Acute compartment syndrome of the forearm and hand in a patient of spine surgery -A case report-.

Abstract

A 38-year-old woman underwent a 4-hour operation in the prone position for a laminectomy at C4-7 and posterior cervical decompressive fusion at C7-T1 under general anesthesia. After undraping at the end of surgery, considerable swelling with many blisters of the left forearm and hand was observed. The chest roll at the left side had moved cephalad into the axilla and compressed the axillary structures. An emergency fasciotomy to decompress the compartments of the forearm and dorsal surface of the hand was performed. In the post anesthesia care unit, the radial pulse of the left hand was palpable and the level of oxygen saturation was normal. Forearm and hand edema subsided gradually over several days and the patient was discharged with full function of her left arm. This compartment syndrome suggests careful attention should be paid to the position of the chest roll when the prone position is established for a long duration.

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Korean J Anesthesiol 2010 July 59(1): 53-55
DOI: 10.4097/kjae.2010.59.1.53
Case Report
Copyright ⓒ Korean Society of Anesthesiologists, 2010
www.ekja.org
A 38-year-old woman underwent a 4-hour operation in the prone position for a laminectomy at C4-7 and posterior
cervical decompressive fusion at C7-T1 under general anesthesia. After undraping at the end of surgery, considerable
swelling with many blisters of the left forearm and hand was observed. The chest roll at the left side had moved
cephalad into the axilla and compressed the axillary structures. An emergency fasciotomy to decompress the
compartments of the forearm and dorsal surface of the hand was performed. In the post anesthesia care unit,
the radial pulse of the left hand was palpable and the level of oxygen saturation was normal. Forearm and hand
edema subsided gradually over several days and the patient was discharged with full function of her left arm. This
compartment syndrome suggests careful attention should be paid to the position of the chest roll when the prone
position is established for a long duration. (Korean J Anesthesiol 2010; 59: 53-55)
Key Words: Axilla, Compartment syndrome, Prone position.
Acute compartment syndrome of the forearm and hand in a
patient of spine surgery
-A case report-
Jung-Ah Lee, Yeon Soo Jeon, Hong Soo Jung, Hyung-Gun Kim, and Yong Shin Kim
Department of Anesthesiology and Pain Medicine, St. Vincent Hospital, Catholic University of Korea, Suwon, Korea
Received: September 16, 2009. Revised: 1st, October 1, 2009; 2nd, October 14, 2009. Accepted: October 23, 2009.
Corresponding author: Yong Shin Kim, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, St. Vincent Hospital, Catholic University
of Korea, 93, Ji-dong, Paldal-gu, Suwon 440-060, Korea. Tel: 82-31-249-7214, Fax: 82-31-258-4212, E-mail: aneskim@catholic.ac.kr
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.
CC
Intraoperative compartment syndrome is reported infrequently
but is a potentially devastating perioperative complication that
typically involves the legs or arms [1]. Most surgical patients
have this problem while being anesthetized for a long duration
and positioned in lithotomy or lateral decubitus [2].
We recently encountered compartment syndrome in a patient
in the prone position. This report describes a case of forearm
and hand compartment syndrome resulting from compression
of the axillary structure due to a displaced chest roll in a patient
in the prone position during spine surgery.
Case Report
A 38-year-old, 160 cm, 60 kg woman, American society of
anesthesiologist physical status 1, with quadriparesis from
ossification of the posterior longitudinal ligament at C4-T1
and myelopathy was scheduled for a laminectomy at C4-7 and
posterior cervical decompressive fusion at C7-T1. Her previous
medical history was unremarkable. The routine monitors
including an electrocardiogram, noninvasive blood pressure
(NIBP), and pulse oxymetry were used. General anesthesia was

