Peripheral Nerve Injury Associated with a Subdermal Contraceptive Implant: Illustrative Cases and Systematic Review of Literature

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Laumonerie, Pierre and Blasco, Laurent and Tibbo, Meagan E. and Leclair, Olivier and Kerezoudis, Panagiotis and Chantalat, Elodie and Mansat, Pierre Peripheral nerve injury associated with a subdermal contraceptive implant: illustrative cases and systematic review of literature. (2018) World Neurosurgery, 111. 317-325. ISSN 1878-8750

Any correspondence concerning this service should be sent to the repository administrator: [email protected] Peripheral Nerve Injury Associated with a Subdermal Contraceptive Implant: Illustrative Cases and Systematic Review of Literature

Pierre Laumonerie1,2, Laurent Blasco3, Meagan E. Tibbo4, Olivier Leclair5, Panagiotis Kerezoudis4, Elodie Chantalat2,6, Pierre Mansat1

Key words - BACKGROUND: Despite demonstrable safety and efficacy of subdermal - Contraceptive implant contraceptive implants (SCIs), both insertion and removal of SCIs in the arm have - Implant removal - Nerve injury been associated with neurovascular complications. The aim of this study was to - Peripheral nerve injury investigate type and prognosis of nerve injuries associated with SCIs.

- Abbreviations and Acronyms METHODS: We performed a comprehensive search of 4 electronic databases IO: Interossei for studies pertaining to patients with nerve injury and concurrent SCI. Studies MABC: Medial antebrachial cutaneous published between January 1987 and June 2017 were included. Implant location, MRI: Magnetic resonance imaging damaged nerves, clinical presentation, preoperative imaging (x-ray, ultrasound, SCI: Subdermal contraceptive implant US: Ultrasound magnetic resonance imaging), neurologic evaluation (nerve conduction studies, electromyography), and treatment methods were reviewed. To outline manage- 1 From the Department of Orthopaedic Surgery, Institut ment strategies, 2 illustrative cases of major nerve injury caused by SCI removal Locomoteur, Hôpital Pierre Paul Riquet, Toulouse, France; 2Anatomy Laboratory, Department of Orthopaedic Surgery, were presented. 3 Faculty of Medicine, Toulouse, France; Department of - Orthopaedic Surgery, Centre Hospitalier Universitaire de RESULTS: We analyzed 10 studies including 12 patients. Fourteen nerve in- 4 Reims, Reims, France; Department of Orthopaedic Surgery, juries in 12 patients were reported during SCI insertion (n 1) and removal 5 Mayo Clinic, Rochester, Minnesota, USA; Department of (n 11). Medial antebrachial cutaneous (n 5) and median (n 5) nerves Orthopaedic Surgery, Médipôle de Koutio, New Caledonia, 6 France; and Department of Gynecological Surgery, Hopital were primarily affected. Neuropathic pain was the main symptom. Primary Paul de Viguier, Toulouse, France reasons for nerve injury were pulling or grasping of the nerve (n 9) after To whom correspondence should be addressed: mistaking it for the implant. Neurapraxia (n 7) was the most common lesion Pierre Laumonerie, M.D. and was treated with implant removal and clinical surveillance (n 6). Five [E mail: [email protected]] patients completely recovered; the remaining patients continued to have motor and/or sensory deficit at mean follow-up of 0.7 year (range, 0 2 years). - CONCLUSIONS: Nerve injuries related to SCIs are rare but potentially serious. For nonpalpable SCIs, a multidisciplinary approach, including practitioners with experience treating peripheral nerve injuries, is invaluable.

