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Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach. Ann Med Surg (Lond) 2021; 72:103055. [PMID: 34815865 PMCID: PMC8593564 DOI: 10.1016/j.amsu.2021.103055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose Accidental femoral nerve injury is a well-known iatrogenic complication of orthopaedic, abdominal, and pelvic surgery. Because of the largely transitory nature of the symptoms associated with nerve damage, its true incidence is in all likelihood underestimated. This work aims to illustrate the surgical contexts within which this nerve injury is reported, based on the evidence obtained from a Scoping Review of the literature of the last 20 years, with specific reference to the underlying etiopathogenetic mechanisms and prognostic outcomes, to highlight the evaluation issues of medico-legal interest related to this pathology. Methods We conducted a Scoping Review of iatrogenic femoral nerve injuries reported between 2000 and 2021 by searching the electronic databases Pubmed, Scopus, Ovid Medline, Ovid Emcare, and Web of Science.We conducted the review according to the five-step methodology outlined by Arksey and O'Malley. Results The literature search identified 104 papers, including case reports, case series, and retrospective studies. Surgical contexts within which iatrogenic femoral nerve injuries were reported include orthopaedic, abdominal, gynaecological, urological, vascular, and plastic surgery, as well as locoregional anaesthesiological procedures. The long-term prognosis was generally favourable. Conclusions Because of its frequent iatrogenic genesis, femoral nerve injury is a topic of intense medico-legal interest. From the perspective of estimating the patient's disability, the mostly favourable nature of the prognosis makes the medico-legal assessment, in some respects, complex, thus requiring a precise evaluation methodology.
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Yamada S, Hotta K, Takahata M, Iwami D, Sugito Y, Tanabe T, Iwahara N, Shinohara N. Femoral nerve palsy following kidney transplantation: A case report and review of the literature. IJU Case Rep 2020; 3:248-251. [PMID: 33163916 PMCID: PMC7609172 DOI: 10.1002/iju5.12207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Femoral nerve palsy is a rare but serious complication of kidney transplantation. We report a case of femoral nerve palsy following kidney transplantation and conduct a review of the literature on this complication. CASE PRESENTATION A 35-year-old woman with end-stage kidney disease, underwent kidney transplantation in the right iliac fossa. The day after the transplantation, she could not straighten her right leg. Physical examination revealed a paresis of her right quadriceps muscle. The patient's sensation of her right thigh was also impaired. We diagnosed her with femoral nerve palsy caused by inappropriate compression from a self-retaining retractor. Rehabilitation was started immediately. The patient's motor weakness gradually improved, and the patient became able to walk independently 4 weeks later. However, the patient's neuropathic pain sustained 6 months after her kidney transplantation. CONCLUSION The improper use of self-retaining retractors can lead to femoral nerve palsy in patients undergoing kidney transplantation.
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Affiliation(s)
- Shuhei Yamada
- Department ofUrologyHokkaido University HospitalSapporoJapan
| | - Kiyohiko Hotta
- Department ofUrologyHokkaido University HospitalSapporoJapan
| | - Masahiko Takahata
- Department ofOrthopaedic SurgeryHokkaido University HospitalSapporoHokkaidoJapan
| | - Daiki Iwami
- Department ofUrologyHokkaido University HospitalSapporoJapan
| | - Yuki Sugito
- Department ofUrologyHokkaido University HospitalSapporoJapan
| | - Tatsu Tanabe
- Department ofUrologyHokkaido University HospitalSapporoJapan
| | - Naoya Iwahara
- Department ofUrologyHokkaido University HospitalSapporoJapan
| | - Nobuo Shinohara
- Department ofUrologyHokkaido University HospitalSapporoJapan
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Kim MH, Jun KW, Hwang JK, Moon IS, Kim JI. Characteristics of Femoral Motor Neuropathies Induced After Kidney Transplantation: A Case Series. Transplant Proc 2016; 48:933-7. [DOI: 10.1016/j.transproceed.2015.12.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/07/2015] [Indexed: 10/21/2022]
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Abrams BM. Femoral and Saphenous Neuropathies. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Al-Ajmi A, Rousseff RT, Khuraibet AJ. Iatrogenic femoral neuropathy: two cases and literature update. J Clin Neuromuscul Dis 2010; 12:66-75. [PMID: 21386773 DOI: 10.1097/cnd.0b013e3181f3dbe7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
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.
