CONTINUING EDUCATION Preventing Perioperative Peripheral Nerve Injuries SHARON BOUYER-FERULLO, MHA, RN, CNOR 2.1 www.aorn.org/CE Continuing Education Contact Hours indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the ex- amination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #13503 Session: #0001 Fee: Members $12.60, Nonmembers $25.20 The contact hours for this article expire January 31, 2016. Purpose/Goal To provide perioperative nurses with the required knowledge to implement strategies to help prevent peripheral nerve injuries (PNIs) in perioperative patients. Objectives 1. Describe how PNIs occur. 2. Discuss risk factors associated with PNI. 3. Identify the nerves most at risk for PNI. 4. Describe common types of intraoperative nerve conduc- tion monitoring. 5. Discuss what perioperative nurses can do to reduce the patient’s risk for PNI. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. Conflict of Interest Disclosures Ms Bouyer-Ferullo has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Peri- operative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2012.10.013 110 j AORN Journal January 2013 Vol 97 No 1 Ó AORN, Inc, 2013
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CONTINUING EDUCATION
Preventing PerioperativePeripheral Nerve Injuries
SHARON BOUYER-FERULLO, MHA, RN, CNOR 2.1
www.aorn.org/CE
Continuing Education Contact Hoursindicates that continuing education contact hours are
available for this activity. Earn the contact hours by reading
this article, reviewing the purpose/goal and objectives, and
completing the online Examination and Learner Evaluation at
http://www.aorn.org/CE. A score of 70% correct on the ex-
amination is required for credit. Participants receive feedback
on incorrect answers. Each applicant who successfully completes
this program can immediately print a certificate of completion.
Event: #13503
Session: #0001
Fee: Members $12.60, Nonmembers $25.20
The contact hours for this article expire January 31, 2016.
Purpose/GoalTo provide perioperative nurses with the required knowledge
to implement strategies to help prevent peripheral nerve
injuries (PNIs) in perioperative patients.
Objectives
1. Describe how PNIs occur.
2. Discuss risk factors associated with PNI.
3. Identify the nerves most at risk for PNI.
4. Describe common types of intraoperative nerve conduc-
tion monitoring.
5. Discuss what perioperative nurses can do to reduce the
patient’s risk for PNI.
AccreditationAORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
110 j AORN Journal � January 2013 Vol 97 No 1
ApprovalsThis program meets criteria for CNOR and CRNFA
recertification, as well as other continuing education
requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
for relicensure.
Conflict of Interest DisclosuresMs Bouyer-Ferullo has no declared affiliation that could be
perceived as posing a potential conflict of interest in the
publication of this article.
The behavioral objectives for this program were created
by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical
editor, and Susan Bakewell, MS, RN-BC, director, Peri-
operative Education. Ms Starbuck Pashley and Ms Bakewell
have no declared affiliations that could be perceived as
posing potential conflicts of interest in the publication of
this article.
Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this
article.
DisclaimerAORN recognizes these activities as continuing education for
registered nurses. This recognition does not imply that AORN
or the American Nurses Credentialing Center approves or
1. About peripheral neuropathy. The Neuropathy Association. http://www.neuropathy.org/site/PageServer?pagename¼About_Symptoms. AccessedAugust 10, 2012.2. Complications and nerve injuries. University of Pittsburgh. http://www.pitt.edu/wposition/complications.htm. Accessed August 10, 2012.3. Peripheral neuropathy fact sheet. National Institute of Neurological Disorders and Stroke (NINDS). http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm Accessed August 10, 2012.
