COMPARTMENT syndrome is a potentially devastating postoperative complication that can occur during or after surgery. It is a tissue injury that causes pain, erythema, edema, and hypoesthesia of the nerves in the affected area. In general, fasciotomy must follow clinical diagnosis quickly to prevent permanent tissue damage. 1If undiagnosed or diagnosed late, it may cause severe rhabdomyolysis, irreversible nerve deficits, loss of limb, or even death. A high proportion of cases have been reported to occur in patients undergoing surgical procedures while in the lithotomy position. 1–12
Perioperative compartment syndrome for which there is no readily apparent cause (e.g. , secondary to trauma or arterial embolism after vascular surgery) is not well-understood. Therefore, we reviewed the outcomes of a large number of surgical procedures to determine this complication’s frequency and to further characterize its natural history and outcomes.
With Mayo Institutional Review Board approval, the medical database at Mayo Medical Center, Rochester, Minnesota, was reviewed to glean the data of all patients who had undergone an index (i.e. , initial) surgical episode and, within 5 days, a subsequent fasciotomy during the 10-yr study period from July 1, 1989 to June 30, 1999. Each unique anesthetic was considered to represent a single surgical episode, regardless of the number of procedures performed during that anesthesia. We attempted to glean only cases in which perioperative positioning or some unrecognized characteristic or event may have caused the compartment syndrome. Therefore, cases of compartment syndrome that occurred in traumatized limbs or limbs that were subject to ischemia from vascular surgical procedures were excluded. All surgical episodes must have been performed while patients underwent general or regional anesthesia or local anesthesia with or without sedation. A single trained reviewer abstracted all records. Outcomes of these patients at least 2 yr after the index surgeries were obtained. A survey of the impact of the syndrome on daily activities, rated as mild, moderate, or major, was obtained from all patients with persistent neurologic dysfunction of at least 2 years’ duration. Mild impact was defined as “often noticeable but not associated with any limitation of activities of daily living.” Moderate impact was defined as “always noticeable and associated with some limitation of one or more activities of daily living.” Major impact was defined as “always noticeable and associated with significant limitation of multiple activities of daily living.”
The frequency of compartment syndrome was calculated along with the corresponding 95% confidence interval. The frequencies of compartment syndrome for various patient positions were compared with the frequency of this event in patients in the supine position using the Fisher exact test. Because less than 20 cases were identified, a case–control evaluation for risk factors was not performed.
During the study period, 499,214 patients underwent 572,498 surgical episodes. Nineteen percent (95,269) underwent more than one surgical episode. The anesthetic care provided during the 572,498 surgical episodes included general or combined general and regional anesthetics in 401,567 episodes (70.1%), regional anesthetics in 62,133 episodes (10.9%), and local anesthetics or sedation in 108,798 episodes (19.0%). The predominant patient position during these 572,498 surgical episodes was supine in 462,204 episodes (80.1%), lithotomy in 52,319 episodes (9.1%), lateral decubitus in 19,422 episodes (3.4%), and either prone, other positions, or unknown in 38,553 episodes (6.7%). Just over half of the 499,214 patients were female (52.2%, n = 260,591). The mean age (± SD) of the surgical population was 49.2 ± 18.3 yr, with ages ranging from 0 to 108 yr.
Overall, 485 of the 499,214 patients (0.1%) underwent a fasciotomy. Just over half of these patients (51.3%, n = 249) underwent this procedure secondary to trauma. Compartment syndrome developed in 173 patients (35.7%), necessitating fasciotomy within 48 h of a vascular surgical procedure. Eighteen patients (3.7%) experienced the syndrome after an arterial embolic event associated with recent onset of atrial fibrillation, 12 patients (2.5%) had a perfusion-limiting lower extremity cancer of the bone or vasculature, and 20 patients had a variety of miscellaneous conditions. There was no apparent preexisting cause for compartment syndrome in 13 patients (2.7%). The patient and procedure characteristics and outcomes of these 13 patients are described in table 1.
The frequency (and 95% confidence interval) for compartment syndrome requiring fasciotomy in the absence of apparent preexisting causes was 2.3 per 100,000 surgical episodes overall (1.2–3.9 per 100,000). The same figures for this event in only those patients to whom general anesthetics were administered during their surgical episodes were 3.2 per 100,000 patients (1.7 to 5.5 per 100,000). It was more likely to occur in patients who underwent procedures while in the lithotomy or lateral decubitus positions than in a supine position. This problem developed in 5 of the 462,204 patients in a supine position (1 per 92,441). In contrast, it developed in 6 of 52,319 patients in the lithotomy position (1 per 8,720) and 2 of 19,422 patients in the lateral decubitus position (1 per 9,711). The event frequencies for patients in the lithotomy and lateral decubitus positions were much higher (P < 0.001 and P = 0.03, respectively) than the frequency for patients in a supine position.
There were few characteristics that distinguished the 13 patients in whom compartment syndrome developed with no apparent preexisting cause. Their ages ranged from 17 to 67 yr; they underwent a variety of procedures, ranging from reimplantation of fingers to hemipelvectomy; and they were positioned in a variety of surgical configurations. All underwent procedures during administration of general anesthetics. The one noteworthy characteristic was their relatively long surgical procedures. These ranged from 3.2 to 15.7 h, with an average duration of 7.2 h. In contrast, the average duration of procedures for all patients during this 10-yr study period was 2.7 h.
