Femoral nerve injury in gynecologic surgery: medico-legal issues for best surgical practices

Background Femoral nerve injury following gynecologic surgery may be a postoperative complication, leading to medical malpractice claims and litigation. Methods and results A retrospective analysis was performed on data collected from 973 medico-legal reports of suspected malpractice in gynecologic surgery, filed with the Italian Court between 2000 and 2010. Twelve cases were selected for proven negligence, after a blinded investigation conducted by a gynecologist and a medico-legal expert. Surgical data included type of procedure (hysterectomy, salpingectomy, cesarean section, endometriosis excision), duration of procedure, patient position, and use of retractors. For each case, the observed neuropathy, degree of severity, and recovery time after physical therapy were described. Neuropathies were classified into three categories: neuropraxia (three cases), axonotmesis (six cases), and neurotmesis (three cases) with high sensory and motor deficits. Many particular conditions and pre-existing comorbidity were observed. Two neuropraxia cases were associated with the lithotomy position; axonotmesis cases were related to the incorrect use of self-retaining retractors and an inadequate lithotomy position. Conclusions To avoid potential malpractice lawsuits, care must be taken to accurately collect data linked to individual factors and the possible complications of a surgical procedure. A detailed description is required of the patient’s position on the surgical table, the self-retaining retractors selected, length of time they were in use, maximum tractive force exerted, and their inspection or repositioning during the operation.

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.

Saphenous Nerve Somatosensory-Evoked Potentials Monitoring During Lateral Interbody Fusion

Study Design.: Retrospective cohort study. Objectives: To clinically evaluate saphenous nerve somatosensory-evoked potentials (SSEPs) as a reliable and predictable way to detect upper lumbar plexus injury intraoperatively during lateral lumbar trans-psoas interbody fusion (LLIF). Methods: Saphenous nerve SSEPs were obtained by stimulation of inferior medial thigh with needle electrodes and recording from transcranial potentials. The primary outcome was measured by testing reproducibility of SSEPs at baseline, changes during the procedure, and relevance to standard modalities. Significant SSEP changes were compared with actual postoperative nerve complications. The sensitivity and specificity of saphenous SSEPs to detect postoperative lumbar plexus nerve injury was calculated. Results: A total of 62 patients were included in the study. Reliable saphenous SSEPs were recorded on the LLIF approach side in 52/62 patients. Persistent saphenous SSEP reduction of amplitude of >50% in 6 cases was observed during expansion of the tubular retractor or during the procedure. Two of 6 patients postoperatively had femoral nerve sensory deficits, and 5 of 6 patients had mild femoral nerve motor weakness, all of which resolved at an average of 12 weeks postoperatively (range 2-24 weeks). One patient had saphenous SSEP changes but demonstrated intraoperative recovery and had no postoperative clinical deficits. Saphenous SSEPs demonstrated 52% to 100% sensitivity and 90% to 100% specificity for detecting postoperative femoral nerve complications. Conclusion: Saphenous SSEPs can be used to detect electrophysiological changes to prevent femoral nerve injury during LLIF. Intraoperative SSEP recovery after amplitude reduction or loss may be a prognostic factor for final clinical outcome.

Hip Arthrography

Chapter 101 describes the indications, technique, and imaging findings of hip arthrography. Hip arthrography is selectively performed in routine clinical practice for MRA, typically in younger patients. Indications include hip pain thought to be caused by acetabular labral injury, femoroacetabular impingement syndromes, as well as therapeutic steroid injections. Contrast should easily inject and disperse throughout the joint away from the needle, opacifying the femoral head and neck recesses and outlining the zona orbicularis. The technique can also be used for arthrocentesis with suspected infection, but contrast should not be injected. Contrast extension into the acetabular labral substance may be occasionally depicted on the standard arthrography images. However, it is nowadays evaluated by MRA or sometimes CTA. Complications include infection, bleeding (especially if arterial puncture), and femoral nerve injury.