INTRODUCTION Use of subdermal contraceptive implants removal time as well as complexity. article, we present a systematic review of (SCIs) has been steadily increasing for However, as procedural standardization the literature on nerve injuries associated 1 occurred, surgeons and obstetrician- with SCIs. We also describe 2 patients at approximately a decade. The first SCI gynecologists became less and less our institution who sustained significant (Norplant; Wyeth-Ayerst International involved in the insertion of SCIs in favor of nerve injuries during removal of SCIs; Inc., Wayne, Pennsylvania, USA) was general practitioners and midwives.2-6 these serve as illustrative cases in an approved in 1983 and consisted of 6 rods Adverse events related to insertion, effort to demonstrate our approach to placed subcutaneously into the medial localization, and removal of the SCI are the treatment of these injuries. The side of the nondominant arm. Norplant rare, affecting 1% of insertions and 1.7% primary aim of this study was to was followed by a succession of innovative of removals, respectively.7 The investigate the types of nerve injuries SCIs, including 2-rod (Jadelle; Bayer manufacturer of Nexplanon implants associated with SCIs. Healthcare, Leverkusen, Germany, and estimates that intravascular placement Sino-implant; Shanghai Dahua Pharma- has occurred in just over 1 patient per 1 ceuticals Co., Shanghai, China) and million Nexplanon implants sold.8 subsequently single-rod (Nexplanon and MATERIALS AND METHODS However, given the recommended site of Implanon; Merck, Darmstadt, Germany) implantation, neurovascular injuries Illustrative Cases designs with a length of 40 mm and a remain a potential complication for both Between 1983 and 2017, 2 patients with diameter of 2 mm. These innovations SCI insertion and removal.9 In this serious nerve injuries resulting from SCI significantly reduced insertion and Figure 1. Case 1. (A) Preoperative photograph depicting prior image of the ulnar nerve (arrow). (C and D) Close up of the ulnar incision (arrow) used to insert the subdermal contraceptive nerve neuromas (arrow). UN, ulnar nerve. implant into the medial aspect of the arm. (B) Intraoperative

insertion were treated at our institution fire the palmar and dorsal interossei (IO), No nerve action potential was recorded (Médipôle de Koutio, Nouvelle-Calédonie, flexor carpi ulnaris, or flexor digitorum across the lesion. Resection of the neu- France); their cases were retrospectively profundus (fourth and fifth digits) roma was performed to expose healthy reviewed. The SCIs were inserted at another muscles; she had a positive Froment sign nerve tissue (1.5 cm); histologic examina- institution, and the patients were referred and grade S3 sensory loss over the ulnar tion later confirmed the diagnosis of to a peripheral nerve specialist (O.L.) in our aspect of the palm (according to the British neuroma. A 15-cm external neurolysis in department to remove the device and treat Medical Research Council). The addition to subcutaneous transposition resulting nerve injuries. Records pertaining aforementioned findings were initially were performed. The nerve was repaired to consultations, hospitalizations, and diagnosed by the treating physician and using a 10-0 nonabsorbable monofilament surgical interventions in addition to labo- subsequently confirmed by a neurologist. epiperineurial suture in an interrupted ratory examination data (nerve conduction At 1 month, atrophy of IO and flexible fashion. At 12 months postoperatively, studies and electromyography, ultrasound ulnar claw posturing were also reported. extrinsic and intrinsic muscles had grade [US], magnetic resonance imaging [MRI]) Electrophysiologic testing confirmed a M3 (British Medical Research Council) were reviewed for each case by an ortho- severe sensorimotor ulnar neuropathy. The strength, and ulnar clawing was dimin- paedic surgeon (P.L.) with experience in first dorsal IO and abductor digiti minimi ished. Partial sensory recovery was ob- peripheral nerve surgery. demonstrated 3þ fibrillations without tained (S3þ according to the British activation. Sensory recordings were Medical Research Council), but the pa- Case 1. A 25-year-old woman was referred to significant for persistence of tient’s ulnar paresthesias persisted. our department after experiencing radiating low-amplitude signals (25 mV). US Sequential postoperative electromyograms pain in the ulnar nerve distribution during revealed fusiform enlargement of the ulnar documented reinnervation of ulnar nerve. removal of an expired SCI (Figure 1). The nerve fascicle as it coursed over the distal Implanon device was palpable on the third of the arm. Case 2. A 31-year-old woman was referred to medial aspect of the arm and had been Owing to lack of improvement, surgical our department for a sensorimotor deficit removed under local anesthesia by a exploration under general anesthesia was occurring after failed removal of her SCI midwife in clinic. Immediately performed 2 months later. The ulnar nerve (Figure 2). The procedure had been postoperatively, the patient was unable to was in continuity with a 1-cm neuroma. performed in the operating room under Figure 2. Case 2. (A) Preoperative photograph depicting (asterisk) in contact with the median nerve. (C and D) The ulnar previous incision (arrow) over the subdermal contraceptive nerve after neuroma resection (arrow in C) at the time of implant implant on the medial aspect of the arm. (B) Intraoperative removal was treated with a sural nerve graft (arrow in D). photograph showing the subdermal contraceptive implant MN, median nerve; BA, brachial artery; UN, ulnar nerve.