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Li QS, Huo WQ, Nie ZL, Wang HF, Liang PH, Jin FS. Acute Femoral Neuropathy Following Renal Transplantation: A Retrospective, Multicenter Study in China. Transplant Proc 2010; 42:1699-703. [DOI: 10.1016/j.transproceed.2010.02.082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 12/23/2009] [Accepted: 02/10/2010] [Indexed: 11/30/2022]
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Krishnan AV, Pussell BA, Kiernan MC. Neuromuscular disease in the dialysis patient: an update for the nephrologist. Semin Dial 2009; 22:267-78. [PMID: 19386072 DOI: 10.1111/j.1525-139x.2008.00555.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neuromuscular disease is an extremely common complication of end-stage kidney disease (ESKD), manifesting in almost all dialysis patients, and leading to weakness, reduced exercise capacity, and disability. Recent studies have suggested that hyperkalemia may underlie the development of neuropathy. As such, maintenance of serum K(+) within normal limits between periods of dialysis in ESKD patients manifesting early neuropathic symptoms may reduce neuropathy development and progression. For patients with more severe neuropathic syndromes, increased dialysis frequency or a switch to high-flux dialysis may prevent further deterioration, while ultimately, renal transplantation is required to improve and restore nerve function. Exercise training programs are beneficial for ESKD patients with muscle weakness due to neuropathy or myopathy, and are capable of improving exercise tolerance and quality of life. Specific treatments have recently been evaluated for symptoms of autonomic neuropathy, including sildenafil for impotence and midodrine for intra-dialytic hypotension, and have been shown to be effective and well tolerated. Other important management strategies for neuropathy include attention to foot care to prevent callus and ulceration, vitamin supplementation, and erythropoietin. Treatment with membrane-stabilizing agents, such as amitryptiline and gabapentin, are highly effective in patients with painful neuropathy.
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Affiliation(s)
- Arun V Krishnan
- Prince of Wales Medical Research Institute, Barker Street, Randwick, Sydney, NSW 2031, Australia
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Nikoobakht M, Mahboobi A, Saraji A, Mehrsai A, Emamzadeh A, Mahmoudi MT, Pourmand G. Pelvic nerve neuropathy after kidney transplantation. Transplant Proc 2007; 39:1108-10. [PMID: 17524904 DOI: 10.1016/j.transproceed.2007.03.085] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We examined the relation of various age, gender, diabetes, hypertension, and graft function with the prevalence of femoral and lateral cutaneous nerves sensory and/or motor disturbances after kidney transplantation. MATERIALS AND METHODS Among 129 patients who underwent kidney transplantation from April 2001 to March 2002. We excluded, 10 due to preoperative sensory disturbances. We evaluated the prevalence of sensory and/or motor disturbances preoperatively by physical examination and postoperatively by both physical and electromyography examinations. The clinical findings were correlated with the following risk factors: age, gender, preoperative dialysis duration, background diseases. (e.g., diabetes, hypertension), graft weight, nephron mass index, operative and retraction time, and rejection episodes. RESULTS At 1 to 9 days postoperatively, 31 ng (26%) patients, suffered neuropathy of the lateral cutaneous nerve and 4 (3.3%), femoral neuropathy. No meaningful relation was detected between the incidence of neuropathy and these risk factors. The probability of neuropathy was greater among diabetics, hypertensives, women, and those with graft rejection episodes. All of these complaints were temporary. CONCLUSIONS Post-kidney transplant femoral and/or lateral cutaneous nerve neuropathy is a prevalent complication particularly in diabetic, hypertensive, and female patients. Neuropathy is also more evident after graft rejection.
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Affiliation(s)
- M Nikoobakht
- Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Krishnan AV, Kiernan MC. Uremic neuropathy: clinical features and new pathophysiological insights. Muscle Nerve 2007; 35:273-90. [PMID: 17195171 DOI: 10.1002/mus.20713] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neuropathy is a common complication of end-stage kidney disease (ESKD), typically presenting as a distal symmetrical process with greater lower-limb than upper-limb involvement. The condition is of insidious onset, progressing over months. and has been estimated to be present in 60%-100% of patients on dialysis. Neuropathy generally only develops at glomerular filtration rates of less than 12 ml/min. The most frequent clinical features reflect large-fiber involvement, with paresthesias, reduction in deep tendon reflexes, impaired vibration sense, muscle wasting, and weakness. Nerve conduction studies demonstrate findings consistent with a generalized neuropathy of the axonal type. Patients may also develop autonomic features, with postural hypotension, impaired sweating, diarrhea, constipation, or impotence. The development of uremic neuropathy has been related previously to the retention of neurotoxic molecules in the middle molecular range, although this hypothesis lacked formal proof. Studies utilizing novel axonal excitability techniques have recently shed further light on the pathophysiology of this condition. Nerves of uremic patients have been shown to exist in a chronically depolarized state prior to dialysis, with subsequent improvement and normalization of resting membrane potential after dialysis. The degree of depolarization correlates with serum K(+), suggesting that chronic hyperkalemic depolarization plays an important role in the development of nerve dysfunction in ESKD. These recent findings suggest that maintenance of serum K(+) within normal limits between periods of dialysis, rather than simple avoidance of hyperkalemia, is likely to reduce the incidence and severity of uremic neuropathy.
