpositioning.

Pudendal nerve

The pudendal nerve supplies motor branches to the external anal sphincter and sensory branches to the perineum and scrotum. One report detailed its injury after the application of bilateral leg traction, thereby compressing the ischial tuberosities against an insufficiently padded post [70]. Details of the patient's recovery were not provided.

Facial nerve

Injury to the facial nerve results in paralysis of the face muscles, depending on which branches are affected. An anatomic variant of the mandibular branch bends this branch around the angle of the mandible, rendering it susceptible to compression injury at this level. Examples of this type of injury have been reported after the use of the jaw lift during mask ventilation [42]. They typically involve the lower face and resolve in weeks to months.

Lingual nerve

Palsy of the lingual nerve generally results in tongue numbness and loss of taste. Injury to this nerve can occur from compression within the oropharynx from endotracheal tube or laryngeal mask airway placement [2], [58], [68], [107]. One report of lingual nerve injury occurred after placement in the prone position [118]. The authors suggested that pressure on the mandible stretched the pterygoid muscles, thus compressing the nerve. Lingual nerve injuries typically resolve over the course of

Hypoglossal nerve

The hypoglossal nerve provides motor innervation to the tongue. Paralysis of this nerve results in unilateral tongue weakness, slurred speech, difficulty in swallowing, and deviation to the ipsilateral side on examination. As for the lingual nerve, the hypoglossal nerve may become damaged during either endotracheal or laryngeal mask intubation [35], [63], [83]. One proposed mechanism is compression of the nerve between the relatively firm tube and the hyoid bone. Recovery times are likewise

Supraorbital nerve

Supraorbital nerve compression injuries may result from pressure applied to the face during surgery. Injury to this nerve presents with eye pain, forehead numbness, and photophobia. One case involved a neuropraxic injury after securing the endotracheal tube to the face with a Hudson harness, apparently placing pressure directly on the nerve in the forehead [8]. Recovery occurred over a period of nearly 3 weeks.

Recurrent laryngeal nerve

Recurrent laryngeal nerve injury may result in vocal cord paralysis and hoarseness. This type of injury has been reported after placement of a transesophageal echocardiogram probe followed by neck flexion during sitting position surgery [26]. This injury may also occur infrequently after laryngeal mask airway placement [72]. Symptoms typically resolve over weeks to months.

Intraoperative somatosensory evoked potential monitoring

Intraoperative somatosensory evoked potential (SSEP) monitoring is generally used during spinal surgery for monitoring of spinal cord and nerve root function. In selected cases, significant changes in intraoperative SSEP tracings can be predictive of peripheral nerve injuries postoperatively [52]. Used in this manner, SSEP monitoring has picked up intraoperative misadventures that, undetected, likely would have resulted in intraoperative positioning nerve injuries. One study described the use

Medicolegal implications

The American Society of Anesthesiologists Closed Claims Study examined cases of medical malpractice compiled from files of closed claims from medical liability insurance companies [65]. Of 1,541 total cases, 178 (12%) involved one or more peripheral nerves. Ulnar (77, 34%) and brachial plexus (53, 23%) injuries were the most common. Eighteen percent of ulnar nerve injuries occurred despite specific documentation supporting adequate intraoperative elbow padding. Of interest, 63% of all nerve

Conclusion

Intraoperative positioning nerve injuries are thankfully rare and generally preventable; however, they continue to occur. All physicians with responsibility in the operating room must be aware of them and must actively prevent them. A good preoperative history, preoperative examination targeting the presence of preexisting nerve injury or predisposition to injury, and a preoperative check of the tolerance of approximate intraoperative positioning are all vital components of an effective

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