More than what meets the eye in COVID-19 critical illness: A case report of bilateral femoral neuropathy due to psoas hematomas

Bilateral femoral neuropathy is rare, especially that caused by bilateral compressive iliopsoas, psoas, or iliacus muscle hematomas. We present a case of bilateral femoral neuropathy due to spontaneous psoas hematomas developed during COVID-19 critical illness. A 41-year-old patient developed COVID-19 pneumonia, and his condition deteriorated rapidly. A decrease in the hemoglobin level prompted imaging studies during his intensive care unit (ICU) stay. Bilateral psoas hematomas were identified as the source of bleeding. Thereafter, the patient complained of weakness in both upper and lower limbs and numbness in the lower limb. He was considered to have critical illness neuropathy and was referred to rehabilitation. Electrodiagnostic testing suggested bilateral femoral neuropathy because of compression due to hematomas developed during the course of his ICU stay. The consequences of iliopsoas hematomas occurring in the critically ill can be catastrophic, ranging from hemorrhagic shock to severe weakness, highlighting the importance of recognizing this entity.

Magnetic resonance imaging of femoral nerve injury in the setting of anterior approach total hip arthroplasty

PURPOSE

To illustrate MRI findings in patients with femoral neuropathy following anterior approach total hip arthroplasty (THA).

METHODS

This was a retrospective review of patients who underwent MRI for femoral neuropathy following anterior approach THA between January 1, 2010, and July 1, 2022. Included patients had no preexisting neurologic condition. Clinical and diagnostic data were collected. MRIs were reviewed in consensus by 2 musculoskeletal radiologists.

RESULTS

A total of 115 patient records were reviewed, 17 of which were included in the final analysis (mean age 64 years; 11 females). Study subjects presented with weakness with hip flexion and knee extension and pain and numbness in the femoral nerve distribution. In 7 subjects, the femoral nerve appeared normal. In 5 subjects, the femoral nerve was hyperintense on fluid-sensitive fat-suppressed imaging. In 4 patients, mass effect on the femoral nerve by either ill-defined soft tissue edema (n = 2), seroma (n = 1), or heterotopic ossification (n = 1) was detected. Only 1 patient had a nerve transection. Patients were imaged at a median time of 8 months (range: 1 day to 11 years) following arthroplasty placement. Clinical follow-up was available in 8 patients, of whom half had complete symptomatic resolution and half had partial improvement at a mean follow-up time of 39.3 months (SD 51.1). Of these 8, 1 underwent revision arthroplasty, 1 had removal of hardware, and another had excision of heterotopic ossification.

CONCLUSION

MRI provides a means to directly evaluate the femoral nerve following anterior approach THA in both the immediate and chronic postoperative periods.

Femoral neuropathy: A clinical and electrodiagnostic review

INTRODUCTION/AIMS

Femoral neuropathies can cause severe, prolonged debility, yet there have been few clinical and electrodiagnostic (EDx) studies addressing this condition. The aim of this study was to better understand the etiologies, EDx features, and clinical course of femoral neuropathy.

METHODS

We identified patients evaluated at Mayo Clinic Rochester between January 1, 1999 and July 31, 2019, with possible new femoral neuropathy ascertained via International Classification of Diseases-versions 9 and 10 diagnosis codes presenting within 6 months of symptom onset.

RESULTS

A retrospective review of 1084 records was performed and we ultimately identified 159 patients with isolated femoral neuropathy for inclusion. The most common femoral neuropathy etiologies were compressive (40%), perioperative stretch (35%), and inflammatory (6%). Presenting symptoms included weakness (96%), sensory loss (73%), and pain (53%). Presenting motor physical exam findings demonstrated moderate weakness (34%) or no activation (25%) of knee extension and mild (32%) or moderate (35%) weakness of hip flexion. Seventy-two percent of patients underwent EDx testing, including 22 with femoral motor nerve conduction studies. Treatment often involved physical therapy (89%) and was otherwise etiology-specific. In patients with follow-up data available (n = 154), 83% had subjective clinical improvement at follow-up with a mean time to initial improvement of 3.3 months and mean time to recovery at final follow-up of 14.8 months. Only 48% of patients had nearly complete or complete recovery.

