View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Open Archive Toulouse Archive Ouverte OATAO Open Archive Toulouse Archive Ouverte Open Archive Toulouse Archive Ouverte (OATAO) OATAO is an open access repository that collects the work of some Toulouse researchers and makes it freely available over the web where possible. This is an author's version published in: https://oatao.univ-toulouse.fr/23100 Official URL : https://doi.org/10.1016/j.wneu.2017.12.160 To cite this version : 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 é ô (n 11). Medial antebrachial cutaneous (n 5) and median (n 5) nerves Orthopaedic Surgery, M dip le 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 practi- tioners 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 However, as procedural standardization the literature on nerve injuries associated (SCIs) has been steadily increasing for 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;