Femoral nerve injury complicating surgery for gynecologic cancer

A case series title: femoral nerve injury with an episode of motor neuropathy caused by gynecological surgery: a case series

Background

Although iatrogenic nerve injury is sometimes diagnosed after gynecological surgery, its incidence is underestimated because most cases are self-limiting and underreported. Herein, we report on six cases of femoral nerve injury after gynecological surgery with both sensory and motor neuropathy.

Methods

We retrospectively analyzed 785 patients with gynecological cancer requiring surgery, including lymph node dissection, between 2012 and 2016 at our center. The functional damage due to femoral nerve injury was postoperatively assessed and classified according to the Medical Research Council (MRC) scale by an orthopedist and a physiatrist. The eligibility criteria were grade 3 or less hip joint bending and muscular weakness due to nerve injury. Patients were excluded if they had been diagnosed with an isolated sensory disorder.

Results

We found six cases (0.76%) of femoral motor neuropathy resulting from gynecological surgery. All six patients underwent laparotomy using energy devices under general anesthesia with epidural anesthesia in the lithotomy position. Four of them recovered fully within 8 months from surgery with either physical therapy or no treatment, while the other two died within a year post-treatment; thus, recovery evaluation could not be accurately performed.

Conclusion

Postoperative femoral nerve injury can be diagnosed based on gait disturbances and difficulties climbing stairs. It is difficult to identify risk factors for femoral nerve injury as they may involve a combination of features, such as intraoperative compression with self-retaining retractors, the lithotomy position, and the use of energy devices. The surgeon should be familiar with the nature of energy devices, make every effort to understand the necessary anatomy, and make every effort to avoid femoral nerve injury. Iatrogenic femoral nerve injury caused by gynecological surgery should be further investigated regarding the patients' quality of life postoperatively.

Postoperative Femoral Nerve Palsy and Meralgia Paresthetica after Gynecologic Oncologic Surgery

Femoral nerve palsy and meralgia paresthetica following gynecologic cancer surgery are rare, but severe and long lasting. Here, we aimed to study their incidence, severity, possible risk factors and its time to remission. Between January 2008 and December 2017 976 gynecologic cancer patients were identified in our institutional database receiving surgery. Complete patient charts were reviewed retrospectively. Possible risk factors were analyzed by Fisher’s exact test. 441 (45.18%) out 976 were treated for Ovarian cancer. In total 23 patients were identified with a postoperative neurological leg disorder. A femoral nerve palsy was present in 15 patients (1.5%) and a meralgia paresthetica in 8 patients (0.82%). Three patients showed both disorders. Duration of surgery (p = 0.0000), positioning during surgery (p = 0.0040), femoral artery catheter (p = 0.0051), prior chemotherapy (p = 0.0007), nicotine abuse (p = 0.00456) and prior polyneuropathy (p = 0.0181) showed a significant association with a postoperative femoral nerve palsy. Nicotine abuse (p = 0.0335) and prior chemotherapy (p = 0.0151) were significant for the development of a meralgia paresthetica. Long lasting surgery, patient positioning and femoral arterial catheter placement are risk factors for a postoperative femoral nerve palsy in gynecologic cancer surgery. Polyneuropathy, nicotine abuse, and prior chemotherapy are predisposing risk factors for a femoral nerve palsy and a meralgia paresthetica. A resolution of symptoms is the rule for both disorders within different time schedules.

Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach

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.

Transfer of Sciatic Nerve Motor Branches in High Femoral Nerve Injury: A Cadaver Feasibility Study and Clinical Case Report

BACKGROUND

Femoral nerve injury causes knee dysfunction, and high femoral nerve injury is difficult to repair.

OBJECTIVE

To evaluate the anatomic feasibility of transferring the sciatic nerve motor branches in high femoral nerve injury.

METHODS

The femoral nerve was exposed in both lower extremities of 3 adult fresh-frozen cadavers; each branch was noninvasively dissected to its proximal nerve fiber intersection point and distal muscle entry point. The branches of the sciatic nerve were also exposed. The length, diameter, and number of myelinated fibers were measured in each femoral and sciatic nerve branch. The feasibility of tension-free direct suture between the femoral and sciatic nerve branches was evaluated. One patient was treated with transfer of a nerve branch innervating the semitendinosus muscle to the femoral nerve branch and was followed up for 18 mo.

RESULTS

The diameters and numbers of myelinated fibers in the femoral nerve branches matched those of the sciatic nerve branches. In the single patient, a combined femoral nerve bundle (comprising the rectus femoris and vastus lateralis branches) was used as a graft. The branch of the sciatic nerve was sutured with the muscle branch of the femoral by using a sural nerve as a nerve graft. The knee joint straightening strength reached medical research council grade 4+.

CONCLUSION

The proximal motor branches of the sciatic nerve may be transferred as donor nerves to repair high femoral nerve injury. A femoral nerve bundle comprising the rectus femoris and vastus lateralis branches may be used as the receptor nerve.

Femoral neuropathy following a psoas hitch vesicopexy

A 68-year-old man classified as III on the American Society of Anaesthesiologists (ASA) physical status classification system, with a high-grade papillary urothelial cell carcinoma of the left distal ureter, underwent open retroperitoneal distal ureterectomy followed by a ureteroneocystostomy with a vesico-psoas hitch. Postoperatively, the patient complained of left proximal lower limb weakness, severe pain and hypaesthesia of the ventral left thigh suggestive of femoral neuropathy. After excluding common causes for postsurgical pain, a surgical re-exploration was eventually performed during which the sutures used in the vesicopexy were removed, resulting in almost complete resolution of the symptoms. Electromyographic analysis 4 weeks after discharge confirmed the diagnosis of femoral neuropathy, most likely caused by the sutures used in the vesicopexy. This is a rare complication with major consequences for postoperative recovery.

The utility of anatomic diagnosis for identifying femoral nerve palsy following gynecologic surgery

We describe a case in which an anatomic diagnosis was useful for diagnosing and estimating the cause of femoral nerve palsy following gynecologic surgery. A 49-year-old female received general and epidural anesthesia for radical ovarian cancer surgery. Although injection pain was noted in the left medial shin with 1 % mepivacaine administered as a test dose, the catheter was left indwelling because it improved her symptoms. The surgery, which lasted 195 min, was performed in the lithotomy position, and a self-retained retractor was used to gain a good surgical field. Postoperatively, the patient complained of difficulty in stretching her knee joint and left lower limb paresthesia that did not improve after stopping continuous epidural administration. A spinal cord injury related to epidural anesthesia was suspected because the sites of sensory impairment and epidural injection pain were the same; however, the patient had greater weakness of the quadriceps muscle than the iliopsoas, and no other muscle weakness was observed. These findings and previous reports suggest that her femoral nerve palsy was caused by compression of the inguinal ligament from the self-retaining retractor and lithotomy position. Twenty months after surgery, her muscle strength had fully recovered.