DISCUSSION

In our cohort, the most common etiologies of femoral neuropathy were compression or perioperative stretch with high initial morbidity. Although motor recovery is common, improvement is often prolonged and incomplete.

Unusual causes for meralgia paresthetica: systematic review of the literature and single center experience

Meralgia paresthetica is often idiopathic, but sometimes symptoms may be caused by traumatic injury to the lateral femoral cutaneous nerve (LFCN) or compression of this nerve by a mass lesion. In this article the literature is reviewed on unusual causes for meralgia paresthetica, including different types of traumatic injury and compression of the LFCN by mass lesions. In addition, the experience from our center with the surgical treatment of unusual causes of meralgia paresthetica is presented. A PubMed search was performed on unusual causes for meralgia paresthetica. Specific attention was paid to factors that may have predisposed to LFCN injury and clues that may have pointed at a mass lesion. Moreover, our own database on all surgically treated cases of meralgia paresthetica between April 2014 and September 2022 was reviewed to identify unusual causes for meralgia paresthetica. A total of 66 articles was identified that reported results on unusual causes for meralgia paresthetica: 37 on traumatic injuries of the LFCN and 29 on compression of the LFCN by mass lesions. Most frequent cause of traumatic injury in the literature was iatrogenic, including different procedures around the anterior superior iliac spine, intra-abdominal procedures and positioning for surgery. In our own surgical database of 187 cases, there were 14 cases of traumatic LFCN injury and 4 cases in which symptoms were related to a mass lesion. It is important to consider traumatic causes or compression by a mass lesion in patients that present with meralgia paresthetica.

Compressive femoral neuropathy caused by anticoagulant therapy induced retroperitoneal hematoma: A case report

RATIONALE

Spontaneous retroperitoneal hematomas due to anticoagulant therapy rarely occur. Retroperitoneal hematomas can cause severe pain in the groin, quadriceps femoris muscle weakness, hemodynamic instability, and abdominal distension. They rarely cause compressive neuropathy of the femoral nerve transversing the iliacus muscle. Differential diagnosis is not easy because they have similar clinical features to retroperitoneal hematomas.

PATIENT CONCERNS

A 72-year-old female patient whose right arm was stuck in a bookshelf for 5 days developed right cephalic vein thrombosis. After 5 days of intravenous heparin therapy for venous thrombosis, she presented with sudden right groin pain, right leg paresis, hemodynamic instability, and abdominal distension.

DIAGNOSIS

Emergency abdominal and pelvic CT showed a large number of hematomas in the bilateral retroperitoneal space with active bleeding of the right lumbar artery. An electrodiagnostic study was performed 2 weeks later to check for neuromuscular damage in the right lower extremity, and right compressive femoral neuropathy was confirmed.

INTERVENTIONS

Heparin therapy was discontinued; emergency embolization of the lumbar artery was performed. After 2 weeks, the patient started receiving physical, occupational, and transcutaneous electrical stimulation therapies.

OUTCOMES

She became hemodynamically stable after arterial embolization; a significant decrease in hematoma and patency of the femoral nerve was confirmed on follow-up pelvic MRI. After 2 months of comprehensive rehabilitation, the muscle strength of the right leg significantly improved, and the pain disappeared.

LESSONS

Although rare, spontaneous retroperitoneal hematomas may occur in patients receiving anticoagulant medications. They may even occur in patients receiving emergency anticoagulant therapy. Compressive femoral neuropathy due to retroperitoneal hematomas should be considered if muscle weakness and groin pain are observed. Early diagnosis and appropriate treatment plan of compressive femoral neuropathy due to retroperitoneal hematoma are helpful for a good prognosis.

