Postgrad Med J: first published as 10.1136/pgmj.58.677.142 on 1 March 1982. Downloaded from

Postgraduate Medical Journal (March 1982) 58, 142-145

latrogenic injuries J. B. WINER M. J. G. HARRISON M.R.C.P. D.M., F.R.C.P. Department of Neurological Studies, Middlesex Hospital, Mortimer Street, London, W.J.

Summary more than one nerve in the EMG examination in Thirty-one examples of iatrogenic peripheral nerve each case. injuries have been collected from a review of the case records of one neurological referral centre over a 7- Results year period. The clinical details are described to call The distribution of involved in 31 cases of attention to the special care needed with the manage- iatrogenic nerve injury is shown in Table 1. ment of patients subjected to certain invasive pro- cedures. TABLE 1. The distribution of nerves involved in 31 cases of iatrogenic injury Introduction Upper limb (n= 16) Lower limb (n= 15) The importance of drug therapy as a cause of Median nerve 6 5 is well appreciated. However, Ulnar nerve 4 Lateral popliteal nerve 4 the risks of iatrogenic isolated traumatic nerve Brachial plexus/root 4 2by copyright. have been less well documented. Tourniquet paralysis I Inguinal nerve 2 injuries Digital nerve I Posterior 1 The authors present a review of the iatrogenic Sural nerve 1 peripheral nerve injuries referred for electromyo- graphy (EMG) and assessment of nerve conduction to the Department of Neurological Studies of the Median nerve Middlesex Hospital over the last seven years. Four examples of median nerve damage occurred The Department provides an EMG service for a as a result of cardiac catheterization. The patients number of hospitals outside the Middlesex group, had often complained of local pain at the site of so the true frequency of these problems cannot be catheterization radiating down the arm. On one simply calculated. occasion the local anaesthetic was mistakenly http://pmj.bmj.com/ injected directly into the nerve, and in another a Method large haematoma was thought to be responsible. The EMG department records for the years The following case is described to illustrate the type 1974-1981 were reviewed, and all cases referred with of injury involved. peripheral nerve injuries were extracted. The notes An 18-year-old Ugandan had left heart catheteriza- of all these patients were reviewed, and only those tion and coronary arteriography for investigation

whose nerve lesions were due to medical intervention of a severely abnormal electrocardiogram (ECG). on September 26, 2021 by guest. Protected were included. A number of patients sustained A high brachial artery division was encountered and nerve damage as a result of operations in which such catheterization of the radial branch produced damage is an obvious and well recognized risk, such spasm; the ulnar branch was eventually used for as facial nerve involvement after the removal of the procedure. The day following catheterization the acoustic neuromas, and parotid tumours. These patient noticed some slight sensory loss in the were not included in the study. median territory of the hand, with severe weakness An effort was made to exclude any patient who of the median supplied muscles of the hand and might have an inherited predisposition to pressure forearm. There was some improvement in the weak- sensitivity of peripheral nerves, as has been reported ness over the next few days but the patient dis- in some families (Earl et al., 1964). During the 7- charged herself and no follow-up was possible. year period of the study, one case of radial and one A fifth patient was referred for EMG studies as of an ulnar nerve injury were seen in such families. an aid to the diagnosis of Friedrich's ataxia. She Care was further taken to exclude underlying also suffered from a cardiomyopathy and had been peripheral neuropathies from the study by including investigated by coronary arteriography in the past 0032-5473/82/0300-0142 $02.00 () 1982 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.58.677.142 on 1 March 1982. Downloaded from

fatrogenic nerve injuries 143 with no complications. There were no symptoms of The cervical root injury occurred following an median nerve damage but nerve conduction studies operation for bilateral cervical ribs in a patient who suggested that damage had occurred at the time of complained of paraesthesiae in the fingers of both catheterization. hands. Immediately following the operation she A further example of median nerve damage developed numbness overlying the left shoulder occurred after venesection. blade and a left C5 root lesion with weakness of the A 25-year-old male had blood taken from the right muscles supplied by this root. The sensory loss antecubital fossa without undue pain or distress. The persisted and, on review 6 years later, there was also next day he developed tingling in the fingers of the persistent slight weakness of the rhomboids and right hand excluding the little finger. There was no spinati. bruising 10 days later but deep pressure over the venepuncture site increased the tingling felt in the Tourniquet paralysis fingers. Electrical studies showed a local conduction The following example of a tourniquet paralysis block in the right median nerve. was seen. A 58-year-old female fractured her right radius Ulnar nerve and ulnar in February 1981. The fracture was Four ulnar nerve injuries occurred post- plated with the use of a tourniquet during the operatively. In one, a 43-year-old male had a procedure. Two days following the operation tone saphenous vein bypass graft to the left anterior was found to be flaccid in the forearm with a descending coronary artery. Five days after the paralysis involving the median radial and ulnar operation when the patient was transferred from nerves. There was almost complete paralysis at the intensive care to the general ward a left ulnar wrist with considerable improvement on review in nerve lesion was noted which clinically was localiz- one month. However, thumb and finger movement able to the elbow. The EMG findings were suggestive was still impaired. of neuropraxia with no denervation and preserva- tion of the ulnar sensory action potential. The notes Digital nerve by copyright. make no mention of the lesion which presumably A 77-year-old man complained of troublesome had recovered completely when the patient was seen paraesthesiae of his left index finger since explora- for review a year later. Another lesion occurred tion of it for a foreign body in a casualty department. after cardiac surgery, and the third following a On examination there was a sensory loss over the period of immobilization in a seriously ill male who distribution of one digital nerve. Nerve conduction developed complications following the drainage of studies supported the clinical view that only one an appendix abscess. A fourth lesion occurred digital nerve was involved. following surgery for ureteric stones.