regional anesthesia by a gynecologist; migration of the implant toward the and S3 in fifth digit) and resolution of preoperative US did not allow for distal third of the medial arm. neuropathic pain. Sequential postoperative identification of the nonpalpable implant. Surgical exploration was performed 7 electromyograms demonstrated reinnerva- The gynecologist noted resistance after months later owing to lack of improvement tion changes in the ulnar nerve. pulling on a nerve rather than the and necessity of implant removal. Preop- implant; the patient described at that erative US-guided hook-wire marking of Literature Review moment radiating pain in the ulnar nerve the implant was performed; this facilitated Literature Search Strategy. A literature distribution. At 1 month postoperatively, removal of the nonpalpable implant. The search was performed using Medical weakness involving the IO, flexor carpi ulnar nerve had a 1.5-cm neuroma in Subject Headings and keywords in the ulnaris, and flexor digitorum profundus continuity at the site of putative injury. No following databases: Ovid Medline, Ovid (fourth and fifth digits) was graded 2 nerve action potential was recorded across Embase, Scopus, Web of Science, and (IO), 0 (flexor carpi ulnaris), and 3 (flexor the lesion. The neuroma was resected to Cochrane. The search was limited to digitorum profundus). Flexible ulnar expose healthy nerve tissue; subsequently, English language literature; the terms clawing and Froment sign were noted. interposition sural nerve grafting was “peripheral nerve injury,”“contraception” The patient reported neuropathic pain performed. Follow-up demonstrated were combined with AND and OR. The and grade S4 and S0 sensory loss continued clinical improvement. By 11 references in each study were reviewed to involving the fourth and fifth digits, months postoperatively, there was resolu- identify additional articles corresponding respectively. At 6 months, atrophy of the tion of ulnar clawing and there were to the research criteria. hypothenar eminence and all IO was improvements in both intrinsic and noted. Electrophysiologic testing extrinsic muscle strength (IO, grade 4; Selection Criteria. Articles included in the confirmed a severe ulnar neuropathy flexor carpi ulnaris, grade 5; flexor dig- present study were limited to articles that without signs of reinnervation. MRI itorum profundus fourth and fifth digits, discussed nerve injuries caused by SCIs demonstrated fusiform enlargement of grades 3 and 0). The patient also experi- published between January 1988 and 2017. the ulnar nerve fascicle in addition to enced sensory recovery (S3þ in fourth digit Studies in a language other than English or 63 Clinical studies were identified from the following medical databases

noitacifitnedI 0 Cochrane 15 Embase 18 Medline 23 Scopus 7 Web of Science

42 Records selected after duplicates removed 0 •Cochrane 9 Embase

gnineercS 18 Medline 14 Scopus 1 Web of science

42 Records screened 27 Records excluded • Did not meet first step inclusion criteria ytilibigilE

15 Full-text articles assessed for eligibility Secondary screening by 2 independent reviewers with • full-text articles • 5 Number of studies and reasons for drop out : 10 Studies included in qualitative synthesis 2 Abstract of congress dedulcnI • 2 Comment, letter to the editor l 1 Radiological case report 10 Studies included in quantitative synthesis