PERIPHERAL NERVE INJURIES www.aornjournal.org
human body into “unphysiological” positions. This
may have been the first article to identify the use
of self-retaining retractors as a probable cause of
nerve injuries.27
According to the literature, some nerves are
more at risk for incurring PNI than others, and
some positions are more inclined to cause nerve
injuries.3,4,11,28,29 Research indicates that the primary
TABLE 2. (continued) Nursing Care Plan for a Patient at Risk for Peripheral Nerve Injury
Diagnosis Nursing interventionsInterim outcome
statementOutcomestatement
n Identifies the patient’s and designatedsupport person’s educational needs.
n Determines knowledge level.n Assesses readiness to learn.n Elicits perceptions of surgery.n Assesses coping mechanisms.n Includes the patient or designated support
person in perioperative teaching.n Explains the expected sequence of events
byn providing preoperative instruction based
on age and identified needs;n reviewing preoperative instructions as
SUPPLEMENTARY TABLE 1. Review of References Related to Peripheral Nerve Injury in the OR
AuthorsArticle typeor subject Summary
Adedeji et al (2010)22 Peer-reviewed article Evidence supports that proper patient positioning in the ORcan prevent postoperative complications and reduce therisk of long-term injury or pain. Reviews nerve compressionand how it can be avoided by identifying risk factors (eg,procedure duration, comorbidities) and proper positioning.
Agostini et al (2010)7 Expert opinion and review ofASA claims database
Describes injury types from surgery that include nerve injuryfrom stretching or compression. Identifies several mecha-nisms of nerve injury, including diabetes and low bodyweight. Diagrams demonstrate correct and incorrect waysto position a patient. Essential points include minimizingtime spent in the lithotomy position. Recommends pro-tective steps for the brachial plexus, ulnar, and peronealnerves.
Akhavan et al (2010)39 Literature review Cites the ASA Closed Claims Project with 143 urologic claimsreviewed, resulting in a payment in 2007 of 4 claims rangingfrom $1,350 to $1,800,000. Ulnar nerve injury is the mostcommon neuropathy with the supine position, and peronealnerve compression is a risk of the lithotomy position.Reviews the lateral decubitus and prone positions. Providesrecommendations for minimizing nerve injuries.
AORN, Inc (2010)14 Perioperativecompetencies, positiondescriptions, andevaluation tools forinpatient and ambulatorysettings
Provides competency statements for perioperative nursingpractice and evaluation tools to help provide quality andsafe care to surgical patients.
AORN, Inc (2012)13 Recommended practices Recommendations based on evidence-based best practices.Risks identified and positioning recommendations to pre-vent injury. Recommendations involve the perioperativecourse of the patient preoperatively, intraoperatively, andpostoperatively.
ASA Closed Claims Projectand its Registries44
Web site Began in 1985; the project consists of more than 7,000closed claims throughout the United States. Created toidentify perioperative safety concerns in anesthesia anddevelop recommendations for injury prevention.
ASA Task Force onPrevention of PerioperativePeripheral Neuropathies(2000)40
Practice advisory/clinicalexperts
Practice advisory review for anesthesiologists on preventingperioperative peripheral neuropathies.
ASA Task Force onPrevention of PerioperativePeripheral Neuropathies(2011)62
Practice advisory/clinicalexperts (updated reportfrom 2000)
Education for anesthesiologists on perioperative peripheralneuropathies, signs and symptoms, and prevention. Riskfactors with a detailed pre-assessment (ie, body habitus,preexisting neuropathy, diabetes, peripheral vasculardisease, alcohol dependence, arthritis, gender) are impor-tant for the anesthesiologist.
Barner et al (2002)15 Literature review Peripheral nerve injury (PNI) is the result of intraoperativeevents and accounts for 16% of anesthesia claims in the
SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
United States (ulnar neuropathy 28%, brachial plexus 20%,lumbosacral 16% of all claims). Risks include alcoholism,diabetes, or an inherited neuropathy. Improper positioningwas the highest reported reason for injury to the extremity.
Barner et al (2003)33 Literature review Reviews PNIs in upper extremities. Risk factors include dia-betes, alcoholism, and hereditary palsies. Men experienceulnar neuropathy more than women but it is unclear whythis happens, perhaps anatomical differences and lesssubcutaneous fat. Signs and symptoms of PNI can appearseveral days after surgery. Offers stretching from a retractoras an etiology for brachial plexus injury.