Sciatic nerve http://pmj.bmj.com/ Cervical roots and brachial plexus Five examples of sciatic nerve damage were seen Three brachial plexus lesions and one cervical and also one example of a posterior tibial lesion root injury were seen. following damage to the sciatic nerve high in the One patient with her arm extended during a buttock. On one occasion the nerve was damaged as nephrectomy developed a traction injury of the a result of a pressure palsy following a therapeutic C8 and TI roots with weakness of the long flexors dose of barbiturate sleeping tablets. One lesion and interossei with sensory loss over the inner followed the application of skeletal traction and aspect of the arm. plaster to a compound fracture of the left femur. A on September 26, 2021 by guest. Protected A second patient sustained a traction injury lateral popliteal palsy may also have been present during a right modified mastectomy for carcinoma secondary to pressure from the plaster cast. A of the breast. Postoperatively there was severe further lesion was noticed in a comatose patient weakness of the deltoid, biceps, brachialis, brachio- nursed in the intensive care unit for a 10-day radialis, and wrist extensors with milder weakness of period of unconsciousness, and one followed a finger flexion and extension. Over the next two weeks Thompson arthroplasty for a right sub-capital there was improvement in wrist extension and the fracture of the femur. The following case illustrates patient was followed-up at another hospital. A the typical history obtained. brachial plexus injury at surgery was considered to A 38-year-old female was operated upon for be the cause. A third patient noticed weakness of primary lymphoedema of the left leg. Immediately the right hand one week after a posterior spinal she recovered consciousness she was noticed to fusion for scoliosis. There was global arm weakness have a left foot drop. EMG studies suggested a with absent reflexes and, again, a brachial plexus sciatic nerve lesion involving both lateral popliteal injury at the time of surgery was blamed. and posterior tibial divisions. One year following the Postgrad Med J: first published as 10.1136/pgmj.58.677.142 on 1 March 1982. Downloaded from

