Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies

PRACTICE advisories are systematically developed reports that are intended to assist decision-making in areas of patient care where scientific evidence is insufficient. Advisories provide a synthesis and analysis of expert opinion, clinical feasibility data, open forum commentary, and consensus surveys. Advisories are not intended as standards, guidelines, or absolute requirements. They may be adopted, modified, or rejected according to clinical needs and constraints.The use of practice advisories cannot guarantee any specific outcome. Practice advisories report the state of the literature and opinions derived from a synthesis of task force members, expert consultants, open forums and public commentary. Scientific literature and other documentation are summarized in practice advisories to provide an additional source of guidance. Practice advisories are not supported by scientific literature to the same degree as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies. Practice advisories are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.The purposes of this advisory are to 1) educate American Society of Anesthesiologists (ASA) members, (2) provide a reference framework for individual practices, and (3) stimulate the pursuit and evaluation of strategies that may prevent or reduce the frequency of occurrence or minimize the severity of peripheral neuropathies that may be related to perioperative positioning of patients.Prevention of peripheral neuropathies is part of the larger process of perioperative care. This advisory specifically focuses on perioperative positioning of the adult patient, use of protective padding, and avoidance of contact with hard surfaces or supports that may apply direct pressure on susceptible peripheral nerves. This advisory does not focus on compartment syndromes or neuropathies that may be associated with anesthetic techniques (e.g. , spinal anesthesia).This advisory is intended to apply to adult patients who are or have been sedated or anesthetized. Areas in which these patients receive care include, but are not limited to, operating rooms and other anesthetizing locations, recovery rooms, intensive care units, outpatient procedural units, and office-based practices.This advisory is intended for use by anesthesiologists or other providers working under the direction of anesthesiologists. It also may serve as a resource for other health care professionals.The ASA appointed a task force of 10 members to (1) review the published evidence, (2) obtain consultant opinion from a representative body of anesthesiologists, nurse anesthetists, anesthesiology assistants, perioperative nurses, surgeons, and emergency medicine physicians, and (3) build consensus within the task force. The task force members consisted of anesthesiologists in both private and academic practices from various geographic areas of the United States and methodologists from the ASA Committee on Practice Parameters. The task force identified a group of 150 consultants from both the national and the international anesthesia communities who have expertise or interest in perioperative peripheral neuropathies.The task force met its objective in a five-step process. First, original published research studies relevant to these issues were reviewed. Second, consultants who practice or work in various settings (e.g. , academic and private practice) were asked to (1) participate in surveys of their opinions of the effectiveness of various positioning and protective strategies to prevent perioperative peripheral neuropathies and (2) review and comment on the initial draft report of the task force. Third, a random sample of anesthesiologists (n = 1,500) from the ASA Directory of Members (active members only) was surveyed regarding their impressions of various elements of the advisory. Fourth, the task force held an open forum at a major national anesthesia meeting to solicit input on its draft advisory from attendees of the meeting. Fifth, all available information was used to build consensus within the task force on the advisory.A summary of the consensus of the task force on all key issues pertinent to this advisory is presented in table 1. Practice advisories are developed by a systematic consensus-based process. Although they do not have the support of sufficient numbers of scientific studies, a source of guidance is provided by the summarization of scientific studies, case reports, descriptive literature, and other documentation. Consensus findings from consultant and ASA membership surveys are summarized and included in advisories in addition to task force opinion, open forum opinion, and public commentary.Preoperative History and Physical AssessmentCertain patient characteristics have been reported to be associated with perioperative neuropathies. Although this advisory found no studies examining the relationship between the performance of a preoperative history or physical assessment and the prevention of perioperative peripheral neuropathies, 25 studies reported postoperative peripheral neuropathies occurring in patients with specific preexisting conditions (e.g. , smoking, diabetes, vascular disease, and extremes of body weight, and age). 