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Correspondence |
USC/Norris Comprehensive Cancer Center and Hospital, Los Angeles, USA, E-mail: thangath{at}usc.edu
To the Editor:
Median nerve injury is an uncommon complication following routine surgical procedures performed under general anesthesia,1 usually resulting from stretching of the nerve at the elbow during prolonged arm extension or hyperextension of the wrist during placement and stabilization of radial arterial lines.2,3 We performed a chart review revealing that over the past ten years ten cases of carpal tunnel syndrome unrelated to prolonged arm extension or wrist hyperextension have been seen at our medical centre.
In all of these cases, the surgeries were prolonged (> 8 hr). The patients received massive amounts of intraoperative fluid resuscitation (> 10 L) and exhibited extensive third spacing of fluid and peripheral edema. As is typical of any iatrogenic perioperative median nerve injury, younger, muscular male patients appeared to be at an increased risk for this complication.2 These patients all had arterial lines; however in some patients the injury occurred in the hand without the arterial line. Symptoms were typical of median nerve injury, with paresthesias and/or sensory loss present in the thumb, index and middle fingers and thenar eminence. There was weakness of thumb abduction and opposition. Sensory-motor function in the ulnar and radial nerve distributions was grossly intact. No EMG or nerve conduction studies were performed. Eight of the patients recovered spontaneously and completely within two weeks of injury, two suffered residual sensory loss over partial distributions of the median nerve.
This complication is an unavoidable potential consequence of prolonged surgery with large iv fluid administration. The median nerve’s location just below the volar carpal ligament in the carpal tunnel makes it more susceptible to injury from compression in the wrist than the radial or ulnar nerves. Extensive, prolonged surgical procedures requiring large amounts of fluid infusion result in extensive leakage of fluid into the extracellular compartment, causing edema of the forearm and hands, which can result in such a compression of the median nerve, compromising its blood supply and causing symptoms similar to those of carpal tunnel syndrome. Because anesthesia-associated nerve injuries are a significant source of patient morbidity and anesthesiologist liability,4 patients should be advised of the risk of median nerve injury prior to surgery and it should be included in the informed consent as a possible complication. Intraoperatively, anesthesiologists should observe the patient’s extremities for edema, and avoid dependency of arms if possible. Postoperatively, the extremities should be elevated and administtration of diuretics should be considered if excessive edema is observed.
References
1 Melli G, Chaudhry V, Dorman T, Cornblath DR. Perioperative bilateral median neuropathy. Anesthesiology 2002; 97: 1632–4.[Medline]
2 Warner M. Perioperative neuropathies. Mayo Clin Proc 1998; 73: 567–74.[Medline]
3 Chowet, A, Lopez JR, Brock-Utne JG, Jaffe RA. Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. Anesthesiology 2004; 100: 287–91.[Medline]
4 Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: a closed claims analysis. Anesthesiology 1999; 90: 1062–9.[Medline]
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