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Prevention of Perioperative Brachial Plexus Injury: A Modified Position

DOI https://doi.org/ 10.1055/s-0038-1660529 ISSN 2348-0548. Copyright ©2018 Indian Society of Neuroanaesthesiology and Critical Care Brachial plexus injury is an important perioperative con­ cern related to patient positioning. Digital subtraction angi­ ography and radiological interventions of the thoracic spinal cord require the positioning of the upper limb such that it does not create any artifact during imaging of the spinal vasculature. The usual positioning of the arms during these procedures entails the risk of brachial plexus injury, though there are not much data available on it till date1 (►Fig. 1A). We suggest a new technique of patient positioning during endovascular procedure of upper thoracic spinal dural arte­ riovenous fistula, under fluoroscopy. A 25­year­old man weighing 54 kg diagnosed to have upper thoracic dural arteriovenous fistula was scheduled for endovascular embolization. Preanesthetic evaluation was unremarkable. General anesthesia was induced with intra­ venous fentanyl 100 μg and propofol 100 mg. Rocuronium 50 mg was administered for muscle relaxation to facilitate tracheal intubation with an 8.5­mm ID endotracheal tube. Anesthesia was maintained with sevoflurane in oxygen, nitrous oxide mixture and intermittent doses of rocuroni­ um and fentanyl. The patient is usually positioned supine such that during fluoroscopy the arms remain away and do not create artifact in the field of interest. For this case, we adopted a new position in which the patient was placed supine with both the shoulders and elbows flexed at 90 degrees such that part of the forearm rests on the head and the wrist remains in neutral position. Upper extremities were strapped in this position with adequate soft protective padding between strap and elbow (►Fig. 1B). Procedure was uneventful and lasted for 5 hours. Neuromuscular block was reversed, trachea extubated, and the patient was shifted to the ward at the end of procedure. Immediate postoperative course was uneventful. The patient did not have any sensory or motor loss nor did he complain of pain in shoulders during postoperative period. He was followed up till 5 days until discharge for home.