preventing perioperative peripheral nerve injuries

CONTINUING EDUCATION

Preventing PerioperativePeripheral Nerve Injuries
SHARON BOUYER-FERULLO, MHA, RN, CNOR 2.1
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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

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recertification, as well as other continuing education

requirements.

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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

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http://dx.doi.org/10.1016/j.aorn.2012.10.013

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P

Preventing Perio
perativePeripheral Nerve InjuriesSHARON BOUYER-FERULLO, MHA, RN, CNOR 2.1
www.aorn.org/CE

ABSTRACT

Peripheral nerve injuries are largely preventable injuries that can result from

incorrect patient positioning during surgery. Patients who are diabetic, are extremely

thin or obese, use tobacco, or undergo surgery lasting more than four hours are at

increased risk for developing these injuries. When peripheral nerve injuries occur,

patients may experience numbness, burning, or tingling and may have difficulty

getting out of bed, walking, gripping objects, or raising their arms. These symptoms

can interrupt activities of daily living and impede recovery. Signs and symptoms

of peripheral nerve injury may appear within 24 to 48 hours of surgery or may

take as long as a week to appear. Careful attention to body alignment and proper

padding of bony prominences when positioning patients for surgery is necessary to

prevent peripheral nerve injury. The use of a preoperative assessment tool to identify

at-risk patients, collaboration between physical therapy and OR staff members

regarding patient positioning, and neurophysiological monitoring can help prevent

peripheral nerve injuries. AORN J 97 (January 2013) 111-121. � AORN, Inc, 2013.


Key words: peripheral nerve injury (PNI), nerve injury prevention, surgical posi-

tioning, positioning injury risk factors, somatosensory evoked potential (SSEP)

monitoring, motor evoked potentials (MEP).

eripheral neuropathies or peripheral nerve

injuries (PNIs) are an uncommon compli-

cation of surgery, with estimates ranging

from 0.02% to 21%.1 They occur intraoperatively

and could extend a patient’s hospital stay by as

much as 24 hours after the scheduled discharge

time (Roya Ghazinouri, PT, DPT, MS, clinical

supervisor of rehabilitation services, Brigham and

Women’s Hospital, Boston, MA; oral communi-

cation; February 10, 2012). Peripheral nerve in-

juries are commonly attributed to improper patient

positioning and lengthy surgeries2; however, some

may be related to a patient’s health (eg, diabetes),


� AORN, Inc, 2013

lifestyle choices (eg, smoking), or other risk factors

(eg, body weight extremes).2-12 These injuries also

may be caused by the equipment staff members

use to position patients in the OR (eg, stirrups, leg

holders, the OR bed, positioning posts).

Properly positioning a patient for surgery is the

responsibility of the entire surgical team. The cor-

rect patient positioning equipment and knowledge

of anatomy, physiology, and body mechanics are

crucial to help ensure safe positioning. Positioning

is based on the surgeon’s preference for optimal

surgical site exposure and the ability to maintain

the patient’s airway and other vital functions.12 A

January 2013 Vol 97 No 1 � AORN Journal j 111



January 2013 Vol 97 No 1 BOUYER-FERULLO

patient’s position also should allow access to in-

travenous lines and monitoring devices while the

patient’s body alignment; circulatory, respiratory,

musculoskeletal, and neurologic structure align-

ment; and optimal physiological functioning are

maintained.2,12-14

I performed a reviewofmedical, nursing, physical

therapy, and anesthesia literature on the subject of

PNIs to ensure thatmy facility’s positioningmanuals

and policies for safe patient positioning were up to

date with the current evidence-based information

and guidelines. I searched for articles using

MEDLINE�, EBSCO�, PubMed�, CINAHL�,

PEGASUSTM, and GoogleTM search engines

(view the Supplementary Table of resources

reviewed at http://www.aornjournal.org).