Figure 3. Preferred Reporting Items for Systematic Reviews and relevant studies on peripheral nerve injuries caused by Meta Analyses ﬂow chart summarizing search strategy for subdermal contraceptive implants. with inadequate design (meta-analysis, re- description of the nerve injuries, contra- criteria, 15 articles underwent full-text view of the literature, abstract for meetings) ceptive implants (model and location), evaluation. After detailed evaluation, 8 and studies centered exclusively on the preoperative clinical and radiographic case reports (level of evidence V) and 2 radiographic method of localization and/or presentation, surgical management, and case series (level of evidence IV) were on removal techniques of nonpalpable midterm to long-term clinical outcomes included in the analysis. A summary of the contraceptive implants were excluded. following surgery. Level of evidence in the search strategy is presented in Figure 3. included studies was assessed using the Data Extraction and Critical Appraisal. Data criteria established by Oxford Centre for Population Characteristics were extracted from article text, tables and Evidence-based Medicine Levels of The cohort consisted of 12 patients with a ﬁgures. Two investigators (P.L. and L.B.) Evidence.10 mean age of 29.8 years (range, 19e44 independently reviewed the full text of all years) who were evaluated at a mean eligible articles. Disagreements between follow-up of 0.7 year (range, 0e2 years); 1 8 the 2 reviewers were resolved via discus- RESULTS patient was lost to follow-up. Norplanon sion and consensus. When information (n ¼ 4), Implanon (n ¼ 4), and was incomplete, the corresponding au- Quality of Studies Nexplanon (n ¼ 4) SCIs were implanted thors of the articles were contacted. Data Our electronic search yielded 63 studies. in the nondominant arm (8 left and 2 extracted from the articles included a After applying inclusion and exclusion right; not available for 2 cases) either Table 1. Patient Characteristics in 10 Articles Oescribing Peripheral Nerve Injuries Secondary to Subdermal Contraceptive Implants Published Between January 1988 and June 2017

Character ist ics

Pat ients Subderma l Contraceptive Imp lant

Age Upper Prior Removal Imp lant Study Country (years) Limb Altempts Mode l lnserted by Site Depth Palpable

Smith et al.. 199818 USA 23 Righi 0 Norplant Gynecologist Media! aspect of arm Subcutaneous Yes Sarma et al.. 199819 USA 36 Left Norplant Gynecologist Media! aspect of arm Subfascial No Marin and Mc:Millian. 19982° USA 17 Left Norplant Gynecologist Media! aspect of arm Subfascial No Nash and Staunton. 200121 United Kingdom 33 Left Norplant NA Media! aspect of arm Subcutaneous NA Wechselberger et al.. 200616 Austria 24 Left lmplanon Gynecologist Medial aspect of arm Subfascial No Gillies et al.. 20 11 13 Australia 44 NA lmplanon General practitioner Media! aspect of arm Subcutaneous No 26 NA lmplanon General practitioner Medial aspect of arm Subcutaneous No Brown and Britton. 201212 United Kingdom 26 Righi 1 lmplanon NA Media! aspect of arm Subcutaneous No Restrepo and Spinner. 201617 USA 19 Left 0 Nexplanon Gynecologist Media! aspect of arm Subcutaneous No Belyea et al.. 201711 USA 39 Left 2 Nexplanon Gynecologist Media! aspect of arm Subfascial No Odom et al.. 201714 USA 36 Left 4 Nexplanon Gynecologist Media! aspect of arm Subfascial No 25 Left Nexplanon Gynecologist Media! aspect of arm Subfascial Yes

NA, not available.

