Ultrasound-guided placement of a permanent percutaneous femoral nerve stimulator leads for the treatment of intractable femoral neuropathy

BACKGROUND

Femoral nerve injury is a rare complication of cardiac catheterization and is usually caused by direct trauma during femoral artery access, compression from a hematoma, or prolonged digital pressure for post-procedural hemostasis. Peripheral nerve stimulation has been used to treat different pain syndromes in the upper and lower extremities with variable success and it typically requires direct vision with open surgical approach. Since the femoral nerve can be readily seen with ultrasonography, an ultrasound-guided lead placement seemed practical.

CASE REPORT

A 61-year-old morbidly obese male who sustained femoral nerve injury during cardiac catheterization continued to complain of intractable femoral neuropathy 18 months afterwords. He failed multiple treatment modalities and continued to complain of severe neuropathic pains that markedly interfere with his daily activities. Two percutaneous leads were placed under real-time ultrasonography and the placement was confirmed with fluoroscopy. One lead was placed along the longitudinal axis of the nerve and the patient had good coverage over the anterior thigh but not below the knee. So another lead was placed horizontally across the femoral nerve in order to stimulate all the branches and the patient reported good coverage along the saphenous nerve distribution down to the foot.

RESULTS

The patient continues to be pain free 20 months after the implant.

CONCLUSION

Here we described a novel non-invasive percutaneous approach for femoral nerve stimulation with ultrasound guidance which allowed precise placement of the stimulating lead very close to the femoral nerve without the need for surgical exploration.

Intrapelvic mass causing femoral compression neuropathy in a patient with Gaucher disease: a case report

Gaucher disease is a lysosomal storage disorder in which glucocerebroside accumulates within the macrophages in any part of the body. Varying degrees of skeletal involvement may occur besides anemia, coagulation abnormalities and hepatosplenomegaly. Most of the factors influencing the quality of life in a patient with Gaucher disease are related to bone involvement. Gaucher cell deposits may extrude through cortical erosions and cause soft tissue masses around bones which are involved by the disease. We present a 38-year-old female patient with Gaucher disease who had a large intrapelvic mass originating from left iliac bone causing femoral compression neuropathy. The classification of disease is based on neurological involvement and if symptoms exist whether the symptoms are acute or subacute. The neurological impairment caused by compression by a tumor should be distinguished from the ones reported in neurogenic forms of the disease.

Femoral nerve palsy due to iliacus hematoma occurred after primary total hip arthroplasty

The perforation of the medial acetabular wall during total hip arthroplasty due to drilling is not uncommon. But, it has rarely been associated with serious adverse events. Here, we present a case report describing an iliacus hematoma with subsequent femoral nerve palsy after primary total hip arthroplasty in a 67-year-old woman who underwent primary total hip arthroplasty due to painful hip osteoarthritis. The diagnosis was made by pelvic magnetic resonance imaging. Conservative treatment was employed and the symptoms were resolved within 3 months. It should be borne in mind that femoral nerve palsy may occur after total hip arthroplasty. It may be due to a treatable cause, such as iliacus hematoma. So, pelvic MRI is recommended in such a condition, rather than just observation.

Involvement of the lateral femoral cutaneous nerve as source of persistent pain after total hip arthroplasty

This report describes a situation in which the lateral femoral cutaneous (LFC) nerve was the source of incisional pain in a patient after a total hip arthroplasty. The painful scar was denervated by an approach that resected just the posterior branch of the LFC nerve. This was done through an incision near the anterior superior iliac crest, avoiding any potential exposure of the implant. One of the 3 patients reported here had a coexisting meralgia paresthetica that was treated by the same operative approach. The orthopedic surgeon should include the LFC nerve as an origin of persistent pain after total hip arthroplasty.