DEFINITION AND SYMPTOMS

A PNI occurs when there is an obstruction of in-

traneural blood vessels.13 Nerve injury can be

caused by a variety of mechanisms: stretching,

compression, or ischemia of the nerve; a surgical

incision; or a metabolic condition that affects

nerves (eg, diabetes).15 Obstruction of intraneural

blood vessels affects the sensory or motor pathways

of the nerve and results in a combination of signs

and symptoms, such as numbness, tingling, pain,

or difficulty walking or grasping objects.16-18

Stretching or compression of a peripheral nerve

can occur during patient positioning. Nerves can be

damaged when they are stretched by as little as 10%

to 15%.19-21 A PNI can occur within 15 to 30

minutes of the start of a surgical procedure.22

Sensory nerve changes may occur within 15 min-

utes of compression, ischemia, or stretching, while

motor nerve injury may occur as early as one min-

ute into a surgical procedure.22

Signs and symptoms of PNI vary depending

on the area where the injury has occurred. For

example, injury to the radial peripheral nerve can

result in a patient’s inability to grasp or reach for

items.16-18 Other nerve injuries may cause impaired

motor function, loss of tendon reflexes, or sensory

loss.16-18,23 Some sensory nerve injury symptoms

112 j AORN Journal

manifest as tingling, numbness, or a pinching feeling

in the patient’s upper extremities.16-18,24 A motor

nerve injury in the upper extremity may prevent

a patient from turning a doorknob; buttoning a shirt;

opening a jar; or performing other simple daily

activities, such as holding objects.16 Motor nerve

injuries in the lower extremities may result in a

patient having difficulty climbing stairs or walking

and may result in the patient tripping over his or her

own feet, which increases the risk of falling. A brief

summary of the six most common areas of PNI and

their signs and symptoms is presented in Table 1.

The severity of nerve compression injuries var-

ies depending on how the force was applied, the

amount of force, and the length of time force was

applied.4,25 Recovering from PNI can take a few

days to as long as a year, depending on the severity

of the injury.2,11,24,26 Sometimes a PNI does not

resolve, and the patient’s quality of life is perma-

nently impaired. Physical therapy treatments are

frequently prescribed for patients who experience

PNI; these include

n the use of a brace;

n passive range-of-motion exercises;

n active, assisted range-of-motion exercises;

n muscle strengthening exercises;

n nerve stimulation;

n stretching; and

n fine motor skills training.24

CAUSES AND RISK FACTORS

The identification of general nerve injuries dates

back to 1894, when Budinger discovered that these

types of injury occur because of improper posi-

tioning of patients on the OR bed.27 Stretching

injuries to the nerves of patients under anesthesia

were documented by Clausen in 1942 and by

Ewing in 1952.27 Many causes of PNI that were

documented in anesthesia journals more than a

century ago are still noted as causes today. Britt

and Gordon,27 for example, noted that one histor-

ical article states that general anesthesia and

muscle relaxants given to patients can contort the

http://www.aornjournal.org

TABLE 1. Signs and Symptoms of a Peripheral Nerve Injury1-3

Nerves affected

Axillary PeronealBrachialplexus Ulnar Radial Femoral

Function

affected

Motor andsensory

Motor andsensory

Motor andsensory

Motor andsensory

Motor andsensory

Motor andsensory

Area affected Outershoulder

Dorsum ofthe foot

Arm, shoulder 4th and 5thfinger, palmside of thehand

Back of thehand, fore-arm, 2nd and3rd fingersclosest to thethumb

Thigh, knee, orleg

Extremity

weakness

Yes Yes Yes Yes Yes Yes

Location and

motor

symptoms

Arm abduction,to a lesserextentflexion andextension ofthe arm

Foot drop Lack of armmusclecontrol, limpor paralyzedarm

Weakness inhand flexion

Difficultystraighteningthe elbow orfingers, weakthumbabduction,wrist or fingerdrop