subcutaneously (n = 6) or beneath the were reported. The 2 most co=only DISCUSSION fuscia (n = 6). The implants were not injured nerves were the medial ante Difficulties encountered during the palpable in 7 patients; tbis information brachial cutaneous (MABC) nerve (n = 5) removal ofSCis have stimulated intensive was not available for 1 case. Ali patients and median nerve (n = 5). Nerve injury research into the development of easy-to 23 had an abnormal clinical examination or was primarily due to pulling or grasping of use systems.9• The development of additional study findings. Neuropathie the nerve (n = 9) after mistaking it for the these new devices will Iikely reduce the pain (n = 12) was identified in all implant. Neurapraxia (n = 7) was the most incidence of insertion site complica patients. Clinical examination revealed co=on Jesion and was treated primarily tions. 9•24•25 Although rare, SCis have the paresthesias in u patients, weakness in 6 with implant removal and clinical surveil potential to cause serious peripheral nerve patients, and sensory Joss in 8 patients. lance (n = 6). Nerve coaptation (n = 2) m1ur1es during insertion and was performed for partial nerve transec 11 14 17 Electrodiagnostic studies were performed removal. • • The broader, more corn in symptomatic patients (n = 4) either tion. Neurolysis (extemal neurolysis mon spectrurn of adverse implant site re before or after device removal. [ n = 1] or epineurolysis [n = 1]) was actions include pain, hematoma, swelling, 26 Ultrasound images (n = 8) and/or performed to treat neuroma or nerve redness, and scarring.4• These compli radiographs (n = 2) were sufficient to compression by scar tissues and/or SCis. cations were described in 5.9°/o of women 8 11 16 localize the implant in 7 patients • • Of patients, 5 completely recovered, and 6 within the first few years after SCI inser and, later, to better describe the nerve continued to have a motor and/or sensory tion and/or removal. 27 The insertion 17 injury in 1 patient. No patient deficit at short-term to Jong-term follow procedure is straightforward and can 9 underwent preoperative MRL Population up; 1 patient was Jost to follow-up.' No typically be performed in the office. characteristics are reported in Tables 1 additional interventions were performed Implants must be inserted into the and 2. for the treatrnent of seq uelae. subcutaneous space on the medial aspect Management by a pain specialist was of the nondominant arm 8-10 cm Peripheral Nerve Injuries requested in 1 case owing to persistent proximal to the medial epicondyle under There were 14 peripheral nerve IIlJlmes dysesthesia and paresthesia in the band local anesthesia via a disposable sterile associated with SCis reported during or 4 months after coaptation of the median applicator. The SCI must be palpable 22 after insertion (n = 2) and removal nerve. The results are summarized in throughout the duration of its use.'5.23 (n = 12) procedures; no associated Jesions Table 2. After a maximum of 3 years, the palpable cases,2 with most implants migrating <2cm recommend intraoperative US-guided implant is removed under local from the initial insertion site. Too-deep hook-wire marking of the implant by an anesthesia through a small incision at initial positioning and/or migration of experienced musculoskeletal radiologist to the distal end of the rod. Manual the implant may lead to difficulty with facilitate safe dissection.38 For pressure is applied to the proximal end localization via palpation at the time of symptomatic patients, nerve conduction of the device to push it through the implant removal. In our study, 83% of studies and electromyography can assist 2-mm incision and grasp it with forceps nerve injuries involved patients with non- further by determining the severity of the as it appears; no dissection is palpable implants. A standardized clinical injury and confirming its location; these required.4,5,15,28,29 and radiographic evaluation should be studies also allow for improved clinical In the medial aspect of the midarm, undertaken to locate the nonpalpable SCI, follow-up of patients in whom lesions neurovascular structures are separated the neurovascular structures, and possible are treated with or without surgery. from one another by the brachialis fascia associated lesions to facilitate safe implant All nerve injuries that occurred during that divides the arm into superficial and removal.14,24 Neurovascular sequelae the removal of nonpalpable SCIs were deep compartments. The MABC nerve lies resulting from insertion or removal of a caused by providers without formal micro- within the subcutaneous space along with SCI must be identified at the time of initial surgical training (Table 2). Given the risks the basilic vein.16 The MABC nerve courses evaluation for patients requesting a new of neurovascular injury with nonpalpable within the anterior proximal arm, medial device. Scarring induced by a malposi- SCIs, we recommend asking a peripheral to the