Nerve Injury Due to Gynecologic Surgery 

Health / By

Nerve Injury Due to Gynecologic Surgery – Introduction

  • complication of gynecologic surgery in which injury to nerves innervating the abdominopelvic region, lower extremities, or upper extremities occurs due to improper patient positioning or surgical transection, resulting in pain, numbness, or motor impairment(1,2,3)

Relevant Gynecologic Procedures

Anatomy of Nerves at Risk of Injury During Gynecologic Surgery

Abdominopelvic Nerves

  • Sensory distribution of the lateral femoral cutaneous nerve.Lateral femoral cutaneous nerve – Sensory distribution of the lateral femoral cutaneous nerve.Copyright ©2021 EBSCO Information Services.
  • femoral nerve
    • most common nerve injury from gynecologic surgery, with reported incidence of 11% among gynecologic-associated nerve injuries(2)
    • originates within psoas muscle from portions of L2, L3, and L4 nerve roots(1,5)
    • travels on inferior path between psoas and iliacus muscles, beneath iliacus fascia in retroperitoneal space; provides motor innervation to psoas and iliacus muscles through abdominal course(5)
    • may be vulnerable to injury where nerve passes through inguinal ligament (lateral to femoral artery) to emerge onto thigh where the nerve subsequently divides into(1,5)
      • anterior division, providing motor innervation to sartorius and pectineus muscles and sensory innervation to skin of anterior and medial thigh
      • lateral division, providing motor innervation to quadriceps muscles and sensory innervation to skin of medial lower leg
  • ilioinguinal and iliohypogastric nerves
    • originate from T12 and L1 nerve roots(1)
    • may be vulnerable to injury during gynecologic surgery due to nerve course along abdominal oblique muscles(1)
    • ilioinguinal branch
      • travels around pelvic brim, pierces abdominal wall medial to anterior superior iliac spine, traverses through inguinal canal (Curr Sports Med Rep 2006 Dec;5(6):293)
      • reported to be located 2.5-3.1 cm medial and 2.4-3.7 cm inferior to the anterior superior iliac spine(1)
      • provides sensory innervation to the skin of the medial thigh, groin and labia majora (Curr Sports Med Rep 2006 Dec;5(6):293)
    • iliohypogastric branch
      • goes through abdominal muscles halfway between highest point of iliac crest and anterior superior iliac spine (Curr Sports Med Rep 2006 Dec;5(6):293)
      • reported to be located 2.1-2.5 cm medial and 0.9-2.0 cm inferior to the anterior superior iliac spine(1)
      • provides motor supply to lower abdominal wall and sensory innervation to skin over gluteal and hypogastric regions (Curr Sports Med Rep 2006 Dec;5(6):293)
  • genitofemoral nerve
    • originates from primary ventral rami of L1 and L2
    • passes through the psoas muscle, emerging on top of the muscle
    • travels distally to inguinal ligament, where it divides into genital and femoral branches
      • genital branch enters inguinal canal and supplies sensory information from mons pubis and labium majus
      • femoral branch courses under the inguinal ligament, innervating a small patch of skin over the anterior thigh
      • Reference – Sports Med 1999 Apr;27(4):261
  • lateral femoral cutaneous nerve
    • originates from L2-L4 nerve roots and exits spinal cord between L2-L3 vertebrae(1)
    • emerges in pelvis from the lateral aspect of psoas muscle, courses under iliac fascia, and crosses anterior surface of iliacus muscle while traveling toward anterior superior iliac spine(1)
    • distal to inguinal ligament, divides into anterior and posterior divisions with each penetrating fascia lata several centimeters below anterior superior iliac spine
      • anterior branch provides sensory innervation from anterior thigh to knee
      • posterior branch provides sensory innervation from lateral thigh to greater trochanter
      • Reference – J Am Acad Orthop Surg 2001 Sep;9(5):336
    • may be vulnerable to injury as nerve passes distally under, through, or above the inguinal ligament (J Am Acad Orthop Surg 2001 Sep;9(5):336)
  • obturator nerve(1)
    • originates from anterior division of L2-L4 nerve roots
    • travels through the psoas muscle and in front of sacroiliac joint into lesser pelvis
    • may be vulnerable to injury as nerve transverses through obturator canal and enters thigh through obturator foramen
    • anterior branch innervates adductor longus, gracilis, and adductor brevis
    • posterior branch innervated obturator externus and part of the adductor magnus
  • superior hypogastric plexus and hypogastric nerve
    • superior hypogastric plexus originates from sympathetic nerves of the lumbar sympathetic chain and aortic plexus and is located retroperitoneally near L5 and S1, overlying the aortic bifurcation
    • superior hypogastric plexus bifurcates into left and right hypogastric nerves
    • hypogastric nerve descend into pelvis and run inferior and medically to ureter, and laterally to uterosacral ligaments to join inferior hypogastric plexus
    • motor and sensory innervation of the pelvic viscera
    • Reference – J Minim Invasive Gynecol 2021 Feb;28(2):178
  • inferior hypogastric plexus and pelvic splanchnic nerve
    • originates from S2-S4 nerve roots
    • pelvic splanchnic nerve merges with hypogastric nerve to form inferior hypogastric plexus
    • parasympathetic motor and sensory innervation of abdominopelvic organs, including
      • bladder
      • ureter
      • urethra
      • colon
      • rectum
      • uterus
      • vagina
      • clitoris
    • Reference – J Minim Invasive Gynecol 2021 Feb;28(2):178
  • pudendal nerve
    • originates from S2-S4 nerve roots(2)
    • may be vulnerable to injury during gynecologic surgery as nerve course passes behind sacrospinous ligament medial to ischial spine, where it courses through gluteal region to enter the pudendal canal via a path between sacrospinous and sacrotuberous ligaments(2)
    • exits pudendal canal and branches to form the following:
    • provides sensory and motor innervation to the pelvic floor, vulva, and perineum ((3), Am J Obstet Gynecol 2011 Nov;205(5):504.e1)