Feeling of kneegiving out,bucklingknees

Activities of

daily living

affected

Difficultylifting arm orobjects overhead

Walkingaffected bydragging footor slapping ofthe foot onthe floor

Difficulty movingshoulder,arm, hand, orfingers

Difficulty movingor loss ofcoordinationof fingers forgraspingitems

Difficultygrasping,holdinghands,reaching foritems witharm

Difficulty goingup and downstairs

Sensory

symptoms

Numbness,pain

Numbness,tingling,burning

Lack of sensa-tion in arm,numbness

Pain, numb-ness, tingling,burning

Tingling,burning,numbness,decrease insensation

Decrease insensation,numbness,tingling,burning

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

AORN Journal j 113

http://www.neuropathy.org/site/PageServer%3fpagename%3dAbout_Symptoms


http://www.pitt.edu/%7Eposition/complications.htm


http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm




nerves at risk for injury are the peroneal and ulnar

nerves and the brachial plexus.10,19,20,23,30,31

Surgical positions generally more likely to con-

tribute to PNI are the lithotomy position, which

places the peroneal and femoral nerves at risk for

compression and stretching, and the supine posi-

tion, which contributes to brachial plexus and

ulnar nerve injuries.15,29,32,33 Other positions that

can contribute to PNI are the lateral, prone, park

bench, and Fowler positions.34,35

Peripheral nerve injuries can be attributed to

more than improper patient positioning, however.

Welch et al28 performed a large retrospective

study of 380,680 cases documented between 1997

and 2007 at a tertiary hospital and used these data

to identify patients who had experienced PNI

during hospitalization. The researchers gathered

data from three separate sourcesdquality assur-

ance reports, closed claims, and billing code data-

bases that identified PNIdas well as from all

patients who underwent anesthesia management.28

They were able to identify associations between

the occurrence of PNI and hypertension, type of

anesthesia delivery, and surgical specialty. Welch

et al suggested that hypertension predisposes

patients to PNI by causing a decrease in blood

flow, which is also evident in many chronic dis-

eases, and this reduced blood flow may cause

nerves to become more susceptible to injury.28 This

was the first study to show that specific surgical

services had high incidences of nerve injury (ie,

neurological [8.9%], cardiac [7.1%], general [18%],

and orthopedic [21%] surgeries).28

Researchers have linked patients’ internal risk

factors, such as peripheral vascular disease, dis-

turbances in blood circulation, and tobacco use, to

PNI. The majority of medical experts concur that

patients with diabetes, both controlled and uncon-

trolled; those with body mass index extremes; and

those older than 60 years are at high risk for PNI

development.4,11,36-42

Several studies reveal a strong correlation

between PNI incidence rates and the length of

114 j AORN Journal

surgery.7,11,13,28,37-39 External factors that may

heighten a patient’s risk, especially if he or she

is scheduled for surgery that is expected to last

longer than four hours, include hypothermia; use

of retractors; surgical technique (eg, incorrect in-

cision location); interruption of circulation27,28,43;

type of incision; and, to a lesser extent, types of

medications.

ANESTHESIA AND PNI

General anesthesia removes the patient’s phy-

siological protective responses to pain (eg, reposi-

tioning oneself to relieve discomfort), and without

this response, a patient is predisposed to nerve

and muscle injuries.36 Lawsuits against anesthesia

professionals, anesthesiologists in particular, have

become a source of data germane to PNI. The

number of medical claims against anesthesiologists

can be found at the American Society of Anesthe-

siologists (ASA) Closed Claims Project web site.44

This database was established in the early 1980s

because of the rising costs of professional liability

insurance premiums. The project, which is ongoing,

investigates malpractice claims against anesthesi-

ologists who are accused of anesthesia-related

complications and patient injuries. Metzner et al45

reported that the ASA Closed Claims Project data-

base contained 8,954 claims from 1970 to 2007,

with 5,230 claims added after 1990. The project

does not provide specific details on the cases, but it

is a valuable source of percentage data for a variety

of nerve injuries.