brachial artery; it becomes a tioned implant can also place pressure on nerve specialist for assistance with subcutaneous structure when it pierces the nerve at a distance from the SCI removal.14,24 In the event that an the brachial fascia (basilica hiatus) 14 cm insertion site.20,21 Clinical assessment inadvertent nerve injury is suspected, proximal to the medial epicondyle. SCIs should include a detailed history to accu- immediate action should be undertaken. are typically inserted in this vicinity; rately understand the patient’s symptoms We avoid local anesthetics and paralytics, therefore, it follows that incorrect as well as attempted implant palpation; as they preclude intraoperative nerve subcutaneous positioning of the implant this provides an initial impression stimulation. In the present study, 75% of may induce damage to the branches of regarding the location of possible nerve nerve injuries were associated with the MABC nerve (anterior, or ulnar).16,30 injuries. Neuropathic pain at the level of accidental traction (pulling or grasping) The subaponeurotic course of the MABC the upper arm or a history of SCI use on the nerve when it was mistaken for nerve also places it at risk for injury should prompt the physician to suspect the SCI. For this reason, we advocate for owing to accidental traction at the time nerve injury. Any loss of distal sensory and wide operative exposure, avoiding of implant removal. The spectrum of motor function associated with insertion grasping the nonpalpable implant with injuries to the MABC nerve described in or removal of an SCI should be treated as a surgical instruments until it has been the literature is broad, ranging from suspected serious nerve injury and identified in its entirety and separated neurapraxia to complete nerve addressed within days (Table 2); any delay from adjoining tissues (Figure 1, Tables 1 transection (Table 2). Clinical symptoms in treatment exposes patients to the risk of and 2).17 For patients with clinical or are also variable and may include neuroma formation (Figure 1C).17 Recent electromyographic evidence of nerve impaired sensation. An area of localized, literature describes the use of various injury, the nerves in close proximity to the severe pain in the distribution of the methods to localize nonpalpable SCIs, implant must be exposed and inspected. MABC nerve may occur in the case of a including x-rays, US, computed A nerve stimulator (Vari-Stim III Nerve transected nerve trapped in scar tissue.16 tomography, and MRI.1,14,20,24,26,32-36 US Locator; Medtronic Xomed, Inc., Neurovascular structures beneath the examination should be considered the Jacksonville, Florida, USA) is needed to fascia are also at risk; these structures first-line imaging because of its low cost, identify abnormally functioning nerves in include the brachial artery and terminal lack of ionizing radiation, and wide avail- cases where no striking visual abnormality branches of brachial plexus (Figures 1 ability.24,37 MRI is the best method for is present intraoperatively. When and 2, Table 2). Accidental traction on unequivocal localization of implants not complete nerve transection is the nerve rather than the implant at the detectable on US.24,35,37 High-resolution encountered, timely surgical repair should time of removal and nerve compression 3T MRI with T1-weighted, T2-weighted, be performed using 9-0 or 10-0 epineural are the 2 primary reasons for incomplete or gradient echo sequences (spoiled nonabsorbable monofilament suture injuries. Nerve transection (n ¼ 6) is the gradient recalled echo) with robust fat placed in an interrupted fashion under second most common injury pattern and suppression, with and without gadolinium direct visualization with surgical loupes or affecting the median and/or ulnar nerves enhancement is the recommended amicroscope.32 When direct repair is not overall; emergent surgical treatment second-line imaging for implant localiza- feasible, a graft must be used (Figure 1). should be the rule in this setting because tion and peripheral nerve imaging.24,37 Neurotization and/or tendon transfer of the risk of neuroma formation Despite the fact that US was used in 75% should be considered for proximal nerve (Figures 1 and 2, Table 2). of patients in this study, no diagnostic transections with motor deficits lasting Although previous reports quote MRI studies have been reported in the >6 months.22,32,39 In the case of migration rates reaching 39%,31 a recently literature. In cases where intraoperative superficial lesions, if primary nerve published study of 4294 practitioners implant localization is challenging, coaptation of the MABC nerve is not demonstrated migration in only 0.26% of extensive dissection must be avoided. We possible, its proximal end should be Table 2. Summary of Various Treatment Approaches in 10 Articles Describing Neurovascular Complications After Subdermal Contraceptive Implant Insertion and/or Removal Published Between January 1988 and June 2017

