Vaginal peroneal nerve damage-Tips for avoiding nerve injuries in gynecologic surgery | MDedge ObGyn

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Vaginal peroneal nerve damage

Vaginal peroneal nerve damage

Vaginal peroneal nerve damage

Am J Med. Therefore, care during lithotomy positioning with both candy cane and Allen stirrups is critical during vaginal Vaginal peroneal nerve damage. Barr K. Med Clin North Am. Hence, careful neurological examination of the patient with foot Wifes panking is paramount. In an inpatient setting, this may involve early identification of patients with predisposing factors e. The pathophysiology involves hyperglycaemia-induced cell injury and oxidative stress Thanks for registering! Editorial team. Gehrig is professor and director of gynecologic Vaginal peroneal nerve damage at the University of North Carolina at Chapel Hill.

Bumpy nipple pictures. Common peroneal nerve dysfunction

Bilateral peroneal nerve palsies following intermittent pneumatic compression have been reported [ 12 ]. Further study in this area could help elucidate the clinical significance of a mild and reversible peroneal neuropathy concurrent with ankle sprain [ 11 ]. Less commonly, peroneal nerve injury occurs as a result of laceration. Eighty-six percent of patients with grade III sprains and seventeen percent Vaginal peroneal nerve damage patients with grade II sprains had electrodiagnostic evidence of peroneal nerve injury on needle examination. Skin damage from superficial cold application does not usually occur with the use of a protective barrier for the skin and limited duration of therapy. Cryotherapy induced common peroneal nerve palsy. But the diagnostic value of this in terms of neuropathy is controversial [ 12 ]. Philadelphia: Elsevier; Neuropathy - common peroneal nerve; Peroneal nerve injury; Peroneal nerve palsy; Fibular neuropathy. The deep Two gay boys fucking nerve supplies the area between the first and second toes. Though rare, neurological Vaginal peroneal nerve damage can occur from anesthesia, so if neurological complications do occur, even while there was nothing unusual during the procedure, it is important to decide on the proper course of management Vaginal peroneal nerve damage a thorough history, physical examination, and diagnostic tests. Semin Neurol. Moen V, Irestedt L. Another It is responsible for the flexing of your feet and toes.

Upper- and lower-extremity injuries can occur during gynecologic surgery.

  • Help someone with useful health advice.
  • Maybe you have less feeling in your legs or feet.
  • This peripheral origin of foot drop has been reported due to numerous traumatic and insidious causes.
  • A 26 year old, healthy, 41 week primiparous woman received a patient-controlled epidural analgesia PCEA and experienced paraplegia 11 hours later after a vaginal delivery.

Upper- and lower-extremity injuries can occur during gynecologic surgery. The incidence of lower-extremity injury is 1. The pathophysiology of the nerve injuries can be mechanistically separated into three categories: neuropraxia, axonotmesis, and neurotmesis. This may take up to a year to resolve as axonal regeneration proceeds at the rate of 1 mm per day.

This can be separated into second and third degree and refers to the severity of damage and the resultant persistent deficit. A brachial plexus injury can also occur if shoulder braces are placed too laterally during minimally invasive surgery.

Radial nerve injuries can occur if there is too much pressure on the humerus during positioning. Ulnar injuries arise from pressure placed on the medial aspect of the elbow. Tip 2: Shoulder blocks should be placed over the acromioclavicular AC joint.

As with brachial injury prevention, patients should be positioned prior to draping and care must be taken to not hyperflex or externally rotate the hip during minimally invasive surgical procedures. With the introduction of robot-assisted surgery, care must be taken when docking the robot and surgeons must resist excessive movement of the stirrups.

Tip 3: During laparotomy, surgeons should use the shortest blades that allow for adequate visualization and check the blades during the procedure to ensure that excessive pressure is not placed on the psoas muscle.

Consider intermittently releasing the pressure on the lateral blades during other portions of the procedure. Obturator nerve injuries can occur during retroperitoneal dissection for pelvic lymphadenectomy obturator nodes and can be either a transection or a cautery injury.