As a result of these claims, the ASA has written

a report on preventing perioperative peripheral

neuropathy in surgical patients.40 The report was

prepared by a task force consisting of experts in

the field of anesthesiology, and it is intended

to educate and evaluate current standards for

preventing peripheral neuropathies that may be

related to patient positioning in the OR.40 The

report concludes that the exact mechanisms of

injury are still unclear and that prevention strate-

gies are not apparent.40


NERVE CONDUCTION MONITORING

There are four common types of nerve conduction

monitoring used during surgery: free-run electro-

myography, somatosensory evokedpotential (SSEP),

motor evoked potential (MEP), and pedicle screw

monitoring.22,23,46-48 Somatosensory evoked poten-

tial monitoring has been performed for more than

30 years49 and is used to monitor the status of

nerve somatosensory pathways during any surgical

procedure that may affect the brain; nerve roots; and

the peripheral nerves, nerve plexuses, or the spinal

cord.31 Examples of procedures in which SSEP

monitoring is used are craniotomies and lumbosa-

cral and anterior cervical spine surgery near the spinal

nerve roots.

The SSEP technician places electrodes on the

patient before the surgery begins. Placement de-

pends on the nerve area of interest, and the tech-

nician can then monitor SSEP waves during the

procedure to detect changes in amplitude and la-

tency.31 The SSEP responses represent conduction

of nerve impulses; therefore, if there is a loss in

amplitude, the surgical team can assume that the

nerve is undergoing some form of compression

and/or stretching.31

The use of SSEP may decrease medical costs

for patients identified as being at high risk for

developing PNI.50 After a health care provider

identifies a patient with a PNI, he or she should

initiate a consult from the pain service (if available)

AORN Resources

n Perioperative Competencies, Position Descriptions, and Evalu-

ation Tools for Inpatient and Ambulatory Settings. Denver, CO:

AORN, Inc; 2010.

n Recommended practices for positioning the patient in the peri-

operative practice setting. In: Perioperative Standards and Rec-

ommended Practices. Denver, CO: AORN, Inc; 2012:421-443.

n Safe Patient Handling and Movement Tool Kit. AORN, Inc.

http://www.aorn.org/Clinical_Practice/ToolKits/Safe_Patient

_Handling_Movement_ToolKit/Safe_Patient_Handling_Tool

_Kit.aspx#axzz23XGsDkkG. Accessed August 14, 2012.

or physical therapy depart-

ment. The sooner an as-

sessment can be made,

the sooner treatment and

recovery can begin.

In 1993, a group of anes-

thesiologists published a study

that they initiated after several

cardiac patients experienced

brachial plexus injury after

median sternotomy proce-

dures.51 To address these

adverse patient outcomes,

the anesthesiologists used

intraoperative SSEP monitoring to determine

changes in nerve stimulation for 30 patients who

underwent cardiac surgery.51 The results of the

study revealed significant changes in SSEP when

the surgeons placed self-retaining retractors in the

patients’ sternums to help with dissection of the

internal mammary artery.51

Uribe et al10 agreed that SSEP is useful for de-

tecting a PNI, but SSEP monitoring alone may have

limitations based on findings of previous studies of

false negatives and false positives that occur with

SSEP.10,23,46,52 The researchers suggest using MEP

and electromyography for multimodal monitoring

in spinal surgery.10 This proposed combination

of monitoring techniques may help to reduce false-

positive results and has a greater sensitivity than

the use of SSEP alone.23,46,53 Motor evoked po-

tential monitoring detects electrophysiologic re-

sponses located in the motor portion of the brain.47

This type of nerve monitoring is useful for spinal

procedures and helps to indicate that a nerve injury

is occurring during the procedure when SSEP may

not be able to do so.23,46,47

DISCUSSION

The articles I reviewed did not establish or agree

upon when signs and symptoms of a PNI appear.