[Meralgia paresthetica after prolonged prone position at the intensive care unit among COVID-19 patients. A case report]

Meralgia paresthetica (MP) is an entrapment syndrome that may cause loss of sensation, numbness, paresthesia and pain within the distribution of the lateral femoral cutaneous nerve. This condition is more common in persons with diabetes mellitus, obesity and in old age. MP has previously been described in patients that have undergone surgery in the prone position (PP) and in a case report of a patient with ARDS (Acute Respiratory Distress Syndrome) who was cared for in the intensive care unit (ICU). Due to the COVID-19 pandemic PP has been widely used for periods of 12-16 hours to improve oxygenation. At the rehabilitation unit at our hospital, we have identified cases of MP in patients with COVID-19 that have required this type of positioning for long periods in the ICU. We would like to draw attention to the fact that there is a risk of peripheral nerve injury in the event of prolonged PP and recommend extra controls, careful positioning and extra padding at the areas where peripheral nerves may be exposed to pressure.

Iliopsoas hematoma presenting with sudden knee extensor weakness: A case report

RATIONALE

Hematoma of the iliopsoas muscle is a rare condition. Prolonged pressure conditions due to hematoma of the femoral nerve can cause severe pain in the affected groin, hip, and thigh, and quadriceps weakness. We report a rare case of a spontaneous iliopsoas muscle hematoma that caused sudden femoral neuropathy.

PATIENT CONCERNS

A 71-year-old woman presented sudden left hip pain and knee extensor weakness. The pain was aggravated with left hip extension. She had a bilateral total hip replacement surgery due to avascular necrosis. She was diagnosed as mild stenosis of the cerebral artery and took aspirin to prevent cerebral artery atherosclerosis.

DIAGNOSIS

A hip computed tomography scan demonstrated a suspicious fluid collection at the left iliopsoas bursa. We considered the possibility of lower limb weakness due to neuralgic amyotrophy and performed electromyography and enhanced lumbosacral magnetic resonance imaging (MRI). Electromyography finding showed left femoral neuropathy of moderate severity around the inguinal area was diagnosed. On MRI, left iliopsoas bursitis or hematoma, and displacement of the left femoral nerve due to the iliopsoas bursitis/hematoma were observed.

INTERVENTION

Ultrasonography (US)-guided aspiration of the left iliopsoas hematoma was performed. We started steroid pulse therapy for 8 days.

OUTCOMES

After US-guided aspiration and steroid pulse therapy, the patient's knee extension motor grade improved from grade 1 to 2, and the pain was slightly reduced. At 3 weeks after the aspiration procedure, her hip flexion motor grade had improved from grade 3+ to 4 at follow-up.

LESSONS

Imaging studies are fundamental to diagnose of iliopsoas hematoma. Electromyography examination plays an important role in determining the prognosis of patients and lesion site. Despite the negligible change in sitting position, hematoma can develop. Physicians should consider hematoma that cause femoral neuropathy.

Femoral Nerve Palsy With Concomitant Patellar Dislocation in a Ballet Dancer

Femoral nerve palsy with concomitant patellar dislocation is a rare clinical entity that has not previously been well documented. The authors present the case of a 16-year-old female ballet dancer who sustained a patellar dislocation with concomitant femoral nerve palsy. She experienced muscle weakness after the initial injury and developed neuropathic symptoms through the anterior left thigh. The patient exhibited muscle atrophy in her left lower extremity verified by circumferential thigh measurements as well as magnetic resonance imaging showing clear atrophy of the anterior compartment. Electromyography of the left lower extremity verified femoral neuropathy. Gross improvements in muscle strength were noted during the year following initial injury, but circumferential thigh differences persisted. Two years after initial injury, repeat electrodiagnostic studies had normal findings, but subjective left quadriceps weakness persisted and the patient was unable to return to competitive dance. [Orthopedics. 2019; 42(2):e273-e275.].

