Perineural pressures under the pneumatic tourniquet in the upper extremity

The literature indicates that tourniquet-induced neurological injuries are relatively common and frequently occur at a subclinical level. In order to evaluate the pressure transmitted to the major peripheral nerves of the arm by an externally applied pneumatic tourniquet, a fully implantable biomedical pressure transducer was placed adjacent the radial, median and ulnar nerves in six cadaver upper extremities of average dimensions. This sensor allowed accurate, reproducible measurements of perineural pressures without requiring significant disruption of the normal anatomical structures of the test limb for its installation. At levels of tourniquet cuff inflation which are commonly used in clinical practice, there was little or no decrease in the pressure detected in the perineural regions over that applied to the surface of the limb. In addition, there was a steep gradient of perineural pressure between locations beneath the edge of the cuff and those under its midpoint. This was most marked at the highest levels of tourniquet inflation. At presently accepted levels of inflation, pneumatic tourniquet cuffs transmit high pressures to the peripheral nerves without any significant attenuation by the intervening soft tissues. The distribution of these forces is one which may subject the underlying nerves to deleterious shear forces, especially at higher levels of inflation.