It can also be injured during urogynecologic procedures including paravaginal defect repairs and during the placement of transobturator tapes. The sciatic nerve and its branch, the common peroneal, are generally injured because of excessive stretch or pressure. Both nerves can be injured from hyperflexion of the thigh and the common peroneal can suffer a pressure injury as it courses around the lateral head of the fibula. Therefore, care during lithotomy positioning with both candy cane and Allen stirrups is critical during vaginal surgery.

Tip 5: Ensure that the lateral fibula is not touching the stirrup or that padding is placed between the fibular head and the stirrup. The ilioinguinal and iliohypogastric nerves are typically injured via suture entrapment from low transverse skin incisions, though laparoscopic injury has also been reported.

The incidence after a Pfannenstiel incision is about 3. Pain is typically worse when seated. The genitofemoral nerve is typically injured during retroperitoneal lymph node dissection, particularly the external iliac nodes. The nerve is small and runs lateral to the external iliac artery.

It can suffer cautery and transection injuries. Usually, the paresthesias over the mons pubis, labia majora, and medial inner thigh are temporary. Tip 7: Care should be taken to identify and spare the nerve during retroperitoneal dissection or external iliac node removal.

Nerve injuries during gynecologic surgery are common and are a significant cause of potential morbidity. While occasionally unavoidable and inherent to the surgical procedure, many times the injury could be prevented with proper attention and care to patient positioning and retractor use. Gynecologists should be aware of the risks and have a through understanding of the anatomy.

In a prospective study, the median time to resolution of symptoms was Gynecol Oncol. Fertil Steril. J Minim Invasive Gynecol. Am J Obstet Gynecol. Obstet Gynecol. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. She reported having no financial disclosures relevant to this column. Email her at obnews frontlinemedcom. Skip to main content. Gynecologic Oncology Consult. Tips for avoiding nerve injuries in gynecologic surgery.

By Paola A. Gehrig, MD. Paola A. Gynecologic Cancer Gynecology Surgery. Menu Menu Presented by Register or Login. Menu Close. Gyn News.

Weakness of the ankle dorsiflexors, toe extensors, and ankle evertors, commonly referred to as foot drop, is suggestive of peroneal neuropathy. Fifteen to twenty-eight percent of patients have an accessory peroneal nerve that branches off the superficial peroneal to supply the extensor digitorum brevis usually innervated by the deep peroneal [ 2 — 4 ]. The majority of these patients still had lesions in continuity [ 17 ]. This often occurred in conjunction with injury to the lateral, collateral, or posterior cruciate ligament. J Neurosurg. Less frequently, lumbosacral plexopathy can result in weakness in a similar distribution.

Vaginal peroneal nerve damage

Vaginal peroneal nerve damage. Case Report

The anorectal angle ARA is measured between the anal canal and the central longitudinal axis of the lower rectum. ARA decreased when squeezing B , however not enough to reach normal values. Also, a tendency for proctocolic intussusceptions was observed when defecating D. The patient continued to experience dyschezia, but voiding difficulties improved and self voiding urine was ml with residual urine of ml.

The patient decided to follow up on an outpatient basis while continuing treatment options like biofeedback physiotherapy, but she has not fully recovered currently at 7 month. An epidural block using local anesthetics is commonly used for analgesia for pain relief of the vaginal delivery process.

And when complications arise, epidural blocks are rarely the cause [ 2 , 3 ]. According to Holdcroft et al. If neurological complications from an epidural block occur, it can present as paresthesia and a reduction of muscular strength. Nerve damage can be caused by the Tuohy needle, the catheter, spinal cord ischemia, accidental injection of neurotoxic agents, infection or injection of local anesthetics into the epidural space.

Also neurological complications from an epidural hematoma can occur, but such cases are rare at a rate of 1 : , [ 5 ]. In these patients the time of injection and removal of the catheter is very important. Also, 24 hours following a catheter removal, a thorough neurological examination should be taken. If complications arise, sharp leg and back pains can occur followed by a loss of sensation and strength in both extremities, incontinence, lack of tension of the sphincter ani, and a loss of motor reflexes.

If hematoma is suspected, computer tomography or MRI should be taken and after a hematoma diagnosis, surgical decompression is needed to commence in 6 hours [ 6 ]. The epidural needle can enter a blood vessel, pierce the intervertebral foramen or get tangled in the spinal nerve root and cause complications [ 7 , 8 ].