1–25Such conditions often are noted in a patient's medical history or found during a physical assessment. These studies are not acceptable evidence of causation.Consultants and ASA Members. Ninety-three percent of the consultants who responded (n = 78/84) agree that a focused preoperative history may identify patients with an increased risk for the development of peripheral neuropathies during the perioperative period. Eighty-eight percent of the ASA membership respondents (n = 382/433) agree with the above statement. The majority of consultants and responding ASA members who agree with the above statement indicate that the following preexisting patient attributes are important to review: body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, and arthritis. Eighty-eight percent of the responding consultants (n = 72/82) agree that a focused preoperative physical assessment may identify patients with an increased risk for the development of peripheral neuropathies during the perioperative period. Eighty percent of the ASA membership respondents (n = 344/429) agree with the above statement.The task force consensus is that body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, arthritis, and gender (e.g. , male gender and its association with ulnar neuropathy) are important elements of a preoperative history. The task force consensus also indicates that, when judged appropriate, it would be helpful during a preoperative assessment to ascertain that patients can comfortably tolerate the anticipated operative position. Public commentary from an open forum and from Internet correspondence corroborates the task force opinions.Positioning Strategies to Reduce the Frequency of Perioperative Brachial Plexus NeuropathyNineteen articles were found that reported brachial plexus injuries. 26–44Fifteen were case reports or studies with descriptive information only. 26–40Six of the 15 articles reported brachial plexus neuropathies occurring with arm abduction greater than 90°, 26–31and four of the 15 reported brachial plexus neuropathies occurring with arm abduction equal to 90°. 32–35Four articles reported statistical comparisons, 41–44only one of which was a randomized clinical trial. 44Three of these four articles compared arm abduction less than or equal to 90°versus arms at side in supine patients. 41–43One article compared arm abduction less than 90°versus arm abduction equal to 90°. 44These articles do not provide sufficient data to identify a causal relationship between perioperative conditions and brachial plexus neuropathies.Ninety-two percent of the consultants (n = 75/82), and 96% of the ASA members (n = 411/431) agree that limiting abduction of the arm(s) in a supine patient may decrease the risk of brachial plexus neuropathy. Of those agreeing, 93% of the consultants (n = 67/72) and 84% of the ASA members (n = 342/405) indicate that the upper limit of abduction should be 90°. Seven percent of the consultants (n = 5/72) and 17% of the ASA members (n = 63/405) indicate an upper abduction limit of 60°.The task force consensus is that arm abduction should be limited to 90°. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA members. Eighty-eight percent of the consultants (n = 71/81) and 91% of the ASA members (n = 392/432) agree that limiting abduction of the arm or arms in a prone patient may decrease the risk of brachial plexus neuropathy. Of those agreeing, 67% of the consultants (n = 47/70) and 57% of the ASA members (n = 222/387) agree that the upper limit of abduction should be 90°.The task force notes that the prone position affects shoulder and brachial plexus mobility differently than does the supine position. These differences may allow patients to comfortably tolerate abduction of their arms greater than 90° when positioned prone. Public commentary from an open forum and from Internet correspondence corroborates the task force commentary.Positioning Strategies to Reduce the Frequency of Perioperative Ulnar NeuropathyFive articles were found that reported ulnar neuropathies. 20,25,45–47Three articles were case reports, 25,45,46one was a retrospective comparison of forearm supination and pronation, 20and one was a nonrandomized comparison of supination and pronation. 47These articles do not contain sufficient data to identify a relationship between positioning strategies and ulnar neuropathies.Seventy-four percent of the consultants (n = 61/83) and 75% of the ASA members (n = 318/426) agree that specific forearm positions in a supine patient with an arm or arms abducted on an armboard may decrease the risk of ulnar neuropathy. Of those agreeing, 85% of the consultants (n = 51/60), and 87% of the ASA members (n = 274/315) selected the supinated and neutral forearm positions.The task force consensus is that the forearm should be positioned to decrease pressure on the postcondylar groove of the humerus (ulnar groove). Either supination or the neutral forearm position meets this goal. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Seventy-two percent of the consultants (n = 60/83) and 75% of the ASA members (n = 318/424) agree that specific forearm positions in a supine patient with an arm or arms tucked at the side may decrease the risk of ulnar neuropathy. Of those agreeing, 64% of the consultants (n = 38/59) and 63% of the ASA members (n = 196/312) selected the neutral forearm position.The task force consensus is that the forearm should be in a neutral position. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Fifty-two percent of the consultants (n = 42/81) and 42% of the ASA members (n = 180/426) agree that flexion of the elbow may increase the risk of ulnar neuropathy. Of those agreeing, 72% of the consultants (n = 29/40) and 66% of the ASA members (n = 114/174) indicate that elbow flexion of greater than 90° may increase the risk of ulnar neuropathy.The task force consensus is that flexion of the elbow may increase the risk of ulnar neuropathy, but there is no consensus on an acceptable degree of flexion during the perioperative period. Public commentary from an open forum and from Internet correspondence corroborates the consultant and ASA membership survey results.Positioning Strategies to Reduce the Frequency of Perioperative Radial NeuropathyNo case reports or studies were found addressing perioperative positioning strategies to protect the radial nerve.Consultants and ASA Members. Eighty-nine percent of the consultants (n = 73/82) and 86% of the ASA members (n = 364/425) agree that pressure in the spiral groove of the humerus from prolonged contact with a hard surface may increase the risk of radial neuropathy. The task force consensus is that prolonged pressure on the radial nerve in the spiral groove of the humerus should be avoided. