7/24/2023 0 Comments Mitchell schwartz back surgeryGynecologic procedures were the most frequently implicated ( 2). Iatrogenic injury to the femoral nerve is well documented: a 33-year review of 119 surgically treated femoral nerve injuries found 52 of 89 (58%) traumatic lesions to the femoral nerve to be iatrogenic in nature ( 1). The femoral nerve is particularly vulnerable to penetrating, compressive, and iatrogenic injuries within the body of the psoas muscle, at the iliopsoas groove, and at the inguinal ligament. Peripheral nerves can be compressed anywhere along their course. Injury of the femoral nerve, therefore, may result in weakness or paralysis of hip flexion and knee extension, atrophy of the quadriceps muscle, and numbness of the anterior thigh and medial aspects of the leg and foot. The saphenous nerve provides sensory innervation to the medial knee leg and foot. On its route, it innervates the psoas major, the iliacus, and the sartorius muscles it provides motor innervation to the pectineus and quadriceps muscles and sensation to the anterior and medial thigh. Traveling laterally to the femoral artery, the femoral nerve passes through the Hunter canal and gives rise to the saphenous nerve. It follows a retroperitoneal course through the psoas major muscle and travels posteriorly to the lateral border of the psoas major before passing under the inguinal ligament en route to the thigh and leg. The femoral nerve arises from rootlets of the L2, 元, and L4 nerve roots, with minor contributions from the L1 and L5 spinal nerves. Despite the transient decrease in femoral nerve function, the patient recovered from the surgery with no signs of neurologic deficit and required no postoperative physical therapy. The patient was repositioned, all extrinsic compression along the course of the femoral nerve was removed, and the response of the quadriceps returned to the baseline potential. The surgeon was not manipulating the spinal nerve roots during this decrease and questioned whether it may be caused by direct compression of the femoral nerve in the inguinal region from patient positioning. During this surgery, neurophysiologic monitoring of the quadriceps muscle showed a decrease in the quadriceps responses, but no such abnormality in the anterior tibialis. After an uncomplicated anterior revision surgery, the patient also underwent a staged delayed posterior arthrodesis and decompression. Six months postoperatively, she had complete resolution of her femoral neuropathy and ambulated without assistance.Ī 59-year-old man presented with subacute cauda equina syndrome, neurogenic claudication, and intractable pain from spinal stenosis and adjacent level deterioration several years after an L4 to L5 fusion and kyphotic deformity. ![]() The patient was returned to the operating room to rule out compressive neuropathy, and no evidence was found of either hematoma or extrinsic compression of the femoral nerve. An immediate computed tomography scan of the abdomen/pelvis and spine showed only postoperative changes, with the bone graft and instrumentation in good position ( Figure 1). Immediately postoperatively, the patient had motor and sensory signs of femoral neuropathy: left quadriceps (2/5), iliopsoas (4/5), and decreased sensation over the anteromedial aspect of her left leg. ![]() EMG monitoring, both free-running and evoked, showed no abnormalities, but proximal muscles were not being tested. Intraoperatively, a retractor was placed on the left psoas muscle laterally, and another retractor blade was placed medially to maintain exposure of the spine. After failure to improve with nonoperative treatment measures, the patient underwent a revision anterior and posterior fusion from L4 to S1. Imaging studies showed pseudoarthrosis at L5 to S1 with concurrent spondylolisthesis at L4 to L5. A 51-year-old woman presented with recurrent intractable low back pain after an anteroposterior lumbar fusion for medically refractory diskitis at L5 to S1.
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