Lower Extremity Nerves

  • saphenous nerve(3)
    • originates from the posterior division of the femoral nerve after it passes below the inguinal ligament
    • provides sensory innervation to
      • anterior patella
      • anteromedial aspect of lower leg
      • medial aspect of the food
  • sciatic, common peroneal, and tibial nerves(5)
    • originate from L4 to S3 nerve root fibers which travel through lumbosacral plexus before forming sciatic nerve in combination with fibers that eventually join tibial nerve
    • sciatic nerve travels through posterior thigh then branches into common peroneal and tibial nerves above popliteal fossa
    • common peroneal nerve
      • wraps around head of fibula in proximal lower leg where it is prone to compression or excessive stretch injury against bony protuberance of fibula
      • below fibular head, common peroneal nerve divides into
        • superficial branch which provides
          • sensory innervation to dorsum of foot and lateral aspect of distal lower leg
          • motor innervation to peroneus longus muscle required for foot eversion
        • deep branch which provides
          • sensory innervation to first digital webspace of foot
          • motor innervation to ankle dorsiflexors (tibialis anterior muscle) and toe dorsiflexors (extensor hallucis longus and extensor hallucis brevis muscles)
    • tibial nerve
      • proximally provides innervation to posterior compartment of leg including
        • motor innervation of popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior, plantaris, soleus, and gastrocnemius muscles
        • sensory innervation of posterolateral side of leg
      • distally at foot travels through the tarsal tunnel (site of entrapment causing posterior tarsal tunnel syndrome) and splits into 3 terminal branches
        • medial calcaneal nerve provides sensory innervation to medial heel
        • lateral and medial plantar nerves provide
          • sensory innervation to respective sides of foot sole
          • motor innervation to deep muscles of plantar aspect of foot
        • site where nerve divides into terminal branches is variable; may be proximal, distal to, or within tarsal tunnel

Upper Extremity Nerves

  • brachial plexus(1)
    • provides motor and sensory innervation to the upper extremities and shoulder girdle
    • originates from C5-T1 nerve roots, which emerge from the vertebral canal through the vertebral process, merging to form
      • superior trunk (C5, C6)
      • middle trunk (C7)
      • inferior trunk (C8, T1)
    • each trunk divides into 2 parts (anterior part supplies flexor muscles, posterior part supplies extensor muscles), which pass from the neck into the axilla to form 3 nerve cords (posterior, lateral, and medial)
    • nerve cords terminate at the bottom of the axilla and form 5 main nerves, including
      • ulnar
      • radial
      • median
      • axillary
      • musculocutaneous
    • may be vulnerable to injury during gynecologic surgery due to its
      • long superficial anatomic course
      • firm attachment to prevertebral and axial fascia
      • proximity to mobile bony structures that may be malpositioned in the anesthetized patient
  • radial nerve
    • originates from C5-C8 (and sometimes T1) nerve roots(6)
    • travels through medial upper arm then laterally across posterior surface of humerus through spiral groove(1,6)
    • provides
      • motor innervation to extensor muscles of the wrist and fingers
      • sensory innervation to posterior aspect of lateral 3.5 fingers
  • ulnar nerve
    • originates from C8-T1 nerve roots(6)
    • passes between medial epicondyle of humerus and ulnar olecranon at ulnar groove, where it is vulnerable to compression injury against operating table or arm boards(1,6)
    • provides(6)
      • motor innervation to small muscles of the hand
      • sensory innervation to little finger and half of ring finger and volar and dorsal sides of hand near ring finger

