Anesth Analg 2007; 105:1747-1748
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000286232.69415.fa
GENERAL ARTICLES
Bilateral Sciatic and Femoral Neuropathies, Rhabdomyolysis, and Acute Renal Failure Caused by Positioning During Radical Retropubic Prostatectomy
Jonathan V. Roth, MD
From the Thomas Jefferson School of Medicine, Philadelphia, Pennsylvania.
Address correspondence and reprint requests to Department of Anesthesiology, Albert Einstein Medical Center, 5501 Old York Rd., Philadelphia, PA 19141. Address e-mail to rothj{at}einstein.edu.
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Abstract
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In the hyperlordotic position, the patient’s hips are above the feet and head. We present a case of rhabdomyolysis, acute renal failure, and bilateral femoral and sciatic neuropathies caused by this position.
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Introduction
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During radical retropubic prostatectomy (RRP), patients are often hyperextended with the kidney rest elevated in order to increase the puboumbilical distance so as to improve surgical exposure. We report a case in which excessive hyperextension likely led to rhabdomyolysis, acute renal failure (ARF), and bilateral femoral and sciatic nerve injuries.
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CASE REPORT
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A 53-yr-old, 6 ft. 2 in. (188 cm), 136 kg, man underwent a RRP for prostate carcinoma (Gleason score = 6). His medical history included obesity (body mass index = 38.5 kg/m2), noninsulin-dependent diabetes mellitus, and hypertension. His preoperative laboratory findings were prostate-specific antigen 9.5, hemoglobin 13.7 g/dL, hematocrit 41.7%, platelet count 370,000/µL, prothrombin time 11.9 s (international normalized ratio = 1.0), partial thromboplastin time 26.8 s, Na 138 mmol/L, K 4.0 mmol/L, Cl 102 mmol/L, CO2 24 mmol/L, random glucose 222 mg/dL, Ca 8.8 mg/dL, blood urea nitrogen 13 mg/dL, creatinine 1.0 mg/dL. Liver function studies were within normal limits. Cardiac echocardiography revealed normal left ventricular function and left ventricular hypertrophy. A chest radiograph showed mild cardiac enlargement with left ventricular prominence and no evidence of metastatic disease. His preoperative chronic medications included amlodipine 10 mg qd, glimepiride 1 PO qd, and chlorpropamide 50 mg bid. His electrocardiogram displayed a nonspecific T wave abnormality, occasional premature ventricular contractions, and left ventricular hypertrophy by voltage criteria. The patient was started on metoprolol 25 mg PO every 12 h, preoperatively.
Before anesthetic induction, the patient received 4 mg midazolam and 100 µg fentanyl. After arterial line insertion, a rapid sequence anesthetic induction was performed with 150 µg fentanyl, 625 mg sodium thiopental, and 200 mg succinylcholine. Anesthesia was maintained with 50% oxygen, 50% nitrous oxide, isoflurane 1%, and cisatracurium. Neuromuscular blockade was reversed with glycopyrrolate and neostigmine. Morphine sulfate was administered both intraoperatively and postoperatively for analgesia.
To increase the puboumbilical distance and displace the large abdominal pannus cephalad, the surgeon requested that the kidney rest be elevated and the patient hyperextended. The surgeon then applied 4 in. tape to displace the abdominal pannus cephalad. After the table was flexed as per the surgeon’s request, it was noted that except for his heels, the patient’s thighs and legs were not in contact with the operating room table. The table flexion was then partially reversed, so that the thighs and legs made contact with the table without causing any obvious change to the topography of the surgical site. In addition, folded blankets were placed under the patient’s thighs and legs in order to help support the weight of the lower extremities (Fig. 1).
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Figure 1. The cartoon illustrates the final position with the table flexed approximately 10–15 degrees. Tape was applied to displace the abdominal pannus cephalad. Folded blankets were placed under the patient’s lower extremities to help support the weight of the lower extremities and reduce the extension of the body to less than that of the table.
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Skin-to-skin operative time was 5 h and 32 min. During the case, the surgeon repeatedly complained about difficult exposure and had to reposition the deep retractors several times. Estimated blood loss for the entire case was 1600 mL, for which the patient received 3 U cell saver blood, 1 L lactated Ringer’s solution, and 4 L 0.9% sodium chloride. The lowest recorded systolic arterial blood pressure was 100 mm Hg, measured via a radial arterial line. During the case, the patient received indigo carmine and furosemide. Intraoperative blood glucose determinations were 294 and 321 mg/dL. Although it was not possible to determine intraoperative urine output, the patient produced 400 mL of blue urine in the postoperative care unit.
The patient was tracheally extubated in the operating room. In the postoperative care unit, the patient reported that he had lower back pain and was unable to move his legs. A neurology consult was obtained. The neurologist initially assessed the patient as having a "L3 spinal cord lesion." The working assumption was that the patient suffered spinal cord compression from a herniated disk secondary to his intraoperative position. The patient received 30 mg/kg methylprednisolone followed by a 5.4 mg · kg–1 · h–1 infusion for 23 h for a presumed spinal cord injury. The resultant hyperglycemia was treated with an insulin drip. A magnetic resonance image (MRI) could not be obtained until the following day.