Recovery from injury of the nerve root of the spine takes a long time, usually months after damage, so extra care should be taken. During the case in question, because there was no pain or paresthesia until the catheter was removed, the likelihood of nerve damage by the Tuohy needle or epidural catheter seems unlikely.

Also, no neurological symptoms were observed during the injection of the drugs, so nerve damage from the toxicity of the drugs also seems unlikely. If neurological complications are suspected, taking a thorough history of the symptoms is vital to the differentiation of the cause of the damage. The onset, area of the symptom, presence of radiating pain or pain during the procedure should be inquired.

Also, through physical examination, it should be recognized whether the pain or the neurologic deficit follows the dermatome or the pathways of the peripheral nerves. An EMG helps to figure out the time of injury and area. Because changes in the EMG shows after 2 weeks of the injury, if changes occur in the first week of delivery, it means the mother had neurologic problems before the delivery.

During vaginal delivery, various factors can lead to nerve damage such as improper vacuum or forceps operation, inappropriate position of the mother, and pressure from the fetal head. Examples include: damage to the Lumbar plexus, sacral plexus, femoral nerve, obturator nerve, common peroneal nerve, and tibial nerve are examples. The pudendal nerve can also receive damage during vaginal delivery [ 9 ], and denervation of the sphinter ani can cause trouble with defecation [ 10 , 11 ].

It is not known if such neurological damage is caused by extension of the pudendal nerve or direct pressure from the fetal head at the small branch of the nerve or neuromuscular junction.

If damages to the sacral plexus were to occur, urination and defecation disorders similar to cauda equina syndrome can occur, which is due to damage to the automatic nervous system of the rectum and bladder. The pelvic splanchnic nerve from the ventral roots, through the parasympathetic fiber and pudendal plexus, sends arousal signals to the bladder's destrusor muscle, while it sends repression signals to the internal sphincter muscle of the urethra and the smooth muscle of the rectum.

The sensation of pain and expansion from the bladder and lower rectum is sent to the central nervous system, it passes through the pudendal nerve and posterior rami to be terminated at the anterolateral column of the S spine. The pudendal nerve also includes motor fibers and relays repression or arousal signals to the external sphincter of the urethra and anus. In this case, urological testing showed a flaccid neurogenic bladder, which was consistent with the T11, T12, L1 and L2 sympathetic nerve signaling the bladder, while S2 through S4 parasympathetic nerve signals were being blocked, causing detrusor muscle relaxation, and persistent arousal of the internal sphincter muscle of the urethra.

Also severe degradation of the desire to void and defecate showed there may have been problems with parasympathetic signaling between the bladder and rectum.

Upon evaluation of the patient's anorectal function, an anorectal angle greater than the normal value and proctocolic intussusception during defecation was observed by defecography. But the diagnostic value of this in terms of neuropathy is controversial [ 12 ]. There is no specific way of evaluating pelvic splanchnic nerve damage, while the PNTML test exists for pudendal nerve damage.

The PNTML test has its limitations in that even while nerve damage has progressed severely, motion conduction ability can be maintained since motion conduction can occur through the small diameter axon of the pudendal nerve [ 13 ]. Other testing methods excluding PNTML only examines end-organ functions, and it can be said is a practical and accurate method of measuring pudendal nerve function does not exist [ 14 ].

When a mother experiences neurological symptoms after epidural analgesia for a cesarean section or vaginal delivery, the anesthesiologist is the first to be called. Since neurologic regional anesthesia related complications have a lower incidence than obstetric origins, an anesthesiologist may initially have difficulties handling such cases.

Though rare, neurological consequences can occur from anesthesia, so if neurological complications do occur, even while there was nothing unusual during the procedure, it is important to decide on the proper course of management after a thorough history, physical examination, and diagnostic tests.

National Center for Biotechnology Information , U. Journal List Korean J Anesthesiol v. Korean J Anesthesiol. Published online Feb Find articles by Seil Park. Find articles by Sung Wook Park. Find articles by Keon Sik Kim. Author information Article notes Copyright and License information Disclaimer.

