Improper positioning during surgery may result in neurologic damage that could be permanent. In a right thoracotomy procedure using the lateral decubitus position the standard of care addresses two concerns about a patient's position that the surgeon in charge of the operation must keep in mind. One concern is that the "down arm" (i.e., the arm that is below the patient's torso while the patient is in the lateral decubitus position) will be positioned out from the torso with proper support, typically on an arm board, and that a pillow or roll will be placed at the pressure points, primarily in the patient's armpit (i.e., an axillary pillow). Incorrect positioning of the "down arm" or failure to provide proper support can cause a "crush injury" to the soft tissues of that "down arm," including damage to nerves. The second concern is for the "up arm" (i.e., the arm that is above the patient's torso) which is positioned in such a way that it is out of the operative field by extending it out at less than 90 degrees in front of the torso. Incorrect positioning of the "up arm," by overly extending upward across the face, can stretch the brachial plexus (i.e., the collection of nerves in the armpit area that innervate the arm). This traction can be severe enough to cause permanent neurologic damage which is what happened here.
The anesthesiology standard of care for a thoracotomy procedure with a patient in a lateral decubitus position requires that the "up arm" (here, the right arm) is positioned and maintained by the anesthesiologist safely so as not to stretch the brachial plexus. It is also necessary to make sure that the "up arm" is not resting against a boney structure of the head or face (e.g., the jaw bone), which could be a point of continuous pressure against internal soft tissues such as nerves and blood vessels and thus a potential source of injury to them.
Patient positioning during anesthesia medical expert witness specialties include anesthesiology, obstetric anesthesiology, cardiac anesthesiology, orthopaedic surgery, general surgery, neurosurgery, plastic surgery, and neurology.