PATIENT POSITIONIG &
PERIOPERATIVE NEUROPATHY
By
Heba Fouad Tolan

Patient positioning is a major responsibility that is
shared by the entire operating room team. A balance
between optimal surgical positioning and patient wellbeing is sometimes required.
 Many patient positions that are used for surgery result in
undesirable physiologic consequences, including significant
cardiovascular and respiratory compromise.

Anesthetics blunt natural compensatory mechanisms,
rendering surgical patients vulnerable to positional changes.
PATIENT POSITIONS DURING SURGERIES:

Supine position (most common position).

Lithotomy position ( 2nd common).

Prone position.

Sitting position.

Lateral decubitus position.

Trendlenberg & Reverse trendlenberg position.
SUPINE POSITION:
COMPLICATIONS:
Peripheral nerve injury ( ulnar N. injury is most
common )
 Pressure alopecia.
 Backache.
 Pressure sore.

LITHOTOMY POSITION
RISKS OF LITHOTOMY POSITION:
Nerve injuries:
Common peroneal nerve injury.
Saphenous nerve injury
Obturator and femoral nerve injury
 Cardio-vascular effects :
Leg elevation
Increase VR precipitation of cong.
Heart failure
Rapid Leg lowering decrease VR hypotension ,
decreased CO
 Respiratory effects:
Decreased VC , FRC , accentuated by trendlenberg
position

PRONE POSITION:
COMPLICATIONS OF PRONE POSITION:
Nerve injuries;
Brachial plexus, ulnar , radial nerve injury
 Thoacic outlet obstruction.
 Compression on eyes, nose, genitalia, breasts.
 Pressure sores.
 Postural hypotension.
 Abdominal compression leading to impairment
of ventilation.

SITTING POSITION:
COMPLICATIONS OF SITTING POSITION:

Venous air embolism , pneumocephalus.

Postural hypotension.

Hypertension due to pins of May field holder.

Excessive neck flexion may cause increase in ICP ,
compression of cervical spinal cord.
LATERAL DECUBITUS POSITION
COMPLICATIONS OF LATERAL DECUBITUS
POSITION:
 Compression
on eyes , nose.
 Stretch injury to brachial plexus ,
suprascapular , long thoracic nerve injury.
 Compression to axillary neurovascular
structure.
TRENDLENBERG & REVERSETRENDLENBERG
POSITION:
COMPLICATIONS OF TRENDLENBERG POSITION:
Respiratory effects:
Decrease lung compliance, VC, FRC.
 Cardiovascular effects:
Leg elevation
Increase VR
precipitation of
cong. Heart faliure
Rapid Leg lowering
decrease VR hypotension ,
decreased CO.
 Increased incidence of regurgitation & aspiration.
 Venous congestion and edema.

PERIPERATIVE NEUROPATHY:

Causes :






Stretch and traction.
Compression
Generalized ischemia
Metabolic causes
Direct surgical trauma.
Risk factors :



Old age
vascular disease
Obesity
DM
Prolonged surgery , hypotension
ULNAR NEUROPATHY (MOST COMMON):

Causes :
•
•

Presentation:
•
•
•

Elbow flexion> 90- 110 degree
Forearm pronation
Decreased sensation in 4,5th finger.
Inability to abduct or oppose 5th finger
Claw like hand
Prevention:
•
•
Avoid excessive pressure on postcondylar groove of humerus
Keep hand and forearm either supinated or in neutral position
BRACHIAL PLEXUS INJURY (2ND COMMON)
Causes:

Supine position
•
•

Prone position
•
•


High axillary roll.
Trendlenberg position
•

excessive turning of head to contralateral side.
Ipsilateral shoulder abduction , elbow flexion.
Lateral decubitus position
•

excessive abduction of the arm.
sternal separation in median sternotomy.
Shoulder braces.
Direct trauma.
Axillary block , IJV cannulation

Prevention:
•
•
•
•
•
Avoid the use of shoulder braces in patients in
Trendelenburg position (use nonsliding mattresses)
Avoid excessive lateral rotation of head either in supine or
prone position
Limit abduction of the arm to <90 degrees in supine
position
Avoid placement of high axillary roll in decubitus position—
keep roll out of axilla
Use ultrasound to find internal jugular vein for central line
placement
MEDIAN AND RADIAL NEUROPATHY:

Causes:
•Axillary
block.
•Cannulation in antecubital fossa.

Presentation of median nerve injury:
•
•

Inability to oppose 1st , 5th digits
Decreased sensation over palmar surface of lateral three and
half fingers.
Presentation of Radial nerve injury:
•
•
•
Wrist drop.
Inability to abduct the thumb.
Inability to extend metacarpophalengeal joint.
FEMORAL NEUROPATHY:

Causes :




Improper placement of abdominal wall retractors
Direct compression of ilio-psoas muscle.
External iliac artery occlusion.
Presentation:



Loss of sensation over the superior aspect of the thigh.
Decreased hip flexion.
Decreased extension of knee.
SAPHENOUS NEUROPATHY (RARE):

Causes:
•

Improper lithotomy position
Presentation:
•
Numbness along medial calf
OBTURATOR NEUROPATHY:

Causes:




Lower abdominal wall retractors
Difficult forceps delivery
Excessive flexion of thigh to groin.
Presentation:


Inability to adduct leg.
Decreased sensation over medial aspect of the
thigh.
COMMON PERONEAL NEUROPATHY:

Causes:
Improper lithotomy position

Presentation:
Loss of dorsi-flexion of the foot
Sciatic neuropathy:
 Causes:
Improper lithotomy position
 Presentation:
Parasthesia
PREVENTION OF SCIATIC AND COMMON
PERONEAL NERVE INJURY
Minimize time of surgery in lithotomy position
 Use two assistants to coordinate simultaneous
movement of both legs to and from lithotomy
position
 Avoid excessive flexion of hips, extension of
knees, or torsion of lumbar spine
 Avoid excessive pressure on peroneal nerve at
the fibular head

MANAGEMENT OF POST OPERATIVE
NEUROPATHY

For sensory disorders:
•
•
•

Reassure
Follow up
Neurological consultation if deficit> 5 days
For motor disorder:
•
•
•
Neurological consultation
EMG, nerve conduction velocity.
physiotherapy
PROGNOSIS:

Depend on degree of nerve damage:



Neuropraxia has good prognosis.
Axonotemesis has variable prognosis.
Neurotemesis has poor prognosis.