Corresponding author. Corresponding author: Keon Sik Kim, M. Tel: , Fax: , moc. This article has been cited by other articles in PMC. Abstract A 26 year old, healthy, 41 week primiparous woman received a patient-controlled epidural analgesia PCEA and experienced paraplegia 11 hours later after a vaginal delivery. Keywords: Analgesia, Epidural, Lumbosacral plexus, Obstetric delivery. Case Report A primiparous 26 year old mother, 41 weeks of gestational age wanted a vaginal delivery.

Open in a separate window. Discussion An epidural block using local anesthetics is commonly used for analgesia for pain relief of the vaginal delivery process. References 1. Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.

Obstet Gynecol. Neurological complications in obstetric regional anesthesia. Int J Obstet Anesth. Moen V, Irestedt L. Patients with ankle sprain often experience lateral ankle pain and eversion weakness from the primary ligamentous injury. A series of 66 patients with ankle sprain underwent this evaluation. Eighty-six percent of patients with grade III sprains and seventeen percent of patients with grade II sprains had electrodiagnostic evidence of peroneal nerve injury on needle examination.

This feature was not present at initial evaluation and occurred only in those patients with electromyographic abnormalities. At 3-month follow-up, electrical abnormalities were only present in two patients. These abnormalities were consistent with reinnervation. Further study in this area could help elucidate the clinical significance of a mild and reversible peroneal neuropathy concurrent with ankle sprain [ 11 ]. Iatrogenic injury of the peroneal nerve can occur from direct manipulation during orthopedic surgery as previously mentioned or with prolonged compression during lateral hip and leg rotation with knee flexion as occurs in operative positioning.

This position is often used in gynecologic as well as abdominal surgery. In addition to positioning during surgery, patients who require prolonged bed rest after surgery may be at risk for peroneal neuropathy.

Gravity, the shape of the lower extremity, and muscular imbalance contribute to the tendency of the lower limb to rest in external rotation of the hip and knee flexion while lying supine. This position, together with the bony prominence of the fibular head, may jeopardize the peroneal nerve unless a preventative program is instituted. This involves the use of bilateral padded ankle foot orthoses which maintain the feet in dorsiflexion and the lower limbs in neutral without external rotation while the patient is resting in bed.

Frequent repositioning of the supine patient can also minimize pressure on the lateral knee. In addition to peroneal neuropathy, prolonged bed rest is a risk factor for deep venous thrombosis. Currently, the medical community has an increased awareness of the post-operative risk of thromboembolic disease. Pneumatic compression devices may be used in the prevention of this life-threatening disorder.

Bilateral peroneal nerve palsies following intermittent pneumatic compression have been reported [ 12 ]. Unfortunately, malnutrition is a common comorbid condition with bed rest or prolonged surgery.

Since malnutrition leads to weight loss, this may be a complicating factor when considering positioning as the cause of peroneal neuropathy. Since both weight loss and bed rest may result in a neuropathy of subacute onset, chronology does not help to identify the causative factor.

Patients who have weight loss, independent of bed rest or compressive lesion, have developed peroneal neuropathy [ 13 ].

Bilateral peroneal neuropathy has been reported after bariatric surgery [ 14 ]. Currently, there is no agreement as to the quantity of weight loss that will result in peroneal nerve damage. The proposed mechanism is loss of fat previously protecting the peroneal nerve.

Of interest, peroneal neuropathy has also been reported with prolonged squatting [ 16 ]. Biomechanical comparisons of compression of the peroneal nerve in squatting have not been evaluated in terms of body mass index. Less commonly, peroneal nerve injury occurs as a result of laceration. These were due to injury from broken glass, knives, boat propellers, chain saws, or lawn mower blades. Three of the 39 patients had continuity of the nerve despite this mechanism of injury and subsequently had better recovery.

In this same series, 12 patients had peroneal nerve injuries due to gunshot wound. The majority of these patients still had lesions in continuity [ 17 ]. The case series of Kline and colleagues also addressed mass lesions. Other tumors, in order of decreasing frequency, included schwannoma, neurofibroma, osteochondroma, neurogenic sarcoma, focal hypertrophic neuropathy, desmoid tumor, and glomus tumor [ 17 ].

In a much smaller study of nine patients presenting with peroneal nerve palsy who underwent MRI, six patients had ganglion cyst, one had a synovial cyst, one had osteochondroma, and one had an aneurysm [ 18 ]. Intraneural ganglion cyst appears to be a frequently occurring mass lesion in peroneal neuropathy. Osteoarthritis of the knee may contribute to peroneal neuropathy via mechanisms involving nerve stretch or compression.

