Acute Nerve Injury Guidelines

Updated: Jun 13, 2021
  • Author: Idan Sharon, MD; Chief Editor: Brian H Kopell, MD  more...
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Guidelines Summary

Guidelines from the American Society of Anesthesiologists on the prevention of perioperative peripheral nerve injury include recommendations for patient positioning, protective padding and proper placement of equipment. [33]

Upper Extremities

To reduce the risk for perioperative injury in the upper extremities, the following specific strategies for each nerve are recommended [33] :

Brachial plexus:  If possible, arm abduction should be limited to 90° in supine patients.  A prone position may allow abduction greater than 90°.

Ulnar nerve: Avoid elbow flexion

  • If using an armboard, position the arm with hand supination or in a neutral forearm position so as to decrease pressure on the postcondylar groove of the humerus (ulnar groove).

  • For supine patients, place the forearm in a neutral position.

Radial nerve: Avoid positions with prolonged pressure on the radial nerve in the spiral groove of the humerus.

Median nerve:  Conduct a preoperative assessment to determine elbow range of motion. Do not extend the elbow beyond the range that is comfortable for the patient.

In addition, the following general strategies are recommended [33] :

  • Assessments to ensure maintenance of the desired position should be made periodically throughout the procedure.
  • Padded armboards and/or padding at the elbow may be used 
  • Chest rolls may be useful for laterally positioned patients
  • Ensure padding is not too tight
  • Ensure automated blood pressure cuffs on properly placed on the arm
  • If possible, avoid shoulder braces with a steep head-down position

Lower Extremities

Sciatic nerve: Conduct a preoperative assessment of extension and flexion of both the hip and the knee joints to determine the degree of hip flexion. To prevent stretching the sciatic nerve, avoid positions that stretch the hamstring muscles beyond the patient's hip flexion range of motion.

Femoral nerve: If possible, avoid extension or flexion of the hip

Peroneal nerve:  Do not allow prolonged pressure on the peroneal nerve at the fibular head. Specific padding to prevent pressure of a hard surface against the peroneal nerve may be used