Compartment syndrome always was characterized by pain and compartment pressures of 50 mmHg or greater. Although swelling and sensory loss of the affected limbs were common, they were not ubiquitous (table 1). Eight patients (61%) had the syndrome in one leg, two patients (15%) had bilateral involvement of their legs, and three patients (23%) had compartment syndromes of an upper extremity. The average time from the end of surgery to the first noted symptoms was 40 h (range, 6–78 h). Compartment pressures usually were measured in at least two compartments of affected extremities, and the pressures ranged from 50 to 90 mmHg.
Postfasciotomy surveillance was obtained for all patients, either until resolution of their neurologic symptoms or, for those who had persistent symptoms, for at least 2 yr. The symptoms of six patients resolved within the first year, including two who had complete neurologic recoveries within 2 weeks of fasciotomy. Six of the remaining seven patients had persistent neurologic deficits and pain of at least 2 years’ duration. One patient, a 36-yr-old man who underwent a 6.3-h craniotomy in a lateral decubitus position, had development of compartment syndromes in his left forearm and hand, resulting in arterial thrombosis and eventual forearm amputation on the fourth postoperative day. In a surveillance survey of the seven patients with persistent deficits of at least 2 years’ duration, one patient reported that her disability mildly impacted her daily living functions, three reported a moderate impact on daily functions, and three described the impact as major.
Compartment syndrome is considered to occur primarily in patients who undergo procedures while in the lithotomy position. Our data confirm that compartment syndrome is more likely to develop with no apparent cause when the patient is in the lithotomy position than in a supine position. However, we were surprised by three of our findings: (1) patients in lateral decubitus positions unexpectedly had a high frequency of compartment syndrome, (2) compartment syndromes necessitating fasciotomies of the upper extremities developed in three patients (23%), and (3) nearly half of the patients in whom compartment syndromes developed in the lower extremities underwent procedures while in the supine position. There are few case reports of upper extremity compartment syndrome with causes other than trauma or vascular surgery. With the exception of a few reports of compartment syndrome developing in the lower extremities of patients who were positioned prone in “tucked,”“kneeling,” or “knee-chest” positions for lumbar spine surgery, 13–15nearly all other reports of position-related compartment syndrome of the lower extremities occur in patients undergoing procedures while in the lithotomy position.
The cases of upper extremity compartment syndrome were unexpected. Nambisan and Krakousis 16have described a young adult in whom a compartment syndrome of the downside shoulder, arm, and forearm developed 1 day after a 9-h procedure in a lateral decubitus position to remove a tumor from the thoracic vertebrae. The authors speculated that the “axillary” or chest roll under the medial wall of the axilla either was too thin to elevate the chest wall to relieve pressure on the axillary structures or had moved cephalad into the axilla and compressed the axillary structures. Martin 1has reported the malpractice action of a patient in whom an isolated forearm compartment syndrome and anterior interosseous neuropathy developed. The plaintiff alleged that a binder used to retain his supinated forearm on an arm board during general anesthesia and surgery was too tight or compressive and caused the complication. Unfortunately, there is insufficient information (e.g. , size or position of the axillary roll or compressive effect of arm binders) known about our three cases to speculate on the cause. Two of our patients who had compartment syndromes were in the lateral decubitus position, and the problem occurred in their dependent extremities. Our third patient was in the supine position, with both arms tucked at the sides, and compartment syndrome of his right forearm developed.
Most case reports describe lithotomy positioning as the major predisposing factor to compartment syndrome in the lower extremities. 1–12Martin 1notes that characteristics of lithotomy positions that may increase the risk of compartment syndrome include increasing weight of the lower extremities against supportive devices, reducing compartment capacity, and elevation of the lower limbs above the heart, decreasing perfusion pressure to them. Four of our 10 patients in whom lower extremity compartment syndromes developed underwent procedures while in supine and flat positions. Three of these patients were fairly young and quite healthy; the third also was young and healthy except for the presence of a Ewing sarcoma in her right femur. In these cases, it appears that neither of these two characteristics of Martin 1was present.
We were unable to perform a risk factor analysis using case–control methodology because of the small number of cases. Clearly, the frequency of compartment syndrome with no apparent cause is higher in patients undergoing procedures while in the lithotomy and lateral decubitus positions compared with supine positions. However, long surgical duration is one other factor that occurs commonly in these 13 cases. The duration of our cases ranged from 3.2 to 15.7 h, all longer than our mean duration of 2.7 h for all cases performed during the study period. Intuitively, prolonged immobility or external compressive forces from a variety of sources, including positioning, and pathophysiologic changes within extremity compartments during long procedures and anesthetics may be etiologic factors. However, data from this study and numerous isolated case reports are insufficient to confirm any primary factors. The characteristics of these cases suggest that perioperative compartment syndrome can occur in apparently conventional conditions of care, for reasons that currently are beyond our understanding.
In summary, we found that compartment syndrome with no apparent cause necessitating fasciotomy occurred infrequently and in both the upper and lower extremities of patients in this surgical population. Patients in the lithotomy and lateral decubitus positions were more likely to have this problem than those in supine positions. Approximately one half of patients with compartment syndrome who underwent fasciotomy in this study population had persistent neurologic deficits and pain 2 yr afterwards.