Epidemiology

Incidence/Prevalence

  • reported prevalence of postoperative nerve injury due to gynecologic surgery 1.1%-1.9%(2)
  • prevalence of specific nerve injuries
    • ilioinguinal or iliohypogastric nerve injury
      • ilioinguinal or iliohypogastric nerve injury in 7 patients (4.9%) in retrospective cohort study of 144 patients who had laparoscopic gynecologic surgery with fascial wound closure (J Minim Invasive Gynecol 2012 Jul;19(4):448)
      • ilioinguinal or iliohypogastric nerve entrapment in 9 out of 243 patients (3.7%) (mean age 35 years) who had gynecologic surgery requiring low transverse Pfannenstiel incision in case series (Ann Surg 1997 Apr;225(4):365full-text)
    • lower extremity nerve injury
      • reported prevalence of lower extremity nerve injury due to malpositioning during gynecologic surgery 1.5%-1.8%(1)
      • lower extremity nerve injury in 11 patients (1.8%) in prospective cohort study of 616 adult patients (mean age 53 years) having gynecologic surgery
        • lateral femoral cutaneous nerve injury in 4 patients (0.6%)
        • femoral nerve injury in 3 patients (0.48%)
        • common fibular nerve injury in 1 patient (0.16%)
        • genitofemoral nerve injury in 1 patient (0.16%)
        • ilioinguinal and iliohypogastric nerve injury in 1 patient (0.16%)
        • saphenous nerve injury in 1 patient (0.16%)
        • Reference – Am J Obstet Gynecol 2009 Nov;201(5):531.e1
      • lower extremity neuropathy as unexpected complication of lithotomy position in 55 patients (0.02%) having gynecologic surgery in retrospective cohort study of 198,461 patients who had surgery between 1957 and 1991
        • common peroneal nerve injury in 43 patients (78.2%)
        • sciatic nerve injury in 8 patients (14.5%)
        • femoral nerve injury in 4 patients (7.3%)
        • Reference – Anesthesiology 1994 Jul;81(1):6
    • upper extremity nerve injury due to malpositioning reported in 0.02%-0.16% of patients having gynecologic surgery(1)
    • peripheral neuropathy in 23 patients (1.9%) in cohort study of 1,210 patients having laparoscopic or open gynecologic surgery, including
      • obturator nerve injury in 9 patients (39.1%)
      • ilioinguinal and iliohypogastric nerve injury in 5 patients (21.7%)
      • genitofemoral nerve injury in 4 patients (17.4%)
      • femoral nerve injury in 3 patients (13%)
      • lumbosacral nerve plexus injury in 2 patients (8.7%)
      • Reference – Obstet Gynecol 2002 Aug;100(2):240