In addition, reported incidence rates, definitions,

identification criteria, and gender susceptibility

varied. Reported incidence rates, for instance,

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http://www.aorn.org/Clinical_Practice/ToolKits/Safe_Patient_Handling_Movement_ToolKit/Safe_Patient_Handling_Tool_Kit.aspx#axzz23XGsDkkG





varied depending on the type of surgery and

location of the PNI.

In addition, the definition of PNI varied depend-

ing on the study’s criteria. Reported incidences from

several studies varied in upper or lower extremities,

ranging from 0.02% to 21%.1,20,38,39,45 Studies

limited their recognition and definition of when a

PNI appeared in patients, from less than 24 hours13

to 48 hours28,54; however, established data from

previous prospective studies indicate that a number

of PNIs appear after 48 hours.28,33,55 These limita-

tions affect the findings because the percentage of

PNIs could be higher than previously estimated

or reported.

The identification of a PNI varies from institution

to institution. The data used to assess PNIs were

found in billing databases, malpractice claims, or

diagnosis codes. Several studies concluded that men

were more susceptible to PNI23,28,33,41,55,56; how-

ever, not all the literature support this conclusion.57

The results were often influenced by the number of

men and women involved in the studies. If there

were more men than women, then men were de-

termined to be at an increased risk, and if there

were more women, the researchers found that

women were more susceptible. Other studies indi-

cated there were no differences between genders,

and some did not include this conclusion in their

final data analysis.1,2,58-60

PERIOPERATIVE NURSINGRECOMMENDATIONS

Prevention of PNI is one of the issues perioperative

nurses must consider when positioning a patient

for surgery. In addition to clinical knowledge and

experience, perioperative nurses incorporate best

practices for positioning patients from guidelines

established by AORN and other professional orga-

nizations, research, and facility policies and

procedures. In 1990, AORN first published its

“Recommended practices for positioning the sur-

gical patient,” which has been regularly updated

to include the most recent positioning evidence and

recommendations.13 AORN also emphasized the

116 j AORN Journal

importance of proper positioning in its 2010 book

Perioperative Competencies, Position Descrip-

tions, and Evaluation Tools for Inpatient and

Ambulatory Settings,14 a collection of competency

statements to help perioperative nurses provide

safe, quality care to surgical patients and tools to

evaluate nursing practice and patient outcomes.14

For example, evaluation tools address a safe

environment of care, prevention of unplanned per-

ioperative hypothermia, medication safety, and

transfer of patient care information.14

Collaboration with the physical therapy depart-

ment to create a PNI prevention program can prove

to be an invaluable resource. Initiating a PNI

prevention continuing education program for

employees is also helpful. Members of my facili-

ty’s physical therapy department have visited

the OR to observe patient positioning. The peri-

operative quality manager and I asked them

to participate in positioning staff volunteers in

common surgical procedure positions. The phys-

ical therapists observed the most common surgical

positions for each service and contributed their

expertise to help prevent PNIs. Some of their

suggestions for the lateral position included

placing additional padding between the patient

and OR bed under the patient’s dependent knee

and placing positioning tape at the patient’s iliac

crest to secure the patient to the OR bed. We took

photographs during the positioning exercise and

made them available as a resource for current staff

members and new employees.

The creation of a preoperative assessment tool

that includes common internal and external risk

factors for developing PNI would help perioperative

nurses identify patients at high risk. A checklist

format would simplify identification of at-risk

patients. If the nurse checked off more than three

internal risk factors, the patient would be flagged as

at high risk for a PNI. Using the checklist to identify

the patent’s proposed surgical position and length

of surgery also would help to determine whether

the surgery or position was more or less likely to

contribute to PNI.

