An Uncommon Case of Bilateral Peroneal Nerve Palsy following Delivery: A Case Report and Review of the Literature

Acute bilateral foot drop with or without cauda equina syndrome-a case series

Introduction

Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded.

Methods

Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery.

Results

Seven patients are presented. The mean age at presentation was 52.1 years (range 41–66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other.

Conclusion

When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.

Integrative Review of Lower Extremity Nerve Injury During Vaginal Birth

OBJECTIVE

To describe the incidence, health effects, risk factors, and practice implications of lower extremity nerve injury (LENI) related to vaginal births.

DATA SOURCES

We searched MEDLINE, CINAHL, and PubMed from 2000 to 2020 for peer-reviewed published case reports and research studies of LENI related to vaginal births.

STUDY SELECTION

We identified 188 potential records, and 20 met inclusion criteria (six research studies and 14 case studies).

DATA EXTRACTION

Three independent reviewers extracted details of injuries and births into an Excel spreadsheet and analyzed data using SPSS.

DATA SYNTHESIS

Using birth data from each case study and from four of the six research articles, we found the incidence of LENI in vaginal births was 0.3% to 1.8%. The description of health effects includes affected nerves and the location, description, and duration of symptoms. Analyses of risk factors were limited by missing birth data (length of second stage, birth weight, etc). Vaginal births with LENI were 76% spontaneous, 77% with neuraxial anesthesia, and 64% first vaginal birth. Practice implications focused on prevention through specific positioning strategies. Despite nurses being the primary caregivers during labor, LENI was reported most often in anesthesia journals with virtually no reports in nursing journals.

CONCLUSION

LENI is a potential complication of vaginal birth, and little published research is available on prevention and prognosis. While obstetric and anesthesia factors can cause or contribute to nerve injury, LENI is usually caused by positioning and is considered preventable. Care recommendations include the following: avoid prolonged hyperflexion of women's thighs and knees; minimize time in lithotomy, squatting, or kneeling positions; prevent hand or other deep pressure on lateral knee and posterior thigh areas; avoid motor-blocking neuraxial (epidural) anesthesia; and implement frequent repositioning. The paucity of literature contributes to the lack of awareness of LENI among clinicians.

Acute bilateral foot drop in a chronic alcoholic patient

Peroneal palsy is compression neuropathy of the peroneal nerve, which presents with foot drop. Patients with unilateral peroneal nerve palsy are frequently encountered in clinical practice. Although bilateral peroneal nerve palsy is rare, bilateral foot drop due to peroneal nerve palsy is much less common. The main complaint is often walking difficulty due to weakened ankle dorsiflexor muscles. Medical history and physical examination are always a part of the diagnosis, and the most useful method is electroneuromyography to evaluate the degree of the lesion. In this report, we present a 52-year-old male unconscious patient with chronic alcoholism admitted with acute bilateral foot drop and discuss clinical assessment, diagnosis, and treatment planning of this rare case of peroneal palsy after lying in the prone position in the light of literature data.