Risk Factors

  • patient-specific factors associated with increased risk of peripheral nerve injury after gynecologic surgery may include
    • extreme high or low body mass index (BMI), particularly for BMI < 20 kg/m2(1)
    • age > 60 years(1)
    • preexisting generalized peripheral neuropathy secondary to diabetes mellitus, peripheral vascular disease, or hereditary condition(1,3)
    • anatomical factors, such as congenital cervical rib or prior neck or shoulder fracture (risk factor for brachial plexus entrapment during surgery)(1)
    • history of smoking or alcohol use(1,3)
    • hypovolemia(1)
    • hypotension(1)
    • electrolyte disturbance(1)
    • malnutrition(1,3)
  • higher number of prior laparotomy procedures may be associated with increased risk of postoperative ilioinguinal and iliohypogastric nerve injury in patients having laparoscopic gynecologic surgery
    •  based on retrospective cohort study
    • 144 patients who had laparoscopic gynecologic surgery for benign indications between 2008 and 2011 and whose surgery required fascial closure of lower abdominal lateral port in the lower abdomen were included
    • postoperative ilioinguinal or iliohypogastric nerve injury in 7 patients (4.9%)
    • mean number of previous laparotomy procedures 1.6 in patients with iliohypogastric and ilioinguinal nerve injury vs. 0.6 in patients without postoperative nerve injury (p = 0.05)
    • Reference – J Minim Invasive Gynecol 2012 Jul;19(4):448
  • prior abdominal surgery may be associated with increased risk of position-related injury in patients having robotic gynecologic surgery
    •  based on retrospective cohort study
    • 831 patients who had robotic gynecologic surgery between 2006 and 2014 were included
      • prior abdominal surgery in 507 patients (61%)
      • no prior abdominal surgery in 299 patients (39%)
    • positioning-related injury in 7 patients (0.8%), including nerve injury in 3 patients (0.36%), head contusions in 3 patients (0.36%), and subcutaneous ecchymosis on left flank and thigh in 1 patient (0.12%)
    • prior abdominal surgery in 7 patients (100%) with positioning-related injury vs. 0 patients (0%) who did not have position-related injury (p = 0.05)
    • Reference – Gynecol Oncol 2014 Dec;135(3):534full-text

Etiology and Pathogenesis

Causes of Nerve Injury During Gynecologic Surgery

General Causes

  • nerve injury may be caused by any of the following(1,2,3)
    • stretch
    • compression, which can lead to ischemia
    • entrapment
    • laceration or transection
  • nerve injury may occur due to
    • improper patient positioning, such as
      • lithotomy position, especially with
        • excessive hip abduction > 90 degrees(1,2)
        • operative time > 2 hours(2)
        • use of candy cane stirrups rather than boot stirrups(1)
      • steep Trendelenburg positions with head-down tilt of 30-40 degrees, which is reported to be associated with cephalad patient sliding and possible brachial plexus injury(1)
      • insufficient padding of pressure points(1,2)
    • surgical equipment, including
      • leg support stirrups, especially with prolonged operative time(1,2)
      • use of self-retaining retractor blades, which may be associated with femoral nerve injury, particularly
        • when using long retractor blades(3)
        • with prolonged operative time(3)
        • in patients who have
          • thin body habitus(2,3)
          • ill-developed abdominal wall muscles(2)
          • narrow pelvis(2)
    • robotic-assisted laparoscopy, especially with
      • laterally-placed trocars(3)
      • fascial wound closure of port sites(1,3)
    • wide transverse surgical incisions, which may result in nerve transection, specifically(2,3)
      • Pfannenstiel incisions
      • low transverse incisions
      • incisions extending beyond lateral margin of inferior rectus abdominus muscle
    • regional anesthesia administration(2)
    • hematoma formation(2)
  • use of candy cane stirrups may be associated with increased risk of peripheral nerve injury compared to boot stirrups in patients having gynecologic surgery in lithotomy position
    •  based on retrospective cohort study
    • 2,449 patients who had gynecologic surgery ≥ 60 minutes in duration and in lithotomy position were included
      • candy cane stirrups in 611 patients (24.9%)
      • boot stirrups in 1,838 patients (75.1%)
    • postoperative lower extremity neuropathy in 50 patients (2%), 14 of whom (28%) had femoral neuropathy
    • patients in whom candy cane stirrups were used were significantly older and had significantly lower mean body mass index than patients in whom boot stirrups were used
    • comparing candy cane stirrups vs. boot stirrups
      • postoperative lower extremity neuropathy in 21 patients (3.4%) vs. 29 patients (1.6%) (p = 0.008)
      • mean surgical duration 145.3 minutes vs. 176.5 minutes (p < 0.001)
    • Reference – Obstet Gynecol 2021 May 1;137(5):916
  • use of Bookwalter retractors may be associated with increased risk of femoral nerve injury compared to Holzbach retractors in patients having gynecologic surgery via midline laparotomy
    •  based on retrospective and prospective analyses in cohort study
    • 411 patients who had abdominal surgery for gynecologic cancer via midline laparotomy between 2003 and 2011 were included
      • use of Bookwalter retractors in 255 patients (62%)
      • use of Holzbach retractor in 156 patients (38%)
    • postoperative femoral nerve injury in 12 patients (2.2%)
    • femoral nerve injury 12 patients (4.7%) who had Bookwalter retractors vs. 0 patients (0%) who had Holzbach retractors (p < 0.001)
    • Reference – Int J Gynecol Cancer 2014 Jul;24(6):1112
  • pelvic lymphadenectomy may be associated with increased risk of femoral nerve injury in patients having gynecologic surgery
    •  based on retrospective cohort study
    • 406 patients (median age 61 years) who had abdominal surgery for gynecologic cancer (uterine cancer in 48%, ovarian cancer in 35%, cervical cancer in 17%) between 2003 and 2011 were included
    • postoperative femoral nerve injury in 11 patients (2.7%)
    • femoral nerve injury in 9 patients (5.1%) who had pelvic lymphadenectomy vs. 2 patients (0.9%) of patients who did not have pelvic lymphadenectomy (p < 0.01)
    • Reference – Int J Gynecol Cancer 2014 Jul;24(6):1112
  • fascial closure of laparoscopic lateral port sites may be associated with increased risk of postoperative ilioinguinal and iliohypogastric nerve injury compared to no fascial port site closure in patients having laparoscopic gynecologic surgery
    •  based on retrospective cohort study
    • 317 patients who had laparoscopic gynecologic surgery for benign indications between 2008 and 2011 using lateral ports in the lower abdomen were included
      • fascial port site closure using either Cater-Thomason or EndoClose suture device in 144 patients (45.4%)
      • no fascial port site closure in 173 patients (54.6%)
    • postoperative ilioinguinal and iliohypogastric nerve injury in 7 patients (4.9%) who had fascial port site closure vs. 0 patients (0%) who did not have fascial port site closure (p = 0.004)
    • Reference – J Minim Invasive Gynecol 2012 Jul;19(4):448