144 J. B. Winer and M. J. G. Harrison operation there was no evidence of re-inervation pain and numbness in the distribution of the right either clinically or on EMG. sural nerve, had had a prominent right calcaneum trimmed in 1958 and postoperative scar tissue was Femoral nerve thought to have traumatized her sural nerve over Two examples of femoral nerve injury were seen. the years. Nerve conduction studies confirmed a One occurred after the use of anticoagulants. right sural nerve lesion and the patient had a surgical A 65-year-old female was admitted with a 6- decompression. The nerve was found to be embedded month history of amaurosis fugax in the left eye. in scar tissue and a great deal of improvement of There was a left carotid bruit and a reduced left symptoms occurred postoperatively. carotid pulse. She was anticoagulated with heparin, and carotid angiography performed. Three days Inguinal nerve after the angiogram which involved catheterization A 70-year-old male developed left-sided groin of the femoral artery she developed a painful pain radiating to the left side of the scrotum follow- femoral neuropathy with an absent right knee jerk ing a repeat left hernia operation in 1975. Excision and some weakness of the right quadriceps. She of the herniorraphy scar in July 1979 rendered the had a left carotid endarterectomy performed with- patient free of pain although some discomfort out complications and the femoral neuropathy recurred over the next year. It seemed that entrap- resolved with time. ment of the left inguinal nerve in the scar tissue was The second example occurred following the repair responsible for the original symptoms. of a vesico-vaginal fistula. The nerve was damaged A second case of inguinal nerve damage post above the inguinal ligament and electromyography herniorraphy was seen in which the symptoms of showed that Wallerian degeneration had occurred. numbness of the right groin and inner aspect of the A haematoma was thought to be responsible but right thigh started immediately postoperatively. at explorative operation 8 weeks later the nerve was In this case there must have been damage at opera- found to be intact without evidence of pressure from tion. oc- a blood clot. Considerable improvement had by copyright. curred at review 7 months later. Discussion occurred Lateral popliteal nerve The majority of nerve injuries described Four cases of lateral popliteal nerve lesions were as a result of surgery or from faulty body position seen. One occurred following the excision of a during operation. In this way some relatively trivial haemangioma of the left leg involving resection of procedures were able to produce a severe neuro- the middle two-thirds of the fibula. Another oc- logical disability. the curred following a repeat right upper tibial osteo- The largest number of injuries involved tomy and involved only the part of the nerve median nerve and most occurred during cardiac catheterization. In 1960, Schneck described a case of supplying extensor hallucis longus. Unfortunately http://pmj.bmj.com/ in this case it was impossible to get EMG con- anterior interosseus nerve damage following firmation of the lesion acutely because the leg was catheterization and there have been reports of placed in a plaster cast postoperatively. However median nerve damage following arterial catheteriza- the clinical findings were unequivocal. tion for blood gas estimation (Patten, 1969; Macow In the third case the lesion was noted immediately and Furtrell, 1973; Luce et al., 1976) or blood after operation for intermittent claudication of the pressure monitoring (Little, 1976). Haematoma left leg. A left femoral popliteal bypass graft was rather than direct damage to the nerve is often performed but the patient had to be taken back to responsible. The authors' case of asymptomatic on September 26, 2021 by guest. Protected theatre following a haemorrhage from the site of median nerve damage following cardiac angio- the anastomosis and after the second operation a graphy is of particular interest since it suggests that left foot drop developed. There was some sensory the incidence of median nerve damage during this loss over the anterior aspect of the foot as well as procedure is far greater than is generally appreciated. weakness of dorsiflexion and eversion of the left The sciatic and the common peroneal nerves foot. EMG suggested an incomplete lesion and there were the two other nerves most commonly damaged. et was considerable improvement over the next two Hip surgery is often responsible (Campbell al., weeks. 1960; Rodriguez, Austin and McBride, 1964) but or The last case occurred after traction was applied any surgical procedure in the upper thigh buttock to the leg following a hip operation. There was no can place the sciatic nerve at risk. as a result of recovery at 4 months. No example of sciatic nerve damage misplaced injection was seen and it appears that the Sural nerve dangers of this are well publicized and appreciated. A 46-year-old female with a 6-month history of Ulnar nerve injuries and brachial plexus lesions Postgrad Med J: first published as 10.1136/pgmj.58.677.142 on 1 March 1982. Downloaded from

Iatrogenic nerve injuries 145 almost certainly occurred as a result of faulty body fractures of the femoral neck. American Journal ofSurgery, position either with the unconscious surgical 99, 745. patient or the ventilated patient in the intensive EARL, C.J., FULLERTON, P.M., WAKEFIELD, G.S. & SCHUTTA, H.S. (1964) Hereditary neuropathy with liability to care unit. Lincoln and Sawyer (1961) and Seddon pressure palsy. Quarterly Journal of Medicine, 33, 581. (1975) review the common injuries involved and LINCOLN, J.R. & SAWYER, H.P. (1961) Complications related suggest ways in which they can be avoided. to body positions. Anaesthiology, 22, 804. The case of ilio-inguinal nerve injury as a result LITTLE, W.A. (1976) Median nerve palsy-a complication of of nerve entrapment post herniorraphy illustrates brachial artery cannulation. Postgraduate Medical Journal, 7, 110. how some iatrogenic lesions can occur some years LUCE, E.A., FURTRELL, J.W., SHAW WILGES, E.F. & after the operation. Schneck (1960) described one HOOPES, J.E. (1976). Compression neuropathy following case of ilio-inguinal entrapment also occurring after brachial artery puncture on anticoagulated patients. herniorraphy in which the symptoms did not begin Journal of Trauma, 16, 717. until 16 years after the original operation. MACOW, W.C. & FURTRELL, J.W. (1973) Median nerve neuropathy after percutaneous puncture of the brachial While the very nature of some operations must artery in patients receiving anticoagulants. New England always place anatomically vulnerable nerves at Journal of Medicine, 288, 1396. risk it is obvious that heightened awareness of the PATTEN, B.M. (1969) Neuropathy induced by haemorrhage. potential for iatrogenic nerve trauma would help Archives of Neurology, 21, 381. reduce the prevalence of such problems. Physicians RODRIGUEZ, M.J., AUSTIN, E. & MCBRIDE, F.J. (1964) Peroneal nerve damage following insertion of Austin involved in the performance of invasive procedures Moore prosthesis. Archives of Physical Medicine, 45, 283. as well as surgeons need to be aware of these risks. SCHNECK, S.A. (1960) Peripheral and cranial nerve injuries resulting from general surgical procedures. Archives of References Surgery, 81, 855. CAMPBELL, R.D., MASON, J.B., WILSON, P.D. & WADE, P.A. SEDDON, SIR HERBERT (1975) Surgical Disorder of Peripheral (1960) The use of intramedullary prosthetic replacement in Nerves. Churchill Livingstone. Edinburgh. by copyright. http://pmj.bmj.com/ on September 26, 2021 by guest. Protected