Beckett (2010)8 Literature review PNI is a significant issue, and attention to correct patient posi-tioning is important to avoid this type of adverse outcome.Patients at greater risk have a body mass index of > 38, areolder than50 years, andhavepreexisting conditions includingarthritis and diabetes. Some types of surgery and positioningdevices place patients at more risk for injury. Reviews legalimplications from nerve injury claims and suggests includingthe chance of PNI as a risk on the consent form.
Beissel (2011)19 Web site Program to provide nurses with information on patients whoare positioned after receiving sedation or anesthesia toprevent lower extremity nerve injuries. Identifies preexistingpatient conditions and intraoperative risk factors thatincrease the risk of a lower extremity nerve injury.
Bradshaw and Advincula(2010)29
Case studies Review of 9 cases. Discusses possible etiology and preventivesteps to avoid positioning PNIs.
Britt and Gordon (1964)27 Literature review Nerve palsies from improper patient positioning were firstrecognized in 1894. Reviews nerve anatomy, signs andsymptoms, causes of injury to peripheral nerves, treatment,and prognosis.
Brown et al (2008)57 Literature review Review of peripheral nerve anatomy (sciatic, femoral, superiorgluteal) and injury incidence, etiology, prognosis, andtreatments, primarily for total hip arthroplasty. Incidencerate is likely to be higher than reported because of unrec-ognized signs and nonstandardized recording of hospitalcomplications.
Brown and Brown (2011)47 Information/clinical The integration of a nerve monitor technician has proven to beeffective in reducing nerve injuries in high-risk patients andprocedures. Describes types of nerve monitoring.
Cardosi et al (2002)26 Retrospective study Study of 1,210 women who experienced neuropathy aftermajor pelvic surgery between July 1995 and June 2001.Postoperative incidence of nerve injury was 1.9%. Causesincluded overstretching, incision, or retractor position.Physical therapy played a major role in recovery, but somepatients required additional surgery. Complete resolution ofnerve injury for the majority resolved within 10 months.
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SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
Chung et al (2009)31 Prospective study Postoperative upper extremity nerve injury in lumbosacralsurgery may be the result of stretching or compressing thebrachial plexus or ulnar nerve while the patient is in theprone position. Nerve monitoring was conducted usingSSEP in 230 elective posterior lumbosacral spinal proce-dures, and a level of alert was established with the surgeonto notify him or her when changes were occurring duringthe procedure. Demonstrated that nerve monitoring mayhelp in preventing PNI caused by positioning.
Cooper (2011)12 Expert opinion Proper pre-assessment is important to determine whetherpatients are vulnerable to nerve or pressure ulcer injury.Factors to consider include length of the procedure (> 3hours for pressure ulcer formation), age, weight, skincondition, smoking, and comorbid diseases (eg, vascular,diabetes). Proper positioning, devices, and aids are neededto avoid nerve injuries. Documentation is important to avoidmedical lawsuits.
Dillavou et al (1997)4 Review of surgical morbidityand mortality reports from1986 to 1995
Iatrogenic nerve injury from malpositioning and externalcompression is a common adverse outcome from sur-gery. Case details include gender, age of patients, pre-assessment, mean operating time, and follow-up. 7 casesof sciatic or femoral nerve injury (2 sciatic and 5 femoralneuropathies [0.17% abdominal cases]) were confirmedusing electrodiagnostic testing. Recommends using shorterblades on retractors during deep pelvic retraction andcareful padding of the OR bed, especially for longer surgicalprocedures.
Ellsworth et al (2009)9 Review of The JointCommission protocol toprevent perioperativecomplications
Review of patient positioning, patient safety in the OR, ocularprotection, and special attention for those at higher risk (eg,elderly patients, patients with body mass extremes). Au-thors view PNI as a preventable complication and reviewthe most common nerve injuries (brachial plexus, ulnar andradial nerves) from plastic surgical procedures.