TABLE 2. Nursing Care Plan for a Patient at Risk for Peripheral Nerve Injury

Diagnosis Nursing interventionsInterim outcome

statementOutcomestatement

Risk for perioperativepositioning injury;impaired physicalmobility

n Assesses baseline skin conditions, includingn soliciting the patient’s perception of pain;n evaluating peripheral pulses;n identifying mobility impairments;n identifying comorbidities (eg, vascular

disease, diabetes) that predispose thepatient to increased risk of nerve injury;and

n interviewing the patient for a history ofskin disorders, previous radiation expo-sure, previous nerve injuries, and invasivedevice placement.

n Identifies baseline tissue perfusion.n Identifies baseline musculoskeletal status.n Assesses factors related to risks for ineffec-

tive tissue perfusion.n Identifies physical alterations that require

additional precautions for procedure-specificpositioning.

n Positions the patient.n Implements protective measures to prevent

skin/tissue injury caused by mechanicalsources.

n Applies safety devices to secure the patientin position and prevent pressure on bonyprominences.

n Evaluates tissue perfusion.n Evaluates for signs and symptoms of phys-

ical injury to skin and tissue byn comparing postoperative status with the

preoperative nursing assessment;n inspecting and evaluating the patient’s

skin, bony prominences, pressure sites,prepped areas, and adjacent tissue forsigns of injury;

n soliciting the patient for reports ofnumbness, tingling, burning, or overalldecrease in sensation;

n evaluating the patient’s circulation,sensation, and motion of extremities.

n Reports variances to appropriate teammembers.

n The patient’s pres-sure points demon-strate hyperemia forless than 30 minutes.

n The patient has fullreturn of movementof the extremities atthe time of dischargefrom the OR orprocedure room.

n The patient’s periph-eral tissue perfusionis consistent withpreoperative statusat discharge from theOR or procedureroom.

n The patient’s periph-eral pulses arepalpable bilaterallyand of good quality.

n The patient is freefrom pain or numb-ness associated withsurgical positioning.

n The patient is freefrom signs andsymptoms of injuryrelated to positioning.

n The patient’s tissueperfusion is consis-tent with or improvedfrom baseline levels.

Deficient knowledge n Assesses baseline neurological status.n Identifies sensory impairments.n Identifies barriers to communication.

n The patient verbal-izes the sequence ofevents to expect

n The patient or desig-nated supportperson demonstrates

(table continued)

AORN Journal j 117



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

indicated;n reviewing postoperative routines, proce-

dures, and equipment;n describing potential alterations in comfort

levels to be expected postoperatively;n offering information on how to most

effectively minimize postoperativediscomfort;

n providing the patient and designatedsupport person with written dischargeand at-home instructions; and

n reviewing postoperative routines, proce-dures, and equipment.

n Evaluates response to instructions.

before and immedi-ately after surgery.

n The patient statesrealistic expectationsregarding recoveryfrom the procedure.

n The patient anddesignated supportperson identify signsand symptoms toreport to the surgeonor other health careprovider.

n The patient anddesignated supportperson describe theprescribed post-operative regimenaccurately.

knowledge of theexpected responsesto the operative orinvasive procedure.


Capturing this information in the preoperative

area would give the perioperative nurse time to

gather additional positioning aids and padding.

Avoiding the use of blankets as positioning rolls

would be incorporated into the perioperative nurse’s

intraoperative plan of care. The assessment tool also

could be incorporated into the time out before the

surgical procedure. During the time-out pause to

address concerns, the perioperative nurse could

inform the team that the patient is at high risk for

developing a PNI and suggest that if the procedure is

scheduled to last from two to four hours or longer,

the patient should be repositioned if it is safe to

do so.1,4,13,61

Using this preoperative assessment tool and

a nursing care plan (Table 2) is an example of an

118 j AORN Journal

effective nursing intervention that coincides with

one of AORN’s competency outcome statements,

“the patient is free from signs and symptoms of

injury related to positioning.”14(p215) The use of

a “pop-up” window in the computerized OR record

could serve as a reminder for the perioperative

nurse to ask team members whether a brief repo-

sitioning of the patient should be done safely after

four hours.