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Positioning Strategies to Reduce the Frequency of Perioperative Median NeuropathyNo case reports or studies were found addressing perioperative positioning strategies to protect the median nerve.Consultants and ASA Members. Fifty-nine percent of the consultants (n = 48/82) and 62% of the ASA members (n = 264/424) agree that extension of the elbow in an anesthetized, supine patient beyond the normal range of extension that is comfortable during the preoperative examination may increase the risk of median neuropathy. The task force consensus is that extension of the elbow beyond the range that is comfortable during the preoperative assessment may stretch the median nerve. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Periodic Assessment of Position During ProceduresNo case reports or studies were found addressing assessment of patient position perioperatively to protect the upper extremities.Consultants and ASA Members. Ninety-two percent of the consultants (n = 76/83) and 97% of the ASA members (n = 413/425) agree that upper extremity position should be periodically assessed during procedures. The task force consensus is that periodic perioperative assessments may ensure maintenance of the desired position. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Positioning Strategies to Reduce the Frequency of Perioperative Sciatic NeuropathyTwo case reports of postoperative sciatic neuropathy were found. 48,49One report noted hip flexion of 90° in a sitting position, 48and the other reported perioperative vertical leg extension and maximum external rotation of thighs in a lithotomy position. 49Case reports are not acceptable evidence to indicate causation.Forty-eight percent of the consultants (n = 39/81) and 57% of the ASA members (n = 241/423) agree that stretching of the hamstring muscle group (e.g., biceps femoris muscle) beyond the normal range of motion that is comfortable during the preoperative assessment may increase the risk of sciatic neuropathy. The task force consensus is that positions that stretch the hamstring muscle group beyond the range that is comfortable during the preoperative assessment may stretch the sciatic nerve. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. Fifty percent of the consultants (n = 34/68) and 52% of the ASA members (n = 181/346) agree that the risk of sciatic neuropathy in a patient who is positioned in a lithotomy position may be reduced if the degree of hip flexion is limited to 90°.Task Force and Others. The task force consensus is that since the sciatic nerve or its branches cross both the hip and the knee joints, flexion and extension of both of these joints should be considered when determining the degree of hip flexion. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Positioning Strategies to Reduce the Frequency of Perioperative Femoral NeuropathyTwo case reports of postoperative femoral neuropathy were found. 50,51One report found femoral neuropathy to occur in five patients who were placed in a lithotomy position, 50and the other reported a patient with postoperative neuropathy after placement in a lithotomy position with exaggerated hip flexion and "candy cane" stirrups. 51Case reports are not acceptable evidence to indicate causation.Consultants and ASA Members. Forty percent of the consultants (n = 33/83) and 49% of the ASA members (n = 209/424) agree that extension of the hip in an anesthetized, supine patient beyond the normal range of extension that is comfortable during the preoperative examination (e.g., hyperlordosis) may increase the risk of femoral neuropathy. Fifty-one percent of the consultants (n = 42/83) and 44% of the ASA members (n = 186/424) were undecided. Forty percent of the consultants (n = and of the ASA members (n = agree that the risk of femoral neuropathy may be reduced if the degree of hip flexion is limited to 90°. percent of the consultants (n = and of the ASA members (n = agree that the risk of femoral neuropathy in a patient placed in a lithotomy position is not increased with any degree of hip flexion. Force and Others. The task force consensus is that extension flexion of the hip the risk for femoral neuropathy. Public commentary from an open forum and from Internet correspondence is regarding the risk of femoral neuropathy related to hip extension or Strategies to Reduce the Frequency of Perioperative case report of postoperative nerve in a patient placed in a sitting position, sciatic nerve pressure and was found. reports are not acceptable evidence to indicate causation.Consultants and ASA Members. Ninety-two percent of the consultants (n = 76/83) and of the ASA members (n = agree that pressure the from contact with a hard surface or a support may increase the risk of neuropathy. Force and Others. The task force consensus is that prolonged pressure on the nerve at the should be avoided. Public commentary from an open forum and from Internet correspondence corroborates the task force is intended to protect the patient from perioperative neuropathies. articles were found that reported peripheral neuropathies occurring when upper extremity protective was of these reported of brachial the other four reported of ulnar neuropathy. articles do not as a of the neuropathies. of these articles were case reports for one retrospective descriptive articles are not acceptable evidence of studies were found addressing the relationship between the use of and the occurrence of peripheral neuropathies. studies were found addressing the occurrence of peripheral neuropathies when extremity protective was and ASA Members. Eighty-nine percent of the consultants (n = and of the ASA members (n = agree that may decrease the risk of upper extremity neuropathies. Force and Others. The task force