Fox et al (2005)5 Retrospective chart review Chart review of 95 children or adolescents who underwent theNuss procedure. The risk of a patient experiencinga brachial plexus injury decreased with use of an arthros-copy sling suspended from a right angle. Brachial plexus isthe second most common postoperative nerve injury. Riskfactors include improper positioning, body mass extremes,and anatomical anomalies. Older patients were moresusceptible to PNI (mean age with PNI 18.3 years).
Fritzien et al (2003)38 Review of closed medicalliability claims on nerveinjuries
Results from 44 closed claims of anesthesia-related nerveinjuries analyzed showed the most common nerve injurieswere ulnar (16%), radial (11%), peroneal (9%), paraplegia(9%), lumbosacral (7%), and a variety of others (18%).Information lacking from anesthesia documentation were
SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
patient positioning and the use of additional padding. 10%of the brachial plexus injuries were related to patientposition.
Grocott et al (2004)59 Literature review PNIs may be underreported and more attention must be paidto help reduce postoperative complications. Brachial plexusand other PNIs are most likely caused by retractors andarm positioning. Patient risk factors include advanced age.Preventions include the surgical technique used.
Hickey et al (1993)51 Experimental study SSEP recordings were used for 30 patients undergoing electivecoronary artery bypass surgery with 2 different types ofsternal retractors. SSEP monitoring was effective asa predictive tool for a nerve injury. Nerve injury occurredprimarily from use of retractors to stretch the chest cavity forthe procedure. Recommends using nerve monitoring for alltypesof surgery that have thepotential to causenerve injuries.
Hilibrand et al (2004)53 Retrospective chart review Review of 427 patients undergoing anterior or posteriorcervical spine surgery between January 1999 and March2001 to determine which nerve monitoring was sensitive tochanges in potentials during surgery. The patients wereconnected to both Tce motor monitoring and SSEP moni-toring. Transcranial electric motor evoked potentials ortceMEP was 100% sensitive and specific; SSEP was only25% sensitive but 100% specific. Strongly recommendsusing Tce for these types of surgeries.
Horlocker (2011)43 Literature review Discusses several studies evaluating nerve injury from severalmechanisms. Provides recommendations for limiting PNI.Details types of regional anesthesia and how they cancause postoperative complications.
Husain et al (2011)48 Clinical expert Reviews the history of intraoperative neurophysiologic moni-toring techniques. Introduces this topic as a new subspecialtyof neurology and offers recommendations for education andpractice opportunities to minimize risk of nerve injuries.
Jellish et al (1997)60 Randomized controlledstudy
Study of 80 patients undergoing coronary artery bypass graft.The study investigated whether arm positioning duringsurgery would affect postoperative pain and brachial plexusinjury, 50% were randomly selected to have their armsadducted and placed at their sides, and the other 50% hadelbows and hands in the palm upright position. Assessmentincluded perioperative neurologic evaluation, sternalretraction technique, and 3 of 7 patients with arms at theirsides who reported symptoms experienced an ulnar nerveinjury, which indicated this position may increase the risk ofa PNI. The hands-up position reduced the risk of ulnarnerve compression. Position did not affect postoperativebrachial plexus injury.
Jones et al (2004)50 Case reviews Expanded the use of SSEP (upper and lower extremities) todetermine peripheral ischemia and nerve compression
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SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
during orthopedic and spine surgeries. SSEP was effectivein avoiding potential nerve injury.
Kamel et al (2006)21 Retrospective analysis Reported percentage of position-related upper extremitySSEP changes among 5 different positions in 1,000consecutive spinal surgeries from 1995 to 2001. Identifiedthat the lateral decubitus and prone positions had morefrequent incidence of all position-related upper extremitySSEP changes. These are high-risk positions and the use ofSSEP monitoring was valuable in avoiding PNI during spinalsurgery.
Kaur et al (2009)42 Case study Intraoperative positioning nerve injuries are preventable andbrachial plexus injuries are common. Recommends properpre-assessment of patient conditions, padding, properequipment, and documentation on positioning. Earlydetection is necessary for better patient outcomes.