On postoperative day #1 the patient was transferred to a regional spinal cord injury center and a MRI revealed congenital spinal stenosis (diffuse narrowing), edema in the posterior paraspinal muscles (consistent with diabetic motor neuropathy, medication-induced myositis, polymyositis, and rhabdomyolysis), and at L5-S1, spondylolysis, concentric disk bulge which indented the ventral thecal sac, mild bilateral facet hypertrophy, and mild bilateral neural foramina narrowing. The conus medullaris was normally positioned at L1. There was no spinal cord infarction and no epidural hematoma. A repeat MRI several days later revealed bilateral gluteal, psoas, and lumbar paraspinal muscle necrosis.
Table 1 shows pertinent intraoperative and postoperative laboratory studies. The patient required hemodialysis starting postoperative day #4 for 51 days. The ARF was attributed to rhabdomyolysis.
Subsequent left-sided electromyogram and nerve conduction studies yielded a diagnosis of femoral and sciatic neuropathy. The right side was not studied, as it was presumed that the same conditions existed with the right femoral and sciatic nerves.
The remainder of his hospital course was remarkable for an episode of atrial fibrillation/flutter; hypotension secondary to a pelvic hematoma requiring blood transfusion, tracheal intubation, and catecholamine support which resulted in shocked liver; urinary tract infection; and ileus requiring total parenteral nutrition.
After a prolonged acute care hospitalization, the patient was transferred to a rehabilitation hospital. Two years after surgery, the patient has and continues to show gradual neurologic improvement. He can now walk a short distance with a walker.
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DISCUSSION
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The neuropathies, rhabdomyolysis, and ARF were likely caused by the hyperlordotic position. Tung et al. recently reviewed the previously reported complications of the hyperlordotic position and reported fulminant liver failure after RRP in a patient positioned in the hyperlordotic position (1). This report adds to our knowledge of the potential complications associated with the hyperlordotic position.
The immediate postoperative concern was that the patient suffered a spinal cord injury secondary to his intraoperative positioning. Because he was asymptomatic preoperatively, it was not known that he had spinal stenosis. Extension of the lumbar spine will reduce the cross-sectional area of the central canal (2). With severe grades of lumbar stenosis, even the slightest degree of extension may compress neural elements (2). Ultimately, it was determined that there was no spinal cord injury. However, it would seem reasonable to evaluate patients for lumbar stenosis before extreme intraoperative hyperlordosis.
The most likely mechanism for injury to the femoral and sciatic nerves are nerve stretch and nerve compression. Deeply placed femoral retractors can cause femoral nerve injury (3). There is also potential for a stretch injury, since the femoral nerves course anterior to the hip joints and there was hyperextension of the patient’s thighs. The structures in the buttocks, including the sciatic nerve, were probably under increased pressure for approximately 6 h, since the buttocks were partially supporting the weighty lower extremities.
The ARF was almost certainly a result of rhabdomyolysis secondary to a muscle crush injury. Three cases of rhabdomyolysis and ARF have been reported after radical perineal prostatectomy (4–6). These patients were in an extreme lithotomy position for long durations (5, 6, and 6.5 h) and were overweight (95, 118, and 123 kg). Rhabdomyolysis was attributed to compression and ischemia of pelvic and lumbar muscles. Another patient developed rhabdomyolysis of the lumbar muscles and subsequent ARF when a hyperlordotic position was maintained for 11 h during a pancreatoduodenostomy by inflating the bladder of a blood pressure cuff under the lower thoracolumbar spine (7).
In summary, this report presents a case of extreme hyperextension of the lumbar spine in an obese patient leading to bilateral femoral and sciatic nerve injuries, rhabdomyolysis, and ARF.
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Footnotes
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Accepted for publication August 6, 2007.
Worked performed at Albert Einstein Medical Center.
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REFERENCES
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- Tung A, Roth S, O’Connor MF. Liu W, Ellis JE. Fulminant liver failure after radical prostatectomy in the hyperlordotic position. Anesth Analg 2006;103:986–8[Abstract/Free Full Text]
- Porter R. Instability and central spinal stenosis. In: Szpalski M, Gunzburg R, Pope MH, eds. Lumbar segmental instability. Philadelphia, PA: Lippincott, Williams & Wilkins, 1999:91–4; Chap 9
- Warner M. Perioperative neuropathies, blindness, and positioning problems. American Society of Anesthesiologists Annual Meeting Refresher Course Lectures 2003;#115
- Guzzi LM, Mills LM, Greenman P. Rhabdomyolysis, acute renal failure, and the exaggerated lithotomy position. Anesth Analg 1993;77:635–7[Free Full Text]
- Bruce RG, Kim FH, McRoberts JW. Rhabdomyolysis and acute renal failure following radical perineal prostatectomy. Urology 1996;47:427–30[ISI][Medline]
- Ali H, Nieto JG, Phamy RK, Chandarlapaty SK, Vaamonde CA. Acute renal failure due to rhabdomyolysis associated with the extreme lithotomy position. Am J Kidney Dis 1993;22:865–9[ISI][Medline]
- Uratsuji Y, Ijichi K, Irie J, Sagata K, Nijima K, Kitamura S. Rhabdomyolysis after abdominal surgery in the hyperlordotic position enforced by pneumatic support. Anesthesiology 1999; 91:310–2[ISI][Medline]
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Abstract
Introduction