A case of varus knee deformity due to arthritis resulting in peroneal neuropathy at the level of the knee has been reported. There was no evidence of compressive lesion at the time of operative exploration. Consequently, the lesion was thought to be due to repetitive traction injury from varus malalignment.

The patient responded to treatment with total knee arthroplasty with attention to prevention of post-operative varus knee laxity [ 20 ].

There was no noted lateral knee osteophyte in this patient. However, an osteophyte causing peroneal nerve palsy has been reported in a younger patient [ 21 ]. Initially, patients with peroneal neuropathy complain of lateral lower limb and dorsal foot pain. Concurrent low back pain or posterolateral thigh pain suggests L5 radiculopathy.

Pain usually precedes sensory changes in a similar distribution. The patient may complain of foot drop as the first manifestation of this disorder. Evidence of trauma or vascular comprise may help to determine the cause of the lesion. The peroneal nerve may be palpated as it winds around the head of the fibula. Tapping over this area may reproduce dysesthesia in the lateral calf or foot. Careful sensory examination can assist with localizing the lesion.

The deep peroneal nerve supplies the area between the first and second toes. The remaining dorsum of the foot is innervated by the superficial peroneal nerve, except for a small area laterally. Sensation of the plantar foot is spared in lesions of the peroneal nerve. All muscles of the lower limb should be examined for weakness and compared to the contralateral side. Weakness of the ankle dorsiflexors, toe extensors, and ankle evertors, commonly referred to as foot drop, is suggestive of peroneal neuropathy.

Another Less frequently, lumbosacral plexopathy can result in weakness in a similar distribution. Often, patients with L5 radiculopathy or sciatic neuropathy will have similar deficits as those with common peroneal neuropathy.

The tibialis posterior, innervated by the tibial nerve, receives its main segmental innervation from L5. This muscle provides the majority of ankle inversion. Examination of normal and pathologic reflexes can further narrow the differential. The patellar tendon reflex is innervated by the L2 through L4 nerve roots. The Achilles reflex is primarily from S1. Absent or diminished reflexes suggest a peripheral origin of foot drop. The presence of pathologic reflexes, such as a Babinski reflex, suggest foot drop of central origin.

As previously mentioned, the L4, L5, and S1 roots contribute to the common peroneal nerve. Plain radiographs of the knee and ankle should be obtained to evaluate for concurrent fracture, mass lesion, or arthritis if the history suggests one of these etiologies.

Lumbar MRI can provide evidence of L5 radiculopathy if radiographs are negative. Knee and ankle MRI can further elucidate a bony lesion or demonstrate intraneural ganglia. In order to view the anatomy of the actual nerve, 3-tesla MRI is necessary [ 23 ]. These machines are now becoming available at large centers. Another newer technique to assess the area around the fibular head is high-resolution sonography.

Visser suggests that ultrasonography is an accessible and easy way to evaluate the common peroneal nerve in its superficial location [ 24 ]. Electrodiagnostic studies assist with confirming the diagnosis of peroneal neuropathy, excluding alternative diagnoses, and determining prognosis. If the lesion is due to axon loss, compound muscle action potential amplitudes will be decreased at all stimulation sites.

Needle electromyographic exam can further localize the lesion. Routine muscles examined for this study include two muscles innervated by the deep peroneal nerve, one muscle innervated by the superficial peroneal nerve, the tibialis posterior, another muscle innervated by the tibial nerve i. If any of the muscles supplied by the peroneal nerve are abnormal, further muscles supplied by the L5 nerve root but not the peroneal nerve i.

As these provide symptomatic relief only, the choice of medication depends on comorbidities and possible adverse effects. A review of these choices is beyond the scope of this article, but treatment should be individualized to the patient.

Modalities such as heat and ice can also provide effective pain relief. However, patients with sensory loss should be carefully observed during the use of modalities to prevent skin damage. Also, superficial ice treatment may injure the peroneal nerve at the fibular head when applied incorrectly. This was reported in the case of a football player who applied ice to a hamstring muscle strain [ 25 ]. Skin damage from superficial cold application does not usually occur with the use of a protective barrier for the skin and limited duration of therapy.