K€om€urc€u et al (2005)32 Report Study was performed to determine the cause of iatrogeniclesions of the peripheral nerves in 82 patients who under-went reconstructive treatment in one facility from 1990 to2000. Nerve conduction studies were useful for diagnosingnerve lesions and treatment. The patient outcomes wereimproved when the degree of nerve damage was deter-mined early (within 2 to 4 months) using an interdisciplinaryapproach.
Kretschmer et al (2008)11 Retrospective review Cardiac surgery presents a risk for brachial plexus injurybecause of stretching from sternotomy and hypothermia. Areview showed that 210 iatrogenic nerve injuries at oneinstitution from January 1990 to January 2008 were median(16%), peroneal (11%), femoral (4%), and ulnar (4%).Recommends prompt diagnosis and referral for betteroutcomes along with proper documentation to avoidlitigation.
Lad et al (2010)56 Retrospective study Used the Nationwide Inpatient Sample for discharges withICD-9 codes of brachial plexus, ulnar, and radial injuries.PNI discharges decreased from 1993 and 2006, but thehospital cost for treatment increased significantly, frombetween $10,000 to $15,000 per case and $20,000 to$30,000 per case. PNI patients in 2006 were primarily men.
Lalkhen and Bhatia (2012)54 Literature/information/clinical Reviews mechanisms and risk factors for PNI for anesthesi-ologists. Recommends increasing knowledge of anatomicalpositions of nerves. Reviews incidence rates of peripheralnerve injuries, mechanism, and clinical presentation.Asserts that there are confounding factors and they may beunderreported.
Lopes and Galv~ao (2010)36 Literature review Review focused on risk factors for developing complications,complications from surgical positioning, and nursing carerelated to patient positioning. The authors separated each
SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
research article and analyzed for quality, research design,and evidence levels. Used publications from various coun-tries of origin with tables of synthesis of research articlesand research design. Preoperative assessment to deter-mine risk factors is important for planning care. The mainrisk factors were general anesthesia, age (very old or veryyoung), obesity, immobility, or mobilization problems.
Lorenzini and Poterack(1996)52
Experimental study This study was to determine SSEP changes in median andulnar nerves in 14 awake patient volunteers with the meanage of 34 � 3 years. Signs and symptoms of nerve injurycorrelated with SSEP data when patients were placed indifferent positions. 3 patients with no SSEP changesexperienced nerve injury symptoms. SSEP alone may beimperfect in monitoring detection of impending nerve injury.
Meeks and Gray (2011)3 Literature review Most common nerve injuries associated with pelvic surgeryinvolve the femoral, ilioinguinal, genitofemoral, lateral femoralcutaneous, obturator, pudendal, and iliohypogastric nerves.The incidence of PNI is approximately 2% and causes rangefrom the position of the patient, to retractor blades, to incisionand placement of trocars. Stretching or compression of thenerves results in sensory and/or motor symptoms. Femoralneuropathy may occur in as many as 10% of patients whoundergo a laparotomy. Recommends prevention of nerveinjury with proper patient positioning, minimal hip rotation,padding, and attention to stirrup type devices.
Metzner et al (2011)45 Review of ASA closed claimsanalysis
8,954 claims with 5,230 claims between 1990 and 2007.Most common complications include nerve injury (22%).Reviews adverse events and injuries associated withanesthesia procedures from all types of surgeries and offerspractice points and major sources of injury claims.
Nash et al (1977)49 Case studies Preoperative and postoperative physical assessment isimportant to patient outcomes. Intraoperative SSEP nervemonitoring is effective in improving spine and spinal cordsurgery.
National Institute ofNeurological Disorders andStroke (2011)18
Web site Defines peripheral neuropathy, causes, signs and symptoms,diagnosis, and treatment available.
Navarro-Vincente et al (2012)1 Prospective study Reports the incidence of intraoperative PNI after colorectalsurgery in a large prospective series of 2,304 patientsbetween 1996 and 2009. 8 patients (0.3%) experienced anintraoperative PNI. Recommends Allen type stirrups andvacuum bag as protective devices to prevent PNI.