Nerve lnjury Treatment

Times to Nerves Mecbanism Treating Treatment Treating Functional Study lnvolved Lesion Tuning of lnjury Provider Treatment (montbs) Provider Outcomes

Smith et al., 199818 Ulnar Contusion by needle Rernoval Nerva contusion Gyneœlogist Clin.::al and Neurologist Residual deficit ("U" technique)9 physiolog.: surveillance Sarrna et al., 199819 Median Neurapraxia Second rernoval Pulling/grasping on Gyneœlogist Implant rernoval and lnterventional Lost to follow up attempt nerve clinical surveillance radiologist Marin and Ulnar Neurapraxia After removal Compression by scar Gyneœlogist Epineurolysis NA Residual deficit McMillian, 19982° tissues Nash and Staunton, MABC Neurapraxia After insertion Compression by NA Implant rernoval and NA Residual deficit 2001 21 implant clin.:al and and/or scar tissues physiolog.: surveillance Wechselberger MABC Partial section Attempted removal Pulling/grasping on Gyneœlogist Implant rernoval and NA Piast.: surgeon FuIl recovery et al., 200616 nerve nerve coaptation Gillies et al., 2011 13 Median Partial section Attempted removal Pulling/grasping on Gyneœlogist Implant rernoval and 0.4 (12 days) Hand surgeon Residual deficit nerve nerve coaptation Median Partial section Attempted removal Pulling/grasping on Gyneœlogist Implant rernoval and 0.03 (1 day) Hand surgeon Residual deficit nerve nerve coaptation Brown and Britton, MABC Neurapraxia Insertion Compression by NA Implant rernoval and 24 Orthopaed.: FuIl recovery 201212 implant clinical surveillance surgeon (imrnediate postprocedure) Restrepo and MABC, median, Sections (n 3) Rernoval Pulling/grasping on Gyneœlogist External neurolysis 5 Neurosurgeon Full recovery (ulnar Spinner, 201617 and ulna r compl.::ated nerve (median, ulnar, and nerve); residual by neurornas (n 3) MABC) deficit (MABC, rnedian nerves) Belyea et al., 201 ]11 Median nerve Neurapraxia Second rernoval Pulling/grasping on Gyneœlogist Implant rernoval and NA Orthopa ed.: Full recovery attempt nerve clinical surveillance surgeon Odom et al., 201 l14 NA Neurapraxia Fourth rernoval Pulling/grasping on Gyneœlogist Implant rernoval and NA Piast.: surgeon FuIl recovery attempt nerve clinical surveillance MABC Neurapraxia Removal attempt Pulling/grasping on Gyneœlogist Implant rernoval and 0.1 (3 days) Piast.: surgeon FuIl recovery nerve and/or clinical surveillance compression by implant

NA. not available; MMC, medial anteb'adlial cutaneous. transposed proximally and buried deep into Administration to avoid confusion at the 13. Gillies R, Scougall P, Nicklin S. Etonogestrel the muscle of the arm to avoid formation of time of implant removal.14 implants case studies of median nerve injury 16,40 following removal. Aust Fam Physician. 2011;40: a painful neuroma. 799-800. CONCLUSIONS Limitations 14. Odom EB, Eisenberg DL, Fox IK. Difficult removal Nerve injuries related to SCIs are rare but of subdermal contraceptive implants: a multidis- The limitations of this study relate to its ciplinary approach involving a peripheral nerve retrospective, single-center nature and serious. In cases of nonpalpable implants, a expert. Contraception. 2017;96:89-95. sample size. The retrospective design multidisciplinary approach including practitioners with expertise in the treatment of 15. Rowlands S. Legal aspects of contraceptive im- inherently leads to more loss of data and plants. 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