[Cases of femoral nerve palsy after radical prostatectomy]

Although postoperative femoral neuropathy is an uncommon complication occurring after pelvic surgery, we experienced several cases of femoral nerve palsy in patients after radical prostatectomy. All cases had neither previous vascular nor peripheral nerve disease. To investigate the possible etiology, we compared the difference in age, height, body weight, body mass index (BMI), duration of surgery, and volume of bleeding in patients with or without femoral nerve palsy. Although age and volume of bleeding were similar in groups, height, body weight, BMI, and duration of surgery in nerve palsy group (n = 5) were significantly larger than those without nerve palsy (n = 9). To evade these complications, inappropriate stretching and prolonged compression of the nerve during surgery, two major mechanisms of the neuropathy, were asked not to do to urological surgeons. In addition, intravenous patient-controlled analgesia (IV-PCA) was also used for postoperative analgesia instead of epidural analgesia. After these strategies, we found that the frequency of femoral nerve palsy had considerably decreased. Patients received physical therapy and showed nearly total neurological recovery. We report here unusual complication following major pelvic surgery, and discuss the possible etiology and some strategies for prevention of this injury.

Temporary femoral nerve palsy after ilioinguinal nerve blockade combined with splash block for post-inguinal herniorrhaphy analgesia in a pediatric patient

Transient femoral nerve palsy (TFNP) is a complication of ilioinguinal nerve block that may result from spread of large volumes of local anesthetics at the inner surface of the different fascial planes. We report a 7-year-old healthy boy who underwent right inguinal hernia repair under general anesthesia. After induction of anesthesia, a percutaneous ilioinguinal nerve block was performed with 3 mL of 2% lidocaine in single-shot. Before wound closure, the surgeon performed a splash block onto the wound with infiltration of 1.5 mL 0.25% bupivacaine. In the recovery room, quadriceps weakness and sensory loss over the anterior thigh were noted. The patient made a complete recovery 8 hrs after surgery without any treatment. We discuss the mechanism of this complication and strategies to reduce this complication.

Transient femoral nerve palsy associated with a synovial cyst of the hip in a patient with spinal cord injury

We report a case of local compression-induced transient femoral nerve palsy in a 46-year-old man. He had previously undergone surgical release of the soft tissues anterior to both hip joints because of contractures following spinal injury. An MRI scan confirmed a synovial cyst originating from the left hip joint, lying adjacent to the femoral nerve. The cyst expanded on standing, causing a transient femoral nerve palsy. The symptoms resolved after excision of the cyst.

Kompression des Nervus femoralis durch ein sekundär disloziertes Trochanter-minor-Fragment bei pertrochantärer Femurfraktur

Pertrochanteric fractures of the femur are often associated with avulsion of the lesser trochanter. The most commonly applied techniques of osteosynthesis (proximal femur nailing; PFN/dynamic hip screw; DHS/gliding nail) do not involve repositioning or fixation of this fragment, which is dislocated as the result of traction from the iliopsoas muscle so that it is resting in the soft tissue. We report the case of a 70-year-old male patient with a pertrochanteric femur fracture with an initially undisplaced lesser trochanter fragment after a fall (AO classification 31-A2). PFN was performed on the day of the accident after closed reduction. Following an uneventful course, with increasing mobilisation the patient developed a compression syndrome of the femoral nerve with unbearable pain in the thigh. The cause was compression of the femoral nerve by a secondarily dislocated fragment of the lesser trochanter. After revision from a ventral approach with removal of the fragment the patient experienced total relief of the pain. No similar cases have so far been reported in the literature.

Iatrogenic femoral neuropathy following pelvic surgery: a rare and often overlooked complication--four case reports and literature review

Femoral neuropathy can result from diverse etiologies following abdominal surgery. We describe four cases of postoperative femoral neuropathy after proctological procedures that were carried out at our hospital. The related symptoms developed occultly but eventually impaired patient motor or sensory functions in the lower extremities. When the patient fails to address associated suffering, it is easy for clinicians to neglect this type of morbidity. All patients recovered from neuropathy following timely detection of the disease entity confirmed by electromyography and nerve conduction studies, followed by adequate rehabilitation management. We hypothesize that postoperative femoral neuropathy may be closely related to unsuitable applications of self-retaining retractors, rather than being associated with other factors, such as gender, age, surgery time or body mass index (BMI). Furthermore, we used a literature review to examine the pathophysiology, diagnoses and treatment modalities of femoral neuropathy resulting from inappropriate placement of self-retaining retractors. Based on a thorough comprehension of the femoral nerves anatomical course and meticulous placement of retractor blades, these types of iatrogenic complications may be prevented.