CONCLUSION

According to my literature review, PNI remains

a concern in the perioperative setting; however, the

actual incidence rate is unknown. At least one article

points to a lack of research and analysis needed to

develop guidelines for patient positioning compared


with the availability of information on preventing

other perioperative injuries.8

Not only is there minimal information on PNI

incidence rates resulting from incorrect surgical posi-

tioning, but no standard exists to identify, document, or

monitor PNI. I found themajority of information about

these injuries in anesthesia journals, and anesthesia

professionals are frequently held liable for patients’

upper body nerve injuries.8,11,40,62

There are ongoing PNI studies taking place

across the United States. The topic challenges

researchers and health care providers because

identification of risk factors and reporting efforts

vary from institution to institution. Overall, the

origin of a PNI should be considered to be multi-

factorial. Increasing awareness in the OR has the

potential to decrease the incidence of PNI.59 Pre-

disposing factors such as diabetes, smoking, and

body mass index extremes coupled with the length

of surgery and positioning contribute to the risk of

a PNI. The use of electronic health care technology

could provide a qualitative and quantitative anal-

ysis of care and help to improve effective preven-

tion techniques. Nurses should collaborate with

other surgical team members to establish a protocol

for identifying patients at risk for PNI and deter-

mine a standard for their care and for the reporting

of these injuries; these actions will improve the

quality and safety of patient care.

SUPPLEMENTARY DATA

A supplementary table associated with this article

can be found in the online version at http://dx.doi

.org/10.1016/j.aorn.2012.10.013.

Editor’s note: MEDLINE is a registered trade-

mark of the US National Library of Medicine’s

Medical Literature Analysis and Retrieval System,

Bethesda, MD. EBSCO is a registered trademark

of EBSCO Industries, Birmingham, AL. PubMed is

a registered trademark of the US National Library

of Medicine, Bethesda, MD. CINAHL, Cumulative

Index to Nursing and Allied Health Literature,

is a registered trademark of EBSCO Industries,

Birmingham, AL. PEGASUS is a trademark of

Informer Technologies, Inc. Google is a trade-

mark of Google, Inc, Mountain View, CA.

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39. Akhavan A, Gainsburg DM, Stock JA. Complications

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41. Prielipp RC, Warner MA. Perioperative nerve injury:

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http://depts.washington.edu/asaccp/


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A(6):1248-1253.

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Prevention of Perioperative Peripheral Neuropathies.

Anesthesiology. 2011;114(4):741-754.

Sharon Bouyer-Ferullo, MHA, RN, CNOR,

was previously a perioperative staff nurse at the

Brigham and Women’s Hospital, Boston, MA,

and is currently a knowledge engineer/applica-

tions specialist for Partners Healthcare Clinical

Informatics Research and Development Divi-

sion, Wellesley, MA. Ms Bouyer-Ferullo has no

declared affiliation that could be perceived as

posing a potential conflict of interest in the

publication of this article.

AORN Journal j 121


EXAMINATION
CONTINUING EDUCATION PROGRAM
2.1
www.aorn.org/CEPreventing Perioperative Peripheral
Nerve Injuries

PURPOSE/GOAL

12

To provide perioperative nurses with the required knowledge to implement strat-

egies to help prevent peripheral nerve injuries (PNIs) in perioperative patients.

OBJECTIVES

1. Describe how PNIs occur.

2. Discuss risk factors associated with PNIs.


4. Describe common types of intraoperative nerve conduction monitoring.

5. Discuss what perioperative nurses can do to reduce the patient’s risk for PNI.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. Peripheral nerve injuries (PNIs) can be caused by

1. stretching or compression of a nerve.

2. ischemia of a nerve.

3. the surgical incision.