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Acute compartment syndrome
Vol. 59, No. 1, July 2010
induced with intravenous 1% lidocaine 40 mg, propofol 120 mg
and rocuronium 50 mg via a preexisting 18-gauge IV catheter
in the vein on the left antecubital area without difficulty. The
trachea was intubated, and ventilation was controlled. General
anesthesia was maintained with 6 vol% desflurane and 50%
N2O in oxygen. A right radial artery catheter was inserted
successfully to allow continuous monitoring of the arterial
blood pressure. A 16-gauge catheter was also placed in a large
vein on the dorsal surface of the left foot. It was confirmed that
both intravenous catheters functioned well. The patient was
then placed in the prone position on the operating table. The
patient’s arm was tucked at her sides with her palms facing
inward against the lateral thighs under the draw sheet.
To prevent a risk of chest compression, two chest rolls were
placed under the both lateral chest walls. The placement of
chest rolls was checked to confirm that they had been placed
correctly under the medial wall of the axilla. No surgical bolster
or padding was applied under the axilla because her arms
had been tucked to her side. The NIBP was measured using
an automated oscillatory blood pressure cuff on the left upper
arm every 20 minutes and a pulse oximeter probe was placed
on the right thumb. All medication was injected through the
IV catheter on the left foot, not into the left arm. The patient
received 700 ml of a crystalloid solution through the left arm IV
catheter. Nothing unusual was noted intraoperatively. However,
the area of the left arm covered with drapes was unavailable for
a direct inspection. The operation lasted for 4 hours.
After undraping at the end of surgery, the left forearm and
hand of the patient were found to be quite swollen with many
blisters (Fig. 1). The left upper extremity was very cool and
cyanotic, and the radial pulses were not palpable well. The
pulse oximeter did not detect any waveforms on the left hand.
Digital capillary refill was found to be delayed compared to
the contralateral extremity. The NIBP cuff and left antecubital
catheter were removed. A hand surgeon was rapidly consulted
and a fasciotomy was performed on the forearm and dorsal
surface of the hand to reduce the increased pressure of the
compartments. A large amount of fluid, which was likely to
be an extravasated crystalloid solution, was drained when the
surgeon squeezed the patient's arm during the fasciotomy.
The patient was extubated in the operating room. In the post
anesthesia care unit, a physical examination revealed palpable
radial arterial pulses and normal capillary refilling. The pulse
oximeter probe successfully detected a waveform and an
arterial saturation appeared to be 100%. In the intensive care
unit, edema of the forearm and hand gradually subsided over
several days. She was discharged with full function of her left
arm.
Discussion
Compartment syndrome is defined as a condition in which
the circulation and function of the tissues within a closed
space are compromised by increased pressure within that
space [3]. Compartment syndromes related to anesthesia
have been reported to occur with drug extravasation [4,5],
pressurized IV fluids [6], hypertonic saline [7], attempts at
cannulating arteries [8,9], and intraarterial barbiturates [10].
Regardless of the etiology, the pathophysiology is an increasing
intracompartmental pressure that hinders microcirculatory
perfusion, which can result in ischemic injury to the muscle,
nerves and other compressed structures.
The most common postoperative compartment syndrome
is posterior compartment syndrome of the leg from direct
pressure of the calf muscles due to the lithotomy position [11].
However, compartment syndrome of the forearm is being
increasingly recognized [4,5,8,9].
A diagnosis of compartment syndrome is based on evidence
of tissue ischemia, such as pain, pallor, diminished sensation,
motor weakness in addition to compartment swelling and
tightness on the examination. A definitive diagnosis is made
after direct measurements of the intracompartmental pressure.
A diagnosis of compartment syndrome is difficult in an
anesthetized patient, in which the early signs and symptoms can
be masked by the anesthesia. Therefore, intraoperative vigilance
and ongoing patient assessment by the anesthesiologist is
essential for making a timely diagnosis and minimizing the risk
of permanent injury. Monitoring of the upper extremities with
an intraarterial pressure wave and pulse oximetry can lead to
the earlier detection of an increased compartmental pressure.
Once the syndrome is recognized, an immediate fasciotomy
to decompress the neurovascular compartment is essential
to prevent further ischemia and decrease the level of nerve
Fig. 1. Swollen left forearm and hand with many blisters.

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Korean J Anesthesiol
Lee, et al.
dysfunction. A fasciotomy will allow acutely edematous
muscles to bulge through the divided fascia, which will
relieve the pressure on the neurovascular bundle. Increases
in compartment pressure lasting longer than 12 hours are
associated with chronic functional defects, including sensory
changes, motor weakness and eventual contractures [12].
Accordingly, prompt recognition of compartment syndrome in
the immediate postoperative period is essential for preventing
muscle and nerve necrosis and, ultimately, severe disability.
In this case, there were several factors that adversely affect
the local tissue blood flow and perfusion and predispose
the patient to compartment syndrome of the forearm. This
study suggests that the chest roll at the left side, placed under
the medial wall of the axilla, had moved cephalad into the
axilla and compressed the axillary structures. In addition, the
blood pressure cuff had been applied to the left arm and the
noninvasive blood pressure was measured repeatedly using an
automated oscillatory blood pressure cuff. This also could pose
a risk of prolonging the partial venous obstruction and possibly
even reduce the arterial blood flow in the left arm. In addition, a
maintenance crystalloid solution was administered through the
left antecubital vein. Extravasation of the fluids may be one of
the causes resulting in compartment syndrome in this patient
because an increase in pressure within a limited space restricts
the circulation to the area leading to ischemia. Consequently,
the significantly swollen cyanotic forearm with many blisters in
this patient was caused by a displaced chest roll, repeated cuff
pressure and extravasation of fluid.
This type of syndrome might conceivably arise in the
operating room where the patient is lying in deep anesthesia
for a prolonged period. Therefore, care for safe positioning
during anesthesia is essential to avoid these pressure
problems. A frequent assessment of an extremity with an
indwelling IV catheter should be made by the anesthesiologist
because perioperative compartment syndrome can occur in
conventional conditions of care. In addition, it is recommended
that fluid be infused in an observed intravenous site if possible.
In conclusion, a displaced chest roll for a prolonged
procedure in the prone position may result in compartment
syndrome of the upper extremity, which can be complicated
by the administration of IV fluid in the same side, even in an
uncomplicated patient. Surgeons and anesthesiologists need
to be alert to the possibility of a compartment syndrome,
particularly when the patient is unable to communicate with
the medical team.
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