A 61‐year‐old man developed acute renal failure and difficulty ambulating 2 days after radical perineal prostatectomy. He complained of bilateral lower leg pain, numbness, tingling in his toes, and shooting pains in his anterior thighs. He denied any upper‐extremity complaints. He noted normal urine output. His medical history was notable for chronic kidney disease stage II. He was morbidly obese. He had clear lungs and his abdomen was nondistended. He had pitting lower‐extremity edema to his knees, bilateral foot drop, and sensory changes on his upper lateral thighs. The remainder of his neurologic exam was normal. Creatinine was 2.0 mg/dL up from a baseline of 1.4 mg/dL. Urinalysis revealed large blood with >182 RBC/HPF. Urine eosinophils were negative. Creatine kinase was 42,216 IU/L Liver function tests revealed AST 1043 IU/L and ALT 271 IU/L Review of the operative report revealed that he had been placed in the extended dorsal lithotomy position. However, because of his body habitus, adjustments to the usual position were necessary to maintain his difficult airway. Based on his exam and labs, he was diagnosed with rhabdomyolysis, peroneal neuropathy, and meralgia paresthetica secondary to surgical positioning.
Positioning of a morbidly obese patient can be a technical challenge, and complications including muscle breakdown and peripheral nerve compression can result from undue pressure. Rhabdomyolysis is a potentially serious complication that can result from surgical positioning, particularly in urologic and gynecologic procedures. Predisposing factors include obesity and longer operative time. Investigation for rhabdomyolysis should be considered in postoperative patients with myalgias, abnormal urinalysis, or worsening renal function, as aggressive hydration may minimize renal injury. Peroneal neuropathy, often manifested by foot drop, is the most common compressive neuropathy of the lower extremities. It is classically associated with compression of the nerve at the level of the fibular head which can occur in urologic, gynecologic, and abdominal surgeries and can be a rare complication of knee arthroplasty and tibial plateau repair. Meralgia paresthetica, compressive neuropathy of the lateral femoral cutaneous nerve, presents as pain and burning in the outer anterior thighs. Treatment for these compressive neuropathies is mostly supportive.
Hospitalists care for many postoperative patients and should be aware of complications that can result from surgical positioning.