4. a metabolic condition that affects nerves.

a. 1 and 2 b. 2 and 3

2 j AORN Journal

c. 2, 3, and 4 d. 1, 2, 3, and 4

2. Nerves can be damaged when they are stretched

by as little as 10% to 15%.

a. true b. false

3. Signs and symptoms of PNI vary depending on

the area injured but can include

1. cognitive impairment.

2. impaired motor function.

3. loss of tendon reflexes.

4. numbness.

� January 2013 Vol 97 No 1

5. tingling.

a. 1 and 2 b. 3, 4, and 5

c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

4. The severity of nerve compression injuries var-

ies depending on how force was applied, the

amount of force, and the length of time force

was applied.

a. true b. false

5. Research indicates that the nerves most at risk for

PNI are the

1. brachial plexus.

2. obturator nerve.

3. peroneal nerve.

4. radial nerve.

5. solar plexus.

6. ulnar nerve.

a. 2, 4, and 5 b. 1, 3, and 6

c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

� AORN, Inc, 2013



CE EXAMINATION www.aornjournal.org

6. The surgical positions that are generally more

likely to contribute to a PNI are the lateral and

park bench positions.

a. true b. false

7. The types of surgery for which high incidences of

nerve injury have been found to occur are

1. cardiac.

2. neurological.

3. orthopedic.

4. plastic and reconstructive.

5. urologic.

a. 1 and 3 b. 4 and 5

c. 1, 2, and 3 d. 1, 2, 3, 4, and 5

8. Patients’ internal risk factors that can contribute

to PNI include

1. age older than 60 years.

2. body mass extremes.

3. diabetes.

4. peripheral vascular disease.

5. tobacco use.

a. 2 and 4 b. 1, 3, and 5

c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

9. Types of monitoring that can alert the surgical

team that nerve conduction is being interfered

with are

1. arterial pressure.

2. electroencephalogram.

3. motor evoked potential.

4. somatosensory evoked potential.

a. 1 and 2 b. 3 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

10. Actions that the perioperative nurse can take to

help prevent PNI include:

1. identifying patients at high risk for PNI and

alerting the surgical team.

2. using a checklist to identify the proposed

surgical position and length of surgery.

3. setting up and conducting somatosensory

evoked potential monitoring.

4. suggesting that patients undergoing longer

procedures be repositioned if it is safe to

do so.

a. 1 and 2 b. 3 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

AORN Journal j 123


LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
2.1
www.aorn.org/CEPreventing Perioperative Peripheral
Nerve Injuries

This evaluation is used to determine the extent to

which this continuing education program met

your learning needs. Rate the items as described

below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Describe how peripheral nerve injuries (PNIs) occur.

Low 1. 2. 3. 4. 5. High

2. Discuss risk factors associated with PNIs.

Low 1. 2. 3. 4. 5. High


Low 1. 2. 3. 4. 5. High

4. Describe common types of intraoperative nerve

conduction monitoring.

Low 1. 2. 3. 4. 5. High

5. Discuss what perioperative nurses can do to reduce

the patient’s risk for PNI.

Low 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

124 j AORN Journal � January 2013 Vol 97 No 1

9. Will you change your practice as a result of reading

this article? (If yes, answer question #9A. If no,

answer question #9B.)

9A. How will you change your practice? (Select all that

apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: _______________________________

9B. If you will not change your practice as a result of

reading this article, why? (Select all that apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other: _______________________________

10. Our accrediting body requires that we verify

the time you needed to complete the 2.1 con-

tinuing education contact hour (126-minute)

program: ________________________________

� AORN, Inc, 2013


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

(table continued)


AORN Journal j 124.e1


SUPPLEMENTARY TABLE 1. (continued) Review of References Related to Peripheral NerveInjury in the OR


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.


124.e2 j AORN Journal



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

(table continued)






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





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

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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





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

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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





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.




preventing perioperative peripheral nerve injuries

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