Causes of Abdominopelvic Nerve Injuries

  • ilioinguinal and iliohypogastric nerve injury may be caused by
    • nerve transection during abdominal wall incisions, including
      • Pfannenstiel or low transverse abdominal incision sites that extend beyond lateral margin of inferior rectus abdominus muscle(2,3)
      • incisions below anterior superior iliac spine(2)
      • incisions about 5 cm superior to pubic symphysis(2)
      • lateral port placement of laparoscopic trocars(3)
    • excessive lateral stretching of fascia from self-retaining retractors(3)
    • nerve entrapment or ligation during fascial wound closure of laparoscopic port sites or incisions placed low in the abdomen(1,3,4)
    • retropubic midurethral tape procedures(2)
    • neuroma formation(4)
    • neural constriction during healing(4)
  • genitofemoral nerve injury may be caused by compression from a retractor placed on anterior surface of psoas muscle and may be more common during pelvic sidewall surgery or during removal of the external iliac nodes(2,3)
  • femoral or lateral femoral cutaneous nerve injury may be caused by
    • entrapment, stretch, or vascular compromise of femoral or lateral femoral cutaneous nerve near inguinal ligament due to improper positioning of hips in lithotomy position, including excessive hip flexion, abduction, or external rotation(1,2)
    • use of deep self-retaining retractors, which can compress(1,2,3)
      • femoral nerve against pelvic sidewall as it exits lateral border of psoas muscle
      • lateral femoral cutaneous nerve at the anterior surface of the iliacus muscle
    • healthcare provider leaning on patient’s inner thigh during surgery
  • obturator nerve injury may be caused by obturator nerve stretching at the obturator foramen from prolonged intraoperative hip flexion and most often results from retroperitoneal surgery, endometriosis excision, transobturator tape insertion, or paravaginal defect repair(1,2,3)
  • superior hypogastric plexus injury may be caused by
  • hypogastric nerve injury may be caused by dissection of uterosacral ligaments (Gynecol Pelvic Med 2021;4:14)
  • inferior hypogastric plexus injury may be caused by dissection of lateral side wall, uterosacral, or medial cardinal ligaments(Gynecol Pelvic Med 2021;4:14)
  • pelvic splanchnic nerve injury may be caused by dissection of the cardinal ligament as part of radical hysterectomy (Surg J (NY) 2021 Dec;7(Suppl 2):S70full-text)
  • pudendal nerve injury may be caused by
    • entrapment during sacrospinous ligament fixation(2)
    • compression at ischial spine from hemorrhage(3)