Meralgia Paresthetica Due to Body Armor Wear in U.S. Soldiers Serving in Iraq: A Case Report and Review of the Literature

Meralgia paresthetica is a disorder of the lateral femoral cutaneous nerve that results in symptoms of anterolateral thigh paresthesias and dysesthesias without associated loss of reflexes or motor weakness. Chronic meralgia paresthetica, not related to traumatic or lesion-producing compression of the nerve, is associated with obesity, pregnancy, tight-fitting garments, as well as specific duty uniform belts used by police officers and carpenters. Cases are presented in which two U.S. soldiers in Iraq experienced symptoms of meralgia paresthetica, most likely due to repetitive wear of protective body armor. Although use of protective body armor is proven to be lifesaving, modifications to improve current equipment may help to decrease morbidities such as meralgia paresthetica.

Meralgia paresthetica: a result of tight new trendy low cut trousers ('taille basse')

Meralgia paresthetica is an entrapment neuropathy involving the lateral femoral cutaneous nerve of the thigh. Patients complain of a persistent burning sensation, tingling and aching pain, and hypersensitivity or hyposensitivity in the anterolateral aspect of the thigh. Numerous direct and indirect causes for the disease have been suggested in the literature. We present 12 cases that were diagnosed to have meralgia paresthetica due to tight new fashion low cut trousers ('taille basse'). The diagnosis was confirmed by injecting a small amount of a short acting local anesthetic around the lateral femoral cutaneous nerve which alleviated the symptoms for several hours. Electrophysiologic studies were sensitive in 83.3% of the cases. All cases were treated successfully using conservative methods, namely avoiding tight trousers, local steroid infiltration and weight reduction.

Rare peripheral femoral nerve neuropathy in children

Peripheral neuropathy of the femoral nerve is extremely rare. In the literature, we found descriptions of only 50 similar patients, mainly as a complication of coagulopathies, and none of intrapelvic tumors. Three children with a rare peripheral neuropathy of the femoral nerve as a complication of extraperitoneal pelvic masses are described in this report. In all three, the neuropathy was caused by stretching of the femoral nerve over a huge intrapelvic mass. None was related to coagulopathy. After removal of the masses, full recovery from the neurological symptoms was observed in two children and the recovery of the patient with Ewing's sarcoma is satisfying, at the 2-year follow-up and at the time of writing. As early surgical debulking of the mass was a good influence on the recovery of the nerve paresis, we believe that is imperative in the treatment process. Medical staff should be aware that a serious illness can lie behind peripheral femoral nerve neuropathy.

Femoral nerve palsy after mandibular reconstruction with microvascular iliac flap: a complication under anticoagulation therapy

Pharmacological prophylaxis and intervention are used extensively in head and neck reconstructions with microvascular flaps. There is no universally accepted protocol, but the microvascular surgery literature recommends intraoperative anticoagulation with heparin. Here is reported a case of iliacus haematoma with subsequent femoral nerve palsy after the harvest of a microvascular iliac flap for mandibular reconstruction in a patient who had been treated with heparin. The association between femoral nerve palsy and anticoagulant therapy has been well described. It remains unclear as to why the iliacus muscle is particularly vulnerable to intramuscular haemorrhage. Femoral nerve neuropathy is also an uncommon but recognized complication after abdominopelvic surgery. Iliacus haematoma secondary to microvascular surgery has not been previously reported. This case illustrates the need to be aware of this type of complication and its clinical manifestations for patients under anticoagulant therapy in the perioperative period during microvascular reconstructions.

