Acute lumbosacral plexopathy in diabetic women after renal transplantation

Ischaemic lumbosacral plexopathy following aortic dissection

A 57-year-old man was diagnosed with acute myocardial infarction and Stanford type A aortic dissection that had spread to the common iliac arteries. He underwent a Bentall procedure for vascular repair. Immediately after surgery, he developed numbness and severe weakness in his left leg. On examination, he had hypotonia, absent deep tendon reflexes, weakness in the left leg (Medical Research Council (MRC) scale for muscle strength - 0/5 distal, 3/5 proximal) and reduced sensation in the left leg. Electromyography confirmed subacute involvement of the left lumbar and lumbosacral plexus. MR scan of the lumbar plexus showed diffuse muscle oedema involving the left gluteus maximus. We diagnosed ischaemic lumbosacral plexopathy secondary to extensive aorta dissection and internal iliac artery occlusion. We discuss the clinical features of ischaemic plexopathy and the diagnostic approach and review the vascular anatomy of the lumbosacral plexus.

Gluteal Necrosis and Lumbosacral Plexopathy in a Diabetic Patient after Renal Transplantation

A 34-year-old diabetic patient underwent a renal transplant which was complicated by right side lower extremity paresis and numbness with gluteal necrosis. The main reason was ligation of internal iliac artery of the same side as a result of extensive microvascular obstruction due to severe atheromatous plaque. This is a rare complication which is mostly reported in aneurysmal patients after bypass surgery. The gluteal necrosis is a serious complication which, as in our patient, resulted in patient's death in most of the reported cases. Because of catastrophic nature of this condition, identifying preventive measures is extremely important.

Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with pelvic trauma

PURPOSE

To assess the incidence of long- and short-term complications following internal iliac artery (IIA) embolization after blunt pelvic trauma.

MATERIALS AND METHODS

One hundred trauma patients with pelvic fractures underwent pelvic angiography from 1994 through 2006. Sixty-seven patients underwent IIA embolization. These patients were retrospectively identified for medical record review. Short- and long-term complications were defined as those occurring at less than or greater than 30 days, respectively. Complications and outcomes were assessed through chart review and, when possible, a standardized questionnaire. Patients who underwent IIA embolization were compared with matched control patients with blunt pelvic trauma who did not undergo pelvic arteriography. Individuals were matched by age, sex, year of admission, and injury scores.

RESULTS

There were no significant differences in skin necrosis, sloughing, pelvic perineal infection, or nerve injury between embolized and nonembolized patients within 30 days. There was no significant difference in claudication, skin ulceration, or regional pain at a mean of 18.4 months follow-up. In the long term, buttock, thigh, and perineal paresthesia occur at a significantly higher rate in embolized patients. Skin sloughing in the embolized patient group is an important but rare complication.

CONCLUSIONS

IIA embolization is an important means of controlling pelvic arterial hemorrhage. There is no significant increase in the risk of most evaluated long- and short-term complications in trauma patients who underwent IIA embolization versus those who did not. However, IIA embolization is associated with a marginally significantly increased rate of buttock, thigh, or perineal paresthesia.

Lumbosacral plexitis

Lumbosacral plexitis (LSP) is an uncommon idiopathic disorder characterized by the acute onset of severe lower extremity pain followed by wasting and weakness of leg muscles with variable sensory loss. Muscles innervated by multiple roots and multiple nerves are affected, and other causes of lumbosacral plexopathy such as mass lesions and trauma must be excluded. Postulated causes of LSP include vasculitis with subsequent axonal injury and autoimmune-related demyelination, although evidence is accumulating that the former pathophysiology is more likely. Recovery is variable but is often quite slow and incomplete. Immunomodulatory therapies such as corticosteroids, intravenous immunoglobulin, and plasma exchange are inconsistent in their efficacy.