[Iliac haematoma as a differential diagnosis to lumbar disc herniation]

After a fall without fracture an 83-year-old man who was treated with warfarin was admitted with severe groin pain on the left hip. A few days later he had reduced strength in hip flexion and knee extension, absent patellar tendon reflex, and decreased sensibility of the anterior thigh and the medial lower leg. A magnetic resonance imaging revealed a large haematoma in the left iliac muscle. Iliac haematoma-induced femoral nerve compression neuropathy is a rare condition but should be considered as a differential diagnosis for L4 root compression in patients, who are receiving anticoagulant therapy.

Inadvertent Prolonged Femoral Nerve Palsy After Field Block with Liposomal Bupivacaine for Inguinal Herniorrhaphy

Inguinal herniorrhaphy is a common outpatient procedure where analgesia can be augmented with local infiltration. We report a case of prolonged femoral nerve palsy secondary to liposomal bupivacaine use during wound infiltration after inguinal herniorrhaphy. Inadvertent transient femoral nerve palsy is a rare but known complication after ilioinguinal field block. This case both highlights the value of ultrasound imaging in evaluating the complications and demonstrates how the prolonged nature of liposomal bupivacaine can prolong adverse sequela.

[Lower limb paresis after total hip arthroplasty. A rare differential diagnosis]

We report on a case of complex nerve damage during total hip arthroplasty. The most severe clinical symptom was proximal leg paresis with diffuse sensory loss. There was an extensive causal Iliopsoas hematoma which developed during the postoperative rehabilitation under therapeutic anticoagulation for atrial fibrillation. An iliopsoas hematoma with subsequent neurological deficits are rare events in the field of hip arthroplasty and a literature review is provided. The treatment of retroperitoneal hemorrhage is controversial but in most instances a conservative approach is favored. The prognosis of neurological damage is sobering as only 20 % of victims are expected to achieve complete restitution.

[Femoral nerve palsy as delayed complication after total hip replacement: delayed hematoma formation in unexpected screw malpositioning]

Nerve injury after total hip replacement is a rare but severe complication. If the nerve lesion becomes evident in the early postoperative phase the lesion is often due to an incorrect implant position, direct nerve injury or vascular injury with manifestation of a hematoma which results in nerve compression. Secondary nerve lesions are more often due to a chronic hematoma with nerve compression. Secondary nerve lesions in particular are often a diagnostic challenge and should lead to an early revision after comprehensive imaging diagnostics.

Femoral neuropathy following total hip arthroplasty: review and management guidelines

Femoral neuropathy following primary or revision total hip arthroplasty (THA) is a rare but acknowledged complication. Treatment of femoral neuropathy has long been debated and there is a paucity of accepted principles on which to base management. Currently, no definitive management protocol exists in the literature. A literature search was performed by a review of PubMed, Google Scholar and OVID articles published from 1972-2011. The literature reports an incidence rate of femoral neuropathy following THA ranging from 0.1 to 2.4 percent. Determining the precise aetiology, establishing a diagnosis and subsequent treatment of femoral nerve injury remains a difficult task, with conservative management remaining the treatment benchmark. In this review, we aim to summarise the aetiologies and risk factors associated with femoral neuropathy following THA and provide management guidelines.

[A case of femoral neuropathy after radical ovariectomy]

We experienced a 55-year-old female patient who was diagnosed as femoral neuropathy after radical ovariectomy. An epidural catheter was introduced at T11-12 interspace without any problems and general anesthesia was induced and maintained. The operation ended uneventfully. On the first postoperative day, she noticed hypesthesia of the inner surface of her left thigh and could not raise the left leg. The symptom remained after the removal of epidural catheter on the second postoperative day, and the influence of insertion of the epidural catheter on the symptom was suspected. We performed neurological examinations and found weakness of the left quadriceps femoris muscle, weakness of the left patellar reflex, and weakness of touch sensation and cold sensation and hypalgesia on the anterior surface of the left thigh and the inner surface of the left lower leg. Those findings led us to diagnose with femoral neuropathy probably due to abdominal retractors or the operation itself, and insertion of epidural anesthesia could not be the cause of neuropathy. Her symptom was ameliorated with a conservative therapy after four months. We should perform fine neurological examinations when neurological complications occur, especially when we use epidural catheters, and also should have the knowledge about those complications.