Isolated Femoral Nerve Neuropathy After Intra-aortic Balloon Pump Treatment

Intra-aortic balloon pump (IABP)-related neuropathy is an infrequent complication, and the development of motor deficits is even rarer in such cases. We report a 37-year-old man with anterior ST-elevation myocardial infarction who received emergent percutaneous coronary intervention and IABP counterpulsation. Weakness and numbness developed after IABP removal despite lack of evidence of ischemia in the involved extremity. Nerve conduction velocity study and electromyogram led to the diagnosis of femoral nerve neuropathy. The neurologic deficits recovered after 6 months of rehabilitation. This case illustrates the importance of bedside neurologic examination of the involved extremity for early detection of possible injury to the femoral nerve in patients after IABP treatment and insertion of larger bore catheter.

Meralgia paresthetica caused by hip-huggers in a patient with aberrant course of the lateral femoral cutaneous nerve

"Hip-huggers" may be a precipitating factor for meralgia paresthetica (MP), especially in thin persons with an aberrant pathway of the lateral femoral cutaneous nerve (LFCN). We describe a 25-year-old woman with a long-standing history of MP caused by an abnormal course of the LFCN and tight trousers, specifically hip-huggers. Ultrasonography was useful for detecting the lesion site and the abnormal pathway of the LFCN. After neurectomy of the LFCN, most of the symptoms of MP were relieved, but mild hypesthesia remained in the lateral thigh.

Enlarged psoas muscle and iliopsoas bursitis associated with a rapidly destructive hip in a patient with rheumatoid arthritis

A 39-year-old man with rheumatoid arthritis developed femoral neuropathy secondary to iliopsoas bursitis. The adjacent hip joint was severely damaged. Magnetic resonance imaging showed enlargement and inflammation of the psoas muscle at the same side of iliopsoas bursitis. Iliopsoas bursitis and abnormal findings of the psoas muscle disappeared while the symptoms improved.

Femoral Neuropathy following Retroperitoneal Hemorrhage: Case Series and Review of the Literature

Femoral neuropathy due to retroperitoneal hematoma has been infrequently described in the literature. While occasionally due to trauma, it has been most commonly reported in association with various bleeding diatheses and therapeutic anticoagulation. As the indications for the use of anticoagulants and antiplatelet agents increase, associated hemorrhagic complications will likely also increase. The management of retroperitoneal hematoma with consequent femoral nerve palsy remains controversial. We present a series of four cases of femoral nerve palsy due to retroperitoneal hematoma managed by surgical decompression. Hematoma evacuation at the time of the development of femoral neuropathy results in immediate benefit, with greater likelihood of a return to pre-event neurological status. Delays in operative treatment, despite the presence of a neurological deficit, may lead to significant and prolonged neurological dysfunction. Surgical decompression should be highly considered in all patients who develop femoral neuropathy from a retroperitoneal hematoma.

Meralgia paresthetica: A retrospective analysis of 79 patients evaluated and treated according to a standard algorithm

BACKGROUND

The efficacy of various treatment modalities in meralgia paresthetica (MP) is not established. We retrospectively evaluated the management of spontaneous MP (i.e. MP not secondary to trauma or surgery) according to a standard algorithm.

METHODS

Initial management included oral medications, rest, and reduction of aggravating factors. Non-responders underwent a diagnostic local anesthetic nerve block test. Patients who responded with transient symptomatic relief were treated by local infiltration of corticosteroids. Surgical intervention was reserved for patients with positive nerve block test, who did not respond to nonoperative measures.

RESULTS

A negative nerve block test ruled out the diagnosis of MP in 6/86 patients. Of 79 patients with MP, 21 responded to the initial nonoperative treatment and 48 patients responded to local corticosteroids. 3 of the remaining 10 patients underwent surgery (nerve transection 2, neurolysis 1). During an average of 3 (1-13) years of follow-up, symptoms consistent with MP did not recur in any of the 72 patients in whom symptoms had resolved after treatment.

INTERPRETATION

The algorithm used proved to be useful in the management of spontaneous meralgia paresthetica.