A review of perioperative nerve injury to the lower extremities: part I

Perioperative nerve injuries can be a complication of surgical procedures and account for a significant number of anesthesia-related claims in the United States. Whereas ulnar neuropathy at the elbow is the most common, other nerve injuries of the upper extremity and injuries to the lower extremities are not rare occurrences. A number of possible etiologies have been proposed to explain perioperative nerve injury to include stretch, compression, ischemia, and direct trauma from agents such as suture and cement material. An important aspect of perioperative nerve injury is the underrecognition (or underreporting) that can occur for a multitude of reasons. Good collaboration between surgeons and neurologists can lead to more detailed neurologic assessments and well-timed electrodiagnostic studies, ultimately improving our understanding of such unfortunate incidents.

Lumbosacral plexopathy after dual kidney transplantation

A 58-year-old man underwent dual kidney transplantation. He was unable to move his right leg after surgery. This was caused by extensive lumbosacral plexopathy on the side of surgery. Lumbosacral plexopathy after kidney transplantation is uncommon, because the plexus has rich anastomotic blood supply, and ischemic injury is unlikely. However, isolated femoral neuropathy after renal transplantation has been reported, as the distal portion of this nerve is supplied by branches of internal iliac artery only and is more prone to ischemic injury during surgery. Dual-kidney transplantation involves a larger dissection, and the procedure takes 60 to 90 minutes longer than single-kidney transplantation. It involves more vascular reconstruction. This may predispose the lumbosacral plexus to ischemic injury. To the best of our knowledge, this is the first reported case of lumbosacral plexopathy after a dual kidney transplantation, and this may be seen more frequently because this procedure is becoming more common.

Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: analysis of outcomes and complications

PURPOSE

To analyze the complications of internal iliac artery (IIA) embolization in conjunction with stent-graft treatment of aortoiliac aneurysms.

MATERIALS AND METHODS

Seventy-one patients with aortoiliac (n = 47) or iliac (n = 24) aneurysms were treated with endoluminal placement of stent-grafts. Thirty-two patients (31 men, one woman; mean age, 73 years; range, 56-88 years) had embolization or occlusion of one (n = 27) or both (n = 5) IIAs. Status of the IIAs and the collateral circulation was assessed by retrospective review of angiographic images. Follow-up consisted of a standardized patient questionnaire and review of radiologic and medical records.

RESULTS

The mean follow-up time was 35 months (range, 5-64 months). Eleven of the 47 patients with abdominal aortic aneurysms (AAA) (23%) and 19 of the 24 patients with iliac aneurysms (79%) required IIA embolization. One patient with AAA and another with iliac aneurysm had unintentional occlusion of an IIA by extension of the stent-graft over their origins. A total of seven patients had bilateral occlusion of the IIAs after the procedure. Additionally, the inferior mesenteric arteries (IMAs) of two other patients with AAA were also embolized. In six patients, all three vessels were occluded after placement of the stent-grafts. Symptoms were reported in nine of the 20 (45%) patients with iliac aneurysms and in three of the 12 (25%) patients with AAA. Symptoms consisted of buttock claudication (nine of 32, 28%), new sexual dysfunction (two of 16, 12%), and transient urinary retention (3%). Seven of the claudicants had resolution of symptoms after a mean interval of 14 months (range, 1-36 months). There were no instances of bowel ischemia, neurologic sequelae, or buttock necrosis related to these procedures.

CONCLUSION

Embolization of the IIA is associated with symptoms in a significant number of patients. While symptoms are transient in most patients, they can be problematic. Efforts should be made to preserve the pelvic circulation if possible.

Femoral neuropathy in renal transplantation

Acute femoral neuropathy after renal transplantation is an uncommon and rarely recognized complication. Recovery of the nerve is usual. Although rare, five cases have come to our attention in the past twenty years. A detailed clinical and electrophysiological analysis with a six month follow-up is presented. A review of sixteen other reported cases is also provided. The possible pathophysiology including direct compression and nerve ischemia, is discussed. We believe that nerve ischemia, possibly caused by a steal phenomenon, occurs in all cases following the anastomosis of the graft renal artery to the internal iliac artery, with a superimposed component of compression in some cases. The severity of ischemia probably determines the degree of recovery.