Compartment Syndrome after Spinal Surgery and Use of the Codman Frame

To the Editor:--Patients having posterior spinal surgery frequently are placed in various knee-chest positions to facilitate surgical exposure and decrease epidural venous engorgement. Compartment syndromes and accompanying renal failure have been reported as a consequence of limb compression occurring in these positions. ^[1-4] We report a case of lower extremity compartment syndrome occurring after lumbar laminectomy surgery using the Codman frame. The Codman frame consists of padded bolsters that allow the abdomen to hang free, and the thighs to be flexed toward the chest, while the patient is in the prone position.

A 34-yr-old, 110-kg. 73-inch-tall man underwent lumbar spinal surgery while positioned in the Codman frame for 5 h. The anesthetic management consisted of thiopental, succinylcholine, fentanyl, isoflurane, and pancuronium. The surgical procedure was uneventful. In the postanesthesia care unit, the patient appeared distraught and complained of bilateral leg numbness and calf pain. The patient's feet were cold, and the pedal pulses were absent. Laboratory tests revealed myoglobinuria and increased serum creatinine kinase. The patient required urgent surgical fasciotomy of both legs. The hospital course was complicated by urinary tract and clostridium dificile bowel infections, resulting in a hospital stay of 31 days.

Use of the Codman frame and other variations of knee-chest positioning involves the risk of compartment syndrome and the renal crush syndrome. ^[4] These positions can cause dangerous external compression of the legs, particularly in large patients undergoing lengthy procedures. Most authors agree that compartment pressures between 30 and 50 mmHg can cause muscle ischemia. Necrosis results if these pressures are maintained for periods of 4 h or longer.

The benefits of using the Codman frame and the knee-chest position must be weighed against its risks. A high index of suspicion of compartment syndrome facilitates an early diagnosis and expedites appropriate treatment of this serious complication.

Brigitte Kuperwasser, M.D., Assistant Professor, Blaine T. Zaid, D.O., Chief Resident, Rafael Ortega, M.D., Assistant Professor, Department of Anesthesiology Boston University Medical Center 88 East Newton Street Boston, Massachusetts 02118.

(Accepted for publication November 30, 1994.)