Superficial heat may result in burn injury. This can occur with lying on a heating pad or prolonged therapy. Iontophoresis has been suggested for the relief of pain in peroneal neuropathy [ 26 ]. This involves the transcutaneous delivery of ionic medications i. Although there has been little evidence to suggest the actual absorption of steroids into human soft tissue, this may provide symptomatic relief for the patient and is generally well tolerated.

Weakness in peroneal neuropathy may lead to functional gait impairment. If there is transection of a nerve or a complete axon loss lesion, it will be of no use to attempt to strengthen the denervated muscles.

If there is compression, it is best to relieve the offending agent prior to a trial of strengthening. If the patient has subtle peroneal nerve injury, strengthening may help with functional recovery. If the patient has complete loss of strength, passive range of motion may be all that is possible. It is imperative to maintain proper ankle range of motion so that residual heel cord contracture will not preclude the ability to walk.

Recently, peroneal nerve stimulators have been gaining in popularity for the treatment of foot drop of central etiology [ 27 , 28 ]. These devices require an intact functioning peroneal nerve and are not useful in patients with peripheral nerve injury.

Patients with sensory loss should check their feet daily to prevent progression of ulcers. A simple lace-up ankle sleeve with medial and lateral support may assist a patient with proprioceptive loss. If the patient has weakness of the toe extensors only, as would occur in distal deep peroneal neuropathy, sturdy footwear may be all that is needed to optimize gait. A rocker-bottom shoe may decrease the energy required for ambulation.

If the patient has isolated superficial peroneal nerve palsy, he may benefit from a shoe insert with a lateral wedge to prevent supination of the foot from weakness of the evertors. If the patient has a proximal deep peroneal neuropathy, he may be unable to dorsiflex the ankle.

Ankle dorsiflexion is necessary to clear the toes while ambulating. An ankle foot orthosis maintains the foot in neutral so that the patient can achieve a normal gait pattern. If the lesion is at the level of the common peroneal nerve, the foot may tend toward plantarflexion and inversion. This patient would also require an ankle foot orthosis for toe clearance during gait. All patients with weakness should stretch daily to prevent contracture.

Equinovarus foot deformity is a common complication of ankle dorsiflexion weakness. It is essential that the patient maintain his range of motion to have the ability to ambulate. After contracture has developed, the patient may be unable to tolerate bracing. If bracing is not effective, the tibialis posterior tendon can be transferred to the dorsum of the foot to restore active dorsiflexion.

This is often performed in conjunction with fusion of the subtalar joint and after one year post-injury [ 7 ]. Removal of the offending agent, lesion, or activity is the best treatment of peroneal neuropathy. Consequently, prompt recognition and diagnosis is imperative in order to preserve maximum function. Open wounds associated with peroneal nerve palsy should undergo immediate surgical exploration [ 30 ].

Other lesions are followed clinically and may be investigated electromyographically. Operative technique and time to intervention vary according to the nature of the injury. Neurolysis yields the best outcome. End-to-end suture repair is preferable to graft repair, and shorter grafts yield better outcomes. National Center for Biotechnology Information , U.

Curr Rev Musculoskelet Med. Published online Mar Jennifer Baima 1, 2 and Lisa Krivickas 1, 2. Author information Copyright and License information Disclaimer. Jennifer Baima, Email: gro. Corresponding author. This article has been cited by other articles in PMC. Keywords: Peroneal nerve, Ankle dorsiflexors, Foot drop, Sciatic nerve injury. Anatomy The sacral plexus is formed from the L4—S4 ventral rami. Open in a separate window. Etiology Peroneal nerve compromise has been reported due to numerous traumatic and insidious causes.

Patient evaluation Initially, patients with peroneal neuropathy complain of lateral lower limb and dorsal foot pain. Imaging and electrodiagnostic testing Plain radiographs of the knee and ankle should be obtained to evaluate for concurrent fracture, mass lesion, or arthritis if the history suggests one of these etiologies.

Herman & Wallace - Unretractable Vaginal Nerve Pain

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Vaginal peroneal nerve damage

Vaginal peroneal nerve damage

Vaginal peroneal nerve damage