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Affiliation(s)
- Arun V Krishnan
- Prince of Wales Medical Research Institute and Prince of Wales Clinical School, University of New South Wales, Barker Street, Randwick, Sydney, NSW 2031, Australia
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Abrams BM. Femoral and Saphenous Neuropathies. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Padua L, Caliandro P, Bertolini C, Calistri A, Aprile I, Pazzaglia C, Tonali P. Post traumatic femoral mononeuropathy. J Neurol 2006; 253:655-6. [PMID: 16767543 DOI: 10.1007/s00415-006-0972-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Revised: 03/31/2005] [Accepted: 05/06/2005] [Indexed: 10/24/2022]
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Lacomis D, Campellone JV. PERIPHERAL NERVOUS SYSTEM COMPLICATIONS OF ORGAN TRANSPLANTATION. Continuum (Minneap Minn) 2004. [DOI: 10.1212/01.con.0000290711.18583.b4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Zargar MA, Darvishi A, Shadpour P, Shooshtari HZ. Hypoesthesia of the thigh following renal transplantation. Transplant Proc 2003; 35:2672. [PMID: 14612066 DOI: 10.1016/j.transproceed.2003.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M A Zargar
- Department of Urology and Transplantation, Hasheminejad Hospital, University of Medical Science, Tehran, Iran.
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Barner KC, Landau ME, Campbell WW. A review of perioperative nerve injury to the lower extremities: part I. J Clin Neuromuscul Dis 2002; 4:95-99. [PMID: 19078697 DOI: 10.1097/00131402-200212000-00009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Kristen C Barner
- From the Department of Neurology, Walter Reed Army Medical Center, Washington, DC
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SENSORY DISTURBANCE OF THE THIGH AFTER RENAL TRANSPLANTATION. J Urol 2001. [DOI: 10.1097/00005392-200103000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Murata Y, Sakamoto K, Hayashi R, Takahashi K, Nakamura SI, Moriya H. SENSORY DISTURBANCE OF THE THIGH AFTER RENAL TRANSPLANTATION. J Urol 2001. [DOI: 10.1016/s0022-5347(05)66522-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yasuaki Murata
- From the Department of Orthopaedic Surgery, School of Medicine, Chiba University and Departments of Surgery, Sakura National Hospital and Takahashi Clinic, Chiba City, Japan
| | - Kaoru Sakamoto
- From the Department of Orthopaedic Surgery, School of Medicine, Chiba University and Departments of Surgery, Sakura National Hospital and Takahashi Clinic, Chiba City, Japan
| | - Ryosuke Hayashi
- From the Department of Orthopaedic Surgery, School of Medicine, Chiba University and Departments of Surgery, Sakura National Hospital and Takahashi Clinic, Chiba City, Japan
| | - Kazuhisa Takahashi
- From the Department of Orthopaedic Surgery, School of Medicine, Chiba University and Departments of Surgery, Sakura National Hospital and Takahashi Clinic, Chiba City, Japan
| | - Shin-Ichiro Nakamura
- From the Department of Orthopaedic Surgery, School of Medicine, Chiba University and Departments of Surgery, Sakura National Hospital and Takahashi Clinic, Chiba City, Japan
| | - Hideshige Moriya
- From the Department of Orthopaedic Surgery, School of Medicine, Chiba University and Departments of Surgery, Sakura National Hospital and Takahashi Clinic, Chiba City, Japan
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Abstract
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.
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Affiliation(s)
- S S Dhillon
- Department of Internal Medicine, St Elizabeth Health Center, Youngstown, OH, USA.
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Abstract
Femoral, saphenous, and obturator neuropathies have diverse causes, many of which are iatrogenic. They have overlapping, but distinct, clinical features. Electrodiagnostic testing can distinguish between these disorders and others in the differential diagnosis. Imaging studies may demonstrate the origin of the neuropathy in some cases. Conservative treatment is usually sufficient, but occasionally surgical exploration of the affected nerve is indicated.
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Affiliation(s)
- N A Busis
- Department of Neurology, University of Pittsburgh School of Medicine, Division of Neurology, Neurodiagnostic Laboratory, University of Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania, USA
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Abstract
Iatrogenic nerve injuries are an undesired byproduct of the practice of medicine and have been so since antiquity. The majority of such injuries occur perioperatively, and are, therefore, attributed to surgeons and anesthesiologists. Nonetheless, the members of almost every clinical specialty are at risk to some degree. Iatrogenic nerve injuries can affect almost any portion of the peripheral nervous system, and can result from many different causes. This article reviews many of the more common iatrogenic nerve lesions.
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Affiliation(s)
- A J Wilbourn
- EMG Laboratory--Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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