Causes of Lower Extremity Nerve Injuries

  • saphenous nerve injury may be caused by compression of medial aspect of knee against a hard surface without adequate padding while in dorsal lithotomy position(1,3)
  • sciatic nerve injury may be caused by stretching of the nerve at the sciatic notch with hyperflexion of hips combined with knee extension while in dorsal lithotomy position for an extended period of time(1,2,3)
  • common peroneal nerve injury may be caused by direct compression of nerve against lateral edge of fibular head or nerve stretching while in lithotomy position particularly when using hanging candy cane stirrups and with prolonged knee flexion and excessive hip external rotation(1,2,3)
  • tibial nerve injury may be caused by compression of popliteal fossa against a hard surface without proper padding while in lithotomy position(1,3)

Causes of Upper Extremity Nerve Injuries

  • brachial plexus injury(1,2)
    • upper brachial plexus nerve root injury is typically caused by traction from hyperextension of the arm > 90 degrees which can stretch the brachial plexus between the clavicle and first rib, particularly if the arm is pronated and the head is rotated away from the arm
    • lower brachial plexus nerve root injury is typically caused by pressure from steep Trendelenburg position 30-40 degrees, particularly when the arms are extended and when shoulder braces and/or wristlets are used to maintain patient positioning
  • radial nerve injury may be caused by persistent pressure on the spinal groove or humerus due to arm positioning, particularly with inadequate padding(1,2)
  • ulnar nerve injury may be caused by compression of the nerve at medial epicondyle of elbow due to forearm pronation without sufficient elbow padding against arm board, or prolonged extreme flexion of the elbow across chest(1,2)

Pathogenesis

  • severity of nerve injury may depend upon severity and duration of the causative compression or stretching
    • mild compression or stretch may cause temporary nerve ischemia, causing axonal conduction block(1,6)
    • moderate compression or stretch may obstruct venous flow, causing congestion and edema, leading to axonal conduction block(1,6)
    • consistent and chronic compression or stretch may cause reduced axonal signal conduction due to Schwann cell damage and demyelination(1)
    • severe and persistent compression or stretch may lead to axonal degeneration and prolonged dysfunction(1)
  • nerve transection or ligation causes complete neural separation of the axon and Schwann cells(1)

Evaluation and Diagnosis

Making the Diagnosis

  • suspect nerve injury following gynecologic surgery in patients with any of the following(1)
    • loss of sensation
    • pain
    • numbness
    • muscle weakness
    • motor disabilities
    • loss of reflexes
  • perform a careful physical exam to evaluate for sensory deficits, muscle weakness, and loss of reflexes in anatomical areas which would be affected by injury to specific nerves (Med Clin North Am 2019 Mar;103(2):357)
  • patients with suspected postoperative neuropathy should be referred to a neurologist for additional tests to help localize sites of nerve injury, identify causes of injury, and rule out alternative diagnoses; testing options may include(2)

Differential Diagnosis

  • differential diagnosis for postoperative nerve injury may include
    • cervical spinal injury
    • musculoskeletal injury
    • autoimmune neurologic conditions
    • inflammatory conditions, such as acute brachial plexitis
    • Reference – Surg Neurol 2005 Jan;63(1):5

Imaging Studies

Ultrasound

  • ultrasound may be used to(5,6)
    • detect abnormalities in nerve or surrounding tissue and thereby localize nerve compression site
    • determine underlying cause of nerve compression (such as mass lesions)
  • specific mononeuropathies associated with gynecologic surgery where ultrasound has been reported to be useful include(5,6)
    • ulnar neuropathy
    • femoral neuropathy
    • meralgia paresthetica
    • peroneal neuropathy
  • ultrasound might be more sensitive than magnetic resonance imaging for detection of nerve pathology in patients with brachial plexopathy or other selected mononeuropathies
    •  based on diagnostic cohort study with methodologic limitations
    • retrospective cohort study of 53 patients who had
      •  suspected brachial plexopathy or single or multiple mononeuropathies other than idiopathic carpal tunnel syndrome, ulnar neuropathy at elbow, hereditary neuropathies, acquired inflammatory neuropathies, or idiopathic peripheral neuropathies
      •  assessment by both ultrasound and magnetic resonance imaging (MRI) for detection of nerve pathology
    • methodologic limitations include
      •  highly selected patient sample
      •  no blinding between test under investigation and reference standard
      •  variable reference standard, including any surgical, clinical, or electrodiagnostic evaluation of nerve injury
      •  long time delay between imaging and surgery (reference standard) – mean 50 days for ultrasound and 125 days for MRI
    •  46 patients (87%) had nerve pathology by reference standard
    •  7 of these patients had nerve pathology in the brachial plexus or axilla, but results for these 7 patients not specifically reported
    • sensitivity for detecting nerve pathology among these 46 patients
      •  93% for ultrasound
      •  67% for MRI
    •  Reference – Neurology 2013 Apr 30;80(18):1634, editorial can be found in Neurology 2013 Apr 30;80(18):1626
    • CLINICIANS’ PRACTICE POINT: Although specificity reported in the original article, this data may be unreliable based on only 7 patients in this highly selected cohort not having confirmed nerve pathology.