The Neuropathy Association(2012)16
Web site Provides peripheral neuropathy facts, causes, and treatmentrecommendations.
Pereles et al (1996)58 Prospective study Reported incidence of postoperative neuropathies from 0.6%to 2.9% in primary total hip arthroplasties and 1.8% to 7.6%in revision cases. These cases primarily involve the sciatic
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SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
nerve or in combination with the obturator or femoral nerve.Evaluation of 52 arthroplasties using nerve monitoring(SSEP). Although the incidence of sciatic nerve injury is low,the use of SSEP is a safe and effective way to assess sciaticnerve compression.
Pillai et al (2007)30 Clinical case review Reviews case of iatrogenic brachial plexus injury caused byimproper positioning of a patient undergoing posteriorlumbar spine fixation. Ulnar nerve injuries are the mostcommon, followed by brachial plexus, common peroneal,and sciatic nerve injuries. Recommends proper positioningand limiting flexion of extremities.
Porter et al (1999)34 Review article Reviews the risks and safety concerns of using the sittingposition in neurosurgical patients compared with the proneor park bench positions. PNIs have been reported fromprevious studies using this position and the most commonwas peroneal nerve injury. Supplemental monitoring(Doppler ultrasonography) is necessary to detect intracar-diac air. The sitting position offers challenges to anesthesiaprofessionals. Patient selection for this type of position isvery important.
Prielipp and Warner (2009)41 Article review A review of Welch’s 2009 article of 380,680 cases duringa 10-year period and others that refer to PNI. Agrees thatthe 0.03% is an underestimate. Ulnar nerve injuries weremost commonly reported and more appear after 14 days ofhospitalization. Patients with underlying conditions (eg,diabetic polyneuropathy) and hypertrophic neuropathies areat a higher risk for compression injury.
Rains et al (2011)35 Systematic review of theliterature
Review of position-related nerve injuries from shoulderarthroscopy. Overall incidence rate of 10% for paraesthe-sias and true nerve palsies in the lateral decubitus position.SSEP results showed a 100% incidence of abnormality inreadings.
Saidha et al (2010)61 Retrospective review Review of 66 patients diagnosed with postoperative neurop-athy between January 2005 and June 2008 in a tertiaryreferral hospital in Ireland. 30 patients (45.4%) experiencedneuropathies remote from the surgical site and 36 patients(54.5%) experienced neuropathies in close proximity of thesurgical site. Hip arthroplasty resulted in the majority ofremote neuropathies. Increased procedure time contrib-uted to the development of neuropathy. The number ofpostprocedural neuropathies is likely to be underreportedbecause of the belief that they are short lived and do notrequire an intervention. The causes for neuropathies appearto be multifactorial.
Schwartz et al (2006)23 Retrospective review Study reviewed 3,806 patients who underwent anteriorcervical spinal surgery between 1999 and 2003 using
SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
multimodality nerve monitoring (transcranial electric MEP,SSEP, spontaneous electromyography). Nerve monitoringshowed 1.8% had an impending nerve injury related topatient positioning. Identifies factors that increase risk(obesity, diabetes mellitus). Recommends use of multi-modality monitoring.
St-Arnaud and Paquin (2009)6 Review of principles ofpositioning forneurosurgery
Reviews proper pre-assessment of neurosurgery patients andrecommendations for prevention of burns, hypotension,pressure ulcers, maintaining normothermia, and positioningactivities. Several positions are reviewed in detail for properbody alignment and positioning aids. Refers to specificnerve areas that are vulnerable to injury from compression(eg, the lateral femoral nerve from the gel overlays).