Iatrogenic femoral neuropathy: two cases and literature update

Iatrogenic femoral neuropathy is an uncommon surgical or obstetric complication that may be underreported. It results from compression, stretch, ischemia, or direct trauma of the nerve during hip arthroplasty, self-retaining retractor use in pelvicoabdominal surgery, lithotomy positioning for anesthesia or labor, and other more rare causes. Decreasing incidence of this complication after abdominal and gynecologic surgery but increase in its absolute numbers after hip arthroplasty has emerged over the last decade. We describe two illustrative cases related respectively to lithotomy positioning and self-retaining retractor use. The variability in clinical presentation of iatrogenic femoral nerve lesions, some new insights in their diverse pathophysiology, and in the diagnostic and treatment options are discussed with an update from the literature.

Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty

BACKGROUND

Although injury to the lateral femoral cutaneous nerve (LFCN) is a known complication of anterior approaches to the hip and pelvis, no study has quantified its' incidence in anterior arthroplasty procedures.

QUESTIONS/PURPOSES

We therefore defined the incidence, functional impact, and natural history of LFCN neuropraxia after an anterior approach for both hip resurfacing (HR) and primary total hip arthroplasty (THA).

METHODS

We followed 132 patients who underwent an anterior hip approach (55 THA; 77 HR). We administered self-reported questionnaires for sensory deficits of LFCN, neuropathic pain score (DN4), visual analog scale, as well as SF-12, UCLA, and WOMAC scores at one year postoperatively. A subset of 60 patients (30 THA; 30 HR) was evaluated at two time intervals.

RESULTS

One hundred seven patients (81%) reported LFCN neuropraxia with a mean severity score of 2.32/10 and a mean DN4 score of 2.42/10. Hip resurfacing had a higher incidence of neuropraxia as compared with THA: 91% versus 67%, respectively. No functional limitations were reported on SF-12, WOMAC, or UCLA scores. Of the subset of 60 patients followed over an average of 12 months, 53 (88%) reported neuropraxia at the first followup interval with only three (6%) having complete resolution at second followup. Improvement in DN4 scores was observed over time: 3.6 versus 2.5, respectively.

CONCLUSIONS

Although LFCN neuropraxia was a frequent complication after anterior approach THA, it did not lead to functional limitations in our patients. A decrease in symptoms occurred over time but only a small number of patients reported complete resolution.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[A case of regional advanced colon cancer accompanied with right femoral nerve paresis]

The patient is a man in his sixties. A hard tumor that fixed to right iliac bone as big as an adult fist could be palpated in the ileocecal region. He complained a cramp and pain in the right thigh. Computed tomography of the abdomen after the administration of contrast material showed an irregular shape tumor that highly invaded through right iliac muscle, and it widely attached to the right iliac bone. Any distant metastases were not detected. In the abdominal cavity, any peritoneal dissemination nodules were not detected. The tumor was completely removed by excising with periosteum of the iliac bone, iliac muscle, transversus abdominis muscle, and a part of psoas muscle and femoral nerve. The dead space after radical excision was filled with greater omental flap. In the microscopic examination, the tumor was diagnosed moderately differentiated adenocarcinoma with invasion to serosa, muscles, femoral nerve and periosteum and regional lymph nodes involvement. The carcinoma cell was not seen in the excised margin, thus it was judged that it was curative excision. If the colonic cancer obtains the curative excision even if the permeation of the limited part is advanced, an excellent prognosis can often be expected, and the role that the surgical operation plays as limited part treatment is large.