MRI

  • MRI may be considered for(5)
    • suspected intrabdominal mass or hematoma causing femoral nerve compression
    • suspected soft tissue anomalies causing ulnar neuropathy or meralgia paresthetica
  • magnetic resonance neurography

Electrodiagnostic Testing

  • indications for electrodiagnostic testing
    • localize site of injury
    • establish severity of injury
    • identify potential donor nerves for transfer
    • evaluate recovery and rehabilitation
    • Reference – J Hand Surg Eur Vol 2011 Nov;36(9):747
  • may be helpful for localization of nerve damage and prediction of prognosis for some entrapment mononeuropathies(5,6)
  • should be performed in patients having symptoms ≥ 2 weeks, after some degree of demyelination has occurred(2,3)
  • electrodiagnostic tests(5,6)
    • nerve conduction studies (NCS) involve electrical stimulation of nerve and recording over a nerve or muscle
      • recording from nerve yields sensory nerve action potential (SNAP) and from muscle yields compound muscle action potential (CMAP)
      • assess latency (time from stimulus application to SNAP or CMAP activation), amplitude, and conduction velocity
      • can be used to assess focal entrapment neuropathy such as carpal tunnel syndrome, relative motor versus sensory involvement, and distribution and severity and to determine if neuropathy is axonal or demyelinating
        • axonal neuropathy, results first in lower SNAP amplitudes, followed by lower CMAP amplitudes
        • demyelination causes prolonged distal latency and slowed conduction velocity, may also produce reduced proximal CMAP amplitude, temporal dispersion of distal CMAP (multiphasic waveform or prolonged duration), and changes to F wave characteristics
    • needle electromyography (EMG) assesses electrical activity of voluntary muscles
      • detects active axonal damage (presence of spontaneous muscle fiber activity at rest) and motor unit action potential during voluntary muscle contraction
      • can be used to identify distribution of dysfunction