consensus is that may decrease the risk of upper extremity neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and 87% of the ASA members (n = agree that the use of a placed under the in a patient who is positioned may decrease the risk of brachial plexus neuropathy in the Force and Others. The task force consensus is that the use of in the positioned patient may decrease the risk of upper extremity neuropathy. Public commentary from an open forum Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that the use of specific (e.g., or at the elbow may decrease the risk of ulnar neuropathy. Force and Others. The task force consensus is that at the elbow may decrease the risk of upper extremity neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and 91% of the ASA members (n = agree that the use of specific to prevent contact of the nerve the with a hard surface may decrease the risk of neuropathy. The task force consensus is that that the use of specific to prevent pressure of a hard surface the nerve at the may decrease the risk of neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and of the ASA members (n = agree that, in the use of may increase the risk of peripheral neuropathies. Force and Others. The task force consensus is that the use of (e.g. , may increase the risk of perioperative neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force articles were found that the of or supports as a direct of perioperative peripheral neuropathies. upper extremity neuropathies, articles were found that reported peripheral neuropathies occurring when upper extremity contact was with or case reports radial or ulnar nerve occurring when a pressure was used case reports brachial plexus neuropathies occurring when shoulder or were case report radial nerve occurring in a prone patient with an arm abducted a one case report radial neuropathy occurring in a supine patient with an arm by a reports are not acceptable evidence to indicate nonrandomized comparison use no use of a shoulder when patients were in a supine position for and found a frequency of brachial plexus neuropathy when a shoulder was not the research of the does not provide acceptable evidence of articles were found that reported peripheral neuropathies occurring when extremity contact was with or case reports femoral or neuropathies occurring with the use of leg article reported a case of nerve as a of the use of a motion knee article compared in a lithotomy position with stirrups. articles are not acceptable evidence of nonrandomized comparison of femoral neuropathy the use of for research of the does not provide acceptable evidence of causation.Consultants and ASA on Ulnar percent of the consultants (n = agree (n = and are (n = that use of an pressure on the arm may increase the risk of ulnar neuropathy. percent of the ASA members (n = agree (n = and are (n = that the use of an pressure on the arm may increase the risk of ulnar on Radial percent of the consultants (n = agree (n = and are (n = that use of an pressure on the arm may increase the risk of radial neuropathy. percent of the ASA members (n = agree (n = and are (n = that the use of an pressure on the arm may increase the risk of radial neuropathy. on Median percent of the consultants (n = agree (n = and 42% are (n = that use of an pressure on the arm may increase the risk of median neuropathy. percent of the ASA members (n = agree (n = and are (n = that the use of an pressure on the arm may increase the risk of median Force and Others. The task force consensus is that the use of pressure on the arm , placed above the does not the risk of upper extremity neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force opinion.Consultants and ASA Members. percent of the consultants (n = and 66% of the ASA members (n = agree that shoulder placed the to prevent a patient from when placed in a position may increase the risk of brachial plexus neuropathy. Force and Others. The task force consensus is that use of shoulder in a position may increase the risk of perioperative neuropathies. Public commentary from an open forum and from Internet correspondence corroborates the task force articles were found that the relationship between the performance of a physical assessment in the care and the prevention of perioperative peripheral neuropathies. four case reports, four descriptive studies the of a peripheral neuropathy during postoperative assessment. reports and descriptive studies do not provide acceptable evidence to indicate studies were and ASA Members. percent of the consultants (n = 60/83) and 67% of the ASA members (n = agree that examining the patient in the may to of peripheral neuropathy. Force and Others. The task force consensus is that a postoperative assessment of extremity nerve may to of peripheral neuropathy. Public commentary from an open forum and from Internet correspondence corroborates the task force studies were found addressing the of documentation of specific perioperative positioning related to peripheral and ASA Members. Eighty-eight percent of the consultants (n = and 93% of the ASA members (n = agree that documentation on an anesthetic of specific positioning during the care of a patient is of the majority of consultants and ASA members with the above statement indicates that, when appropriate, it is important to the (1) patient position (e.g. , or (2) position of (3) position of use of specific at the elbow or the specific positioning or or used during the as by findings on the preoperative and or of or of peripheral neuropathy in the Force and Others. The task force consensus is that this documentation may be for may in by (1) the focus on relevant of patient positioning and (2) of positioning strategies that to in anesthesia Public commentary from an open forum and from the Internet corroborates the task force this a literature review was used in with consensus opinion to provide guidance to regarding positioning