Arm Positioning
Monitoring for brachial plexus palsy when arms are in superman position is a common issue with surgery. If the arms aren't positioned correctly, and/or the patient has cervical deficits that are unknown that contribute to a lumbar case a palsy can occur rendering the patient without function of one or both upper extremities.
To ensure proper flow of electrons through the complicated brachial plexus web of nerves, the first step is proper positioning:
For greater success, the following system is followed: arms are set in superman position with 90 degree angles at the shoulder to the torso and elbow are positioned with the forearm parallel to the floor in the initial position. Ensure that the arm is floating, meaning that there is easy movement of the shoulder and elbow and there is no visible pressure. foam padding at the forearm which extends to the elbow and wraps underneath the arm to the armpit is idea.
Monitoring of SEP from ulnar nerve stimulation is the most sensitive for positioning changes and MEPs of the hands and forearm can be used in conjunction for the best information.
Establish baseline evoked potential measurements noting any anomalies; amplitude, latency and morphology of wave, Make adjustments to stimulation parameters to establish the most repeatable and reliable wave. Adjust electrodes and anesthesia as necessary. Set the upper extremities on a timer for 10 minutes minimum (approximately 5-10 minutes) and observe any changes from baseline measurements.
Changes in the SEP can be immediate where the arm needs to be repositioned before draping or slowly over time where a trend can be observed (Waterfall). Make not of any amplitude, latency or morphology changes over time and if a change is noticed, alert the surgeon and anesthesia and reposition the arm and look for any return to signal.
To ensure proper flow of electrons through the complicated brachial plexus web of nerves, the first step is proper positioning:
For greater success, the following system is followed: arms are set in superman position with 90 degree angles at the shoulder to the torso and elbow are positioned with the forearm parallel to the floor in the initial position. Ensure that the arm is floating, meaning that there is easy movement of the shoulder and elbow and there is no visible pressure. foam padding at the forearm which extends to the elbow and wraps underneath the arm to the armpit is idea.
Monitoring of SEP from ulnar nerve stimulation is the most sensitive for positioning changes and MEPs of the hands and forearm can be used in conjunction for the best information.
Establish baseline evoked potential measurements noting any anomalies; amplitude, latency and morphology of wave, Make adjustments to stimulation parameters to establish the most repeatable and reliable wave. Adjust electrodes and anesthesia as necessary. Set the upper extremities on a timer for 10 minutes minimum (approximately 5-10 minutes) and observe any changes from baseline measurements.
Changes in the SEP can be immediate where the arm needs to be repositioned before draping or slowly over time where a trend can be observed (Waterfall). Make not of any amplitude, latency or morphology changes over time and if a change is noticed, alert the surgeon and anesthesia and reposition the arm and look for any return to signal.