Perioperative Peripheral Nerve Injury After General Anesthesia

A Qualitative Systematic Review

Jason Chui, MBChB; FANZCA; John M. Murkin, MD; FRCPC; Karen L. Posner, PhD; Karen B. Domino, MD, MPH


Anesth Analg. 2018;127(1):134-143. 

In This Article

Abstract and Introduction


Perioperative peripheral nerve injury (PNI) is a well-recognized complication of general anesthesia that continues to result in patient disability and malpractice claims. However, the multifactorial etiology of PNI is often not appreciated in malpractice claims given that most PNI is alleged to be due to errors in patient positioning. New advances in monitoring may aid anesthesiologists in the early detection of PNI. This article reviews recent studies of perioperative PNI after general anesthesia and discusses the epidemiology and potential mechanisms of injury and preventive measures. We performed a systematic literature search, reviewed the available evidence, and identified areas for further investigation. We also reviewed perioperative PNI in the Anesthesia Closed Claims Project database for adverse events from 1990 to 2013. The incidence of perioperative PNI after general anesthesia varies considerably depending on the type of surgical procedure, the age and risk factors of the patient population, and whether the detection was made retrospectively or prospectively. Taken together, studies suggest that the incidence in a general population of surgical patients undergoing all types of procedures is <1%, with higher incidence in cardiac, neurosurgery, and some orthopedic procedures. PNI represent 12% of general anesthesia malpractice claims since 1990, with injuries to the brachial plexus and ulnar nerves representing two-thirds of PNI claims. The causes of perioperative PNI after general anesthesia are likely multifactorial, resulting in a "difficult to predict and prevent" phenomenon. Nearly half of the PNI closed claims did not have an obvious etiology, and most (91%) were associated with appropriate anesthetic care. Future studies should focus on the interaction between different mechanisms of insult, severity and duration of injury, and underlying neuronal reserves. Recent automated detection technology in neuromonitoring with somatosensory evoked potentials may increase the ability to identify at-risk patients and individualize patient management.


Perioperative peripheral nerve injury (PNI) is a well-recognized complication. It has been increasingly recognized over the past few decades. The American Society of Anesthesiologists (ASA) Closed Claim Project (CCP) report on nerve injuries, first published in 1990[1] and updated in 1999,[2] heightened awareness of PNI. Multiple studies have revealed potential mechanisms of perioperative PNI and these have facilitated the development of preventative strategies. The ASA published the Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies, first in 2000,[3] updated in 2011[4] and 2018,[5] to promote safe and standard practices. However, the multifactorial etiology of PNI may not be appreciated in malpractice claims, with PNI often alleged to be related to errors in patient positioning on the basis of res ipsa loquitur ("the thing speaks for itself").[6] In addition, new advances in monitoring may aid anesthesiologists in early detection of PNI.

The purpose of this article is to comprehensively review perioperative PNI associated with general anesthesia and discuss the epidemiology, mechanism of injury, intraoperative monitoring, and prevention. Regional anesthesia-related traumatic nerve injuries and central nerve injuries will not be discussed.

A systematic literature search in PubMed and Embase was performed from January 1, 1960 to August 30, 2016 (Supplemental Digital Content, Table, We incorporated updated data from the Anesthesia (formerly ASA) CCP for adverse outcomes from 1990 to 2013 to reflect the medicolegal aspects of perioperative PNI. We also identified the most significant issues regarding PNI that require further investigation. The level of evidence of human studies presented in this review was graded according to the 2011 Oxford Centre for Evidence-Based Medicine Levels of Evidence.[7]