strategies and perioperative peripheral neuropathies. the literature review and consensus data were on the following or evidence These between patient positioning and perioperative peripheral neuropathies. are purposes of literature relevant clinical studies were identified and of the The a from The a of from were a of articles that related to the evidence review of the studies not provide direct evidence, and were of articles direct evidence studies with and statistical information to or report that in the published literature can be included as evidence in the development of an advisory if it meets four to one or of these that a that not it for the process. The four are as the studies met the studies acceptable and that provided a of the between and of of the of studies, the published literature not be used as a source of studies should focus on that of the following for the of positioning techniques on perioperative peripheral neuropathies is (1) comparison studies , one (2) and (3) of and examining the of positioning techniques on perioperative peripheral neuropathies, the be to and a patient's preoperative of of and the perioperative position (e.g., are not under the direct of the These perioperative may perioperative , peripheral but are when examining the of positioning techniques (e.g. , arm abduction 90°versus on the occurrence of peripheral the literature not been helpful in determining the of perioperative positioning techniques in the occurrence of peripheral neuropathies. additional controlled studies are evidence from other to be as data and the opinion of and It is that research on positioning techniques for the prevention of peripheral neuropathies focus on research and and on specific techniques under the direct of the during a was from (1) survey opinion from consultants who were selected on their or expertise in perioperative positioning and peripheral neuropathy, (2) survey opinions from a selected sample of members of the (3) from attendees of a open forum at a national Internet commentary, and task force opinion and The of was = for consultants, and = for membership of the surveys are reported in and in the of the The majority of consultants and ASA membership respondents with the following survey (1) a focused preoperative history and (2) a focused preoperative examination to identify patients at risk for the development of peripheral neuropathies during the perioperative (3) upper extremity position should be periodically assessed during limiting abduction of the arm(s) in a supine or prone patient may decrease the risk of brachial plexus specific forearm in a supine patient with an arm(s) tucked at the side or abducted on an armboard may decrease the risk of ulnar pressure in the spiral groove of the humerus from prolonged contact with a hard surface may increase the risk of radial extension of the elbow in an anesthetized, supine patient beyond the normal range of extension that is comfortable during the preoperative may increase the risk of median pressure the from contact with a hard surface or a support may increase the risk of may decrease the risk of upper extremity of a placed under the in a patient who is positioned may decrease the risk of brachial plexus neuropathy in the specific (e.g. , or at the elbow may decrease the risk of ulnar specific to prevent contact of the nerve the with a hard surface may decrease the risk of in the use of may increase the risk of peripheral shoulder placed the to prevent a patient from when placed in a position may increase the risk of brachial plexus examining the patient in the may to of peripheral and documentation on an anesthetic of specific positioning during the care of a patient is where no majority was (1) flexion of the elbow may increase the risk of ulnar (2) stretching of the hamstring muscle group (e.g. , biceps femoris muscle) beyond the normal range of motion that is comfortable during the preoperative assessment may increase the risk of sciatic (3) extension of the hip in an anesthetized, supine patient beyond the normal range of extension that is comfortable during the preoperative (e.g. , hyperlordosis) may increase the risk of femoral and the use of an pressure on the arm may increase the risk of or median and ASA membership respondents who with the above survey responded to specific The majority of these respondents with the following (1) preexisting patient attributes that are important to review during a preoperative history include, but are not limited body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, and (2) in a patient it is important to to range of motion in the elbow range of motion of an range of motion of the hip and knee joints patients in a or lithotomy to patients in a supine and of the hamstring muscle group patients in a or lithotomy (3) the upper limit of abduction of the arm(s) in a supine or prone patient should be in a supine patient with an arm(s) tucked at the the forearm in the neutral position may decrease the risk of ulnar in a supine patient with an arm(s) abducted on an the forearm in the supinated position may decrease the risk of ulnar elbow flexion greater than 90° may increase the risk of ulnar the risk of sciatic neuropathy in a patient who is positioned in a lithotomy position may be reduced if the degree of hip flexion is limited to and it is important to patient position (e.g. , position of position of use of specific at the elbow or the specific positioning or used during a as by findings on a preoperative and the or of or of peripheral neuropathy in the majority was not for the following (1) gender as an important to review in a focused preoperative (2) of the hamstring muscle group patients in a or lithotomy as important to in a preoperative (3) the degree of hip flexion for the risk of femoral neuropathy in a patient placed in a lithotomy position, and the of leg used for a patient in a lithotomy position as an important to