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Ann Thorac Surg 2002;73:122
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Department of Anesthesia, University of Pennsylvania, 3400 Spruce St,, 413 Ravdin Courtyard, Philadelphia, PA 19104-4283, USA

e-mail: ellisonn{at}phs.upenn.edu

Peripheral nerve injuries are a well recognized complication of anesthesia and surgery. Until 1990 ulnar nerve injury was the one most commonly reported to the Closed Claim Project (CCP) of the American Society of Anesthesiologists, but in the 1990s brachial plexus and spinal cord injuries dominated [1]. Logically, the common peroneal nerve, the lower extremity nerve analogous to the ulnar in the upper extremity, would also be at risk. Both nerves are superficial and susceptible to compression as they traverse around the head of the fibula and in the ulnar groove of the medial condyle of the humerus respectively.

The exact mechanism of peripheral nerve injury is rarely defined precisely. Malpositioning of the extremity with stretch or compression of the nerve is often the ascribed etiology, especially in malpractice cases. Arguing against that etiology are reports of ulnar nerve injury in awake, lightly sedated patients under regional anesthesia for lower body surgery [2]. These patients presumably would be aware of compression or stretching sufficient to cause injury.

This article reports that patients with body weight more than 10% below normal or with a history of peripheral vascular disease, diabetis mellitus, and arrythmia appear at greater risk for common peroneal injury (CPNI). In the most recent CCP data (through February 2001) the 21 reported CPNI cases were most commonly associated with hip surgery and dorsal lithotomy position (Karen Domino, MD, personal communication). The risk of CPNI in such cases is well known to physicians.

The etiology of injuries in the current report is similarly not obvious. Recognizing the magnitude of perioperative peripheral nerve injuries, the American Society of Anesthesiologists has issued a practice advisory for their prevention [3] (Unlike standards or guidelines, which are based on more firm scientific evidence, an advisory provides a synthesis and analysis of expert opinion as well as clinical feasibility and consensus data.) With respect to CPNI, the practice advisory suggests "the use of specific padding to prevent contact of the peroneal nerve (at the fibular head) with a hard surface may decrease the risk of peroneal neuropathy." This advice is given with the caveat that "in some circumstances, the use of padding may increase the risk of peripheral neuropathies."

In summary physicians must now be aware of the possibility of CPNI in patients where the surgical site is remote from the head of the fibula. While there are recommendations on how to minimize CPNI, comorbid conditions may be the major determining factor and not preventable.

References

1. Cheney F.W., Domino K.B., Caplan R.A., Posner K.L. Nerve injury associated with anesthesia. Anesth 1999;90:1662-1669.
2. Warner M.A., Warner M.E., Martin J.T. Ulnar neuropathy: incidence, outcome, and risk factors in sedated or anesthetized patients. Anesth 1994;81:1332-1340.
3. Practice advisory for the prevention of perioperative peripheral neuropathies. A report by the American Society of Anesthesiologists Task Force on prevention of perioperative neuropathies. Anesth 2000;92:1168-1182.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ellison, N. Search for Related Content PubMed Articles by Ellison, N. Related Collections Related Article