Perioperative Ulnar Neuropathy: A Contemporary Estimate of Incidence and Risk Factors

Abstract

BACKGROUND: Retrospective and prospective studies 2 decades ago from the authors’ institution reported the incidence of perioperative ulnar neuropathy persisting for at least several months in a noncardiac adult surgical population to be between 30 and 40 per 100,000 cases. The aim of this project was to assess the incidence and explore risk factors for perioperative ulnar neuropathy in a recent cohort of patients from the same institution using a similar definition for ulnar neuropathy. METHODS: We performed a retrospective incidence and case-control study of all adults (≥18 years) undergoing noncardiac procedures with anesthesia services between 2011 and 2015. Each incident case of persistent ulnar neuropathy within 6 months of surgery was matched by age, sex, procedure date, and procedure type to 5 surgical patient controls. For the case-control study, separate conditional logistic regression analyses were performed to assess specific risk factors including the patient’s body position and arm position, as well as body mass index (BMI), surgical duration, and selected patient comorbidities. RESULTS: Persistent ulnar neuropathy of at least 2 months duration was found in 22 of 324,124 anesthetics for patients who underwent these procedures during the study period for an incidence rate of 6.8 (95% confidence interval [CI], 4.3-10.3) per 100,000 anesthetics. The incidence of ulnar neuropathy was higher in men compared to women (10.7 vs 3.0 per 100,000; P = .016). From the matched case-control study, the odds of ulnar neuropathy increased with higher BMI (odds ratio [OR] = 1.67 [1.16-2.42] per 5 kg/m2 increase in BMI; P = .006), history of cancer (OR = 6.46 [1.64-25.49]; P = .008), longer procedures (OR = 1.53 [1.18-1.99] per hour; P = .001), and when 1 or both arms were tucked during surgery (OR = 6.16 [1.85-20.59]; P = .003). CONCLUSIONS: The incidence of persistent perioperative ulnar neuropathy observed in this study was lower than the incidence reported 2 decades ago from the same institution and using a similar definition for ulnar neuropathy. Several of the previously reported risk factors continue to be associated with the development of persistent perioperative ulnar neuropathy, providing ongoing targets for practice changes that might further decrease the incidence of this problem.

Iatrogenic Nerve Injuries of the Upper Extremity

“…Every intervention and nerve carries a unique risk profile for inadvertent injury. The median and spinal accessory nerves (SANs) are reported to be the most frequently injured nerves during surgery 2,4 , whereas the ulnar nerve is the most frequently injured because of patient positioning 6 . Risk factors for perioperative nerve injury are conflicting depending on this study but include age 7-9 , sex 7-10 , abnormal body mass index 7-9 , tobacco use 8-11 , and diabetes 8,9,11 .…”

Guidelines in Practice: Positioning the Patient

“…1 The odds of ulnar neuropathy increase when one arm or both arms are tucked during procedures (odds ratio = 6.16, 95% confidence interval = 1.85 to 20.59, P = .003). 9 AORN provides a conditional recommendation for using intraoperative neurophysiological monitoring, such as somatosensory evoked potentials, to identify possible injuries. 1 Such monitoring detects electrophysical conduction changes associated with nerve damage and alerts personnel that repositioning is needed to avoid injury.…”

Anesthesia Patient Safety: Next Steps to Improve Worldwide Perioperative Safety by 2030

“…For example, the incidences of perioperative vision loss associated with spine surgery and ulnar neuropathy had 65% and 85% reductions, respectively. 57,58 The rate of medical malpractice claims per 100 anesthesiologists decreased from 4.9% to 3.2% during the period of 2010 to 2019. 59 The percentage of closed claims involving an anesthesiologist within the overall number of closed claims for all specialties fell from 11.7% in 2010 to 8.0% in 2019.…”