Sutter et al (2012)46 Prospective study Data from 2001 to 2010 on 7,894 patients who had complexhip surgery. Major hip surgery has an uncommon butserious complication with sciatic and femoral nerve injuries.The incidence of these peripheral nerve injuries has beenreported to be between 0.28% and 3%, but can rise to7.6% with revision and complex total hip revisions. 69patients were chosen to have multimodal nerve monitoringto provide early warnings of an impending nerve injury. Thisconsisted of SSEP and MEP electromyography. Multimodalmonitoring proved to be an effective tool in the preventionof postoperative nerve injury and informing the surgicalteam when a potential nerve injury was occurring.
Tager (2009)37 Interview with clinical expert Discusses the lawsuits filed for hospital-acquired injuries andemphasizes proper positioning based on principles thataffect outcomes. Each hour the patient is in the lithotomyposition, there is a 100-fold increase in risk of neuropathy.Two risk factors identified were the age and length of timeon the OR bed.
Topp and Boyd (2006)25 Review of peripheral nervesand the Physical StressTheory by Mueller andMaluf (2002)
Review of biomechanical modifications in peripheral nerves.Describes mechanisms of injury and treatment rationale forthe physical therapist.
University of Pittsburgh(2006)17
Web site Describes complications from nerve injuries and providesinformation on causes, prevention, symptoms, andtreatments.
Uribe et al (2010)10 Literature review Brachial plexus injuries are a common complication fromspinal surgery. Literature review from 1950 to 2009 reportscases involving brachial plexus injury related to the proneposition. Authors review SSEP and MEP nerve monitoringand report both methods are helpful in detecting and pre-venting nerve injuries.
Warner et al (1994)24 Nonrandomizedcomparative study
991 adult patients who underwent surgery in the lithotomyposition from June 1997 to August 1998 were followedbefore, during, and up to one week after the surgical
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SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR
AuthorsArticle typeor subject Summary
procedure. A baseline questionnaire and potential riskfactors were collected on interview. Lower extremityneuropathy occurred in 15 patients and a significance valuewas assigned to a surgery longer than 2 hours in thelithotomy position. There are multiple causes for PNI(eg, stretching the foot while it is in the stirrups). All post-surgical neuropathies were found several hours after stop-ping of anesthesia gases. The majority of peripheral nerveinjuries resolved within 4 months.
Warner et al (1999)55 Prospective study Review of ulnar neuropathy in 1,502 adult non-cardiac surgerypatients. Ulnar neuropathy developed in 7 patients (0.5%),6 of whom were men. Symptoms of ulnar neuropathybegan 2 to 7 days after surgery. Symptoms resolved in 4patients within 6 weeks, but 3 patients had symptoms 2years later. Suggests men are more susceptible to ulnarnerve injury because of anatomical differences.
Welch et al (2009)28 Retrospective study Study of 380,680 cases from May 1997 to May 2007.Provides a definition for perioperative PNI that limits theidentification to within 48 hours of a new sensory or motordeficit from any patient who was anesthetized or sedated.112 patients (0.03%) were identified using this PNI defini-tion. Risk factors were hypertension, diabetes mellitus, andtobacco use. Significance of association between PNI andsurgical specialties was found with neurosurgery, cardiacsurgery, general, and orthopedic surgery.
Winfree and Kline (2005)2 Literature review Reviews several studies and cases on PNI, possible causes,and treatment. Reviews nerve monitoring and its limitationsand discusses the medicolegal implications using the ASAclaims database. Recommends a thorough preoperativeassessment for risk factors and prompt diagnosis of PNI.Although most PNIs resolve on their own, immediatetreatment is recommended.
Zhang et al (2010)20 Systematic review Iatrogenic upper limb nerve injuries are common and canaffect patients in any surgical specialty. Orthopedic andplastic surgical procedures have a higher number in thesepostoperative complications. Provides several tables withthe context and frequency of various upper limb nerveinjuries. Some may be avoidable, but most are preventableby increasing the awareness of vulnerable peripheralnerves.
ASA ¼ American Society of Anesthesiologists; MEP ¼ motor evoked potentials; PNI ¼ peripheral nerve injury; SSEP ¼ somatosensory evoked potentials;tce ¼ transcranial electric; tceMEP ¼ transcranial electrip motor evoked potentials.