Diagnosis by Nerve Injury

Abdominopelvic Nerve Injuries

  • ilioinguinal and iliohypogastric nerve injury
    • diagnosis of ilioinguinal and iliohypogastric nerve injury is typically based on clinical presentation, including(2)
      • presence of sharp burning pain radiating from incision site to mons pubis, labia, and thigh
      • paresthesia over nerve distribution areas, including skin of groin, inner thigh, labia majora, gluteal, and hypogastric areas
      • pain relief following local anaesthetic injection
    • postoperative neurological pain may(1)
      • occur immediately or weeks to months after surgery
      • persist for months or years due to scarring-induced neural constriction
    • physical exam may reveal
  • genitofemoral nerve injury
    • diagnosis is based on patient history of burning pain and paresthesia over mons pubis, labia majora, and femoral triangle(2,3)
    • patient may report
      • pain or paresthesia worsening with walking or hip extension
      • pain relief in recumbent position with hip flexed
      • Reference – Clin Anat 2015 Jan;28(1):128
  • femoral nerve injury
    • symptoms of femoral nerve injury typically arise ≤ 72 hours after surgery(3)
    • diagnosis is typically based on clinical presentation, which includes(1,5)
      • difficulty walking due to motor weakness of hip flexion, hip adduction, and knee extension
      • paresthesia in anterior thigh, medial thigh, and medial calf
    • physical exam may reveal reduced or absent patellar reflex due to weakness in quadriceps(5)
    • diagnostic testing may include(5)
      • ultrasound, which may identify sites of entrapment or abnormalities in nerve shape, cross-sectional area, or echotexture
      • computed tomography, particularly if intrabdominal mass or hematoma is suspected as cause of femoral nerve compression
    • anatomical symptoms used for diagnosis of postoperative femoral nerve injury in 49-year-old patient who had gynecologic surgery in case report
      • sensory impairment of anterior-medial thigh to medial shin
      • difficulty stretching at the knee joint due to quadriceps weakness
      • impaired flexion of hip joint due to iliopsoas weakness
      • Reference – J Anesth 2016 Apr;30(2):317
  • lateral femoral cutaneous nerve injury
    • diagnosis is typically based on clinical presentation which commonly includes paresthesia, numbness, burning pain, or hypersensitivity in the anterolateral thigh(5)
    • physical exam may reveal(5)
      • sensory loss or hypersensitivity in sharply demarcated area of anterolateral thigh (extending no further than from trochanter of femur to superior margin of patella)
      • intact motor function (presence of motor weakness suggests alternative diagnosis such as radiculopathy at L2, which may present with hip flexion weakness)
    • additional testing usually not needed but may be considered if there is diagnostic uncertainty; options may include
      • lateral femoral cutaneous nerve block(5)
      • electrodiagnostic testing to assess for presence of abnormal sensory nerve action potentials(4)
  • obturator nerve injury
    • diagnosis is based on clinical presentation, which is characterized by sensory loss or paresthesia in upper medial thigh and weakness during hip adduction possibly resulting in minor ambulatory deficits(1,2,3)
    • physical exam may reveal external rotation of affected leg, with tendency to swing outward during ambulation(4)
    • electromyography may reveal denervation of adductor longus and brevis muscles(4)
  • hypogastric plexus injury, hypogastric nerve injury, and pelvic splanchnic nerve injury
    • for hypogastric plexus injury, diagnosis is based on patient history of urinary or bowel symptoms, which may include
    • for hypogastric nerve injury, diagnosis is based on clinical presentation and may be suspected in patients who present with incontinence, dysuria, frequent urination, incomplete bladder emptying (Gynecol Pelvic Med 2021;4:14)
    • for pelvic splanchnic nerve injury, diagnosis is based on clinical presentation and may be suspected in patients with urinary, bowel, or sexual dysfunction (J Minim Invasive Gynecol 2021 Feb;28(2):178)
    • diagnostic testing may include
      • electrodiagnostic tests, which may be useful to assess patient’s control of pelvic floor muscles; see Neurogenic Bladder for additional information
      • urodynamic testing, which may be helpful in characterizing lower urinary tract dysfunction; see Neurogenic Bladder for additional information
  • pudendal nerve injury
    • diagnosis is based on clinical presentation, which may be characterized by
      • loss of sensation and/or pain in vulval, perineal, and gluteal regions(2,3)
      • fecal and/or urinary incontinence(4)
      • perineal pain that worsens while seated(4)
    • electrodiagnostic testing of nerve latency may be helpful in diagnosis(4)

Lower Extremity Nerve Injury

  • Pain typically found in posterior part of lower extremity and follows dermatomal pattern.Distribution of pain in sciatica – Pain typically found in posterior part of lower extremity and follows dermatomal pattern.Copyright ©2015 EBSCO Information Services.
  • saphenous nerve injury
    • diagnosis is based on clinical presentation, which may include loss of sensation over foot and anteromedial lower leg without motor deficit(3,4)
    • physical exam may reveal Tinel sign, characterized by local or radiating paresthesia with percussion at site of nerve injury(4)
  • sciatic nerve injury
    • diagnosis based on clinical presentation, which may include
      • hypoesthesia or paresthesia over posterior aspect of thigh, calf, and/or foot(1)
      • gluteal pain radiating down posterior thigh into popliteal fossa(3)
      • weakness in
        • hamstrings(3)
        • dorsiflexion foot muscles, presenting as foot drop(1)
        • hip extensors (with severe injury)(1)
        • knee flexors (with severe injury)(1)
    • physical exam may reveal
  • common peroneal nerve injury
    • diagnosis is based on clinical presentation, which may include sensory loss at dorsum of foot and lateral leg and weakness in ankle dorsiflexion and foot eversion (foot drop)(5)
    • physical exam may reveal(5)
      • normal Achilles tendon reflex
      • characteristic steppage gait (elevation of pelvis on affected side to lift dropped foot through swing phase); see also Gait Disorders in Adults
    • electrodiagnostic testing
      • may be used to
        • localize site of nerve injury to peroneal nerve(5)
        • detect interruption of nerve conduction to provide evidence of focal compression across fibular head(5)
        • determine severity of nerve compression and extent of axonal injury to guide prognosis(5)
        • differentiate common peroneal nerve injury from L5 radiculopathy or more proximal peroneal lesion(4)
      • results consistent with common peroneal nerve injury may include(4)
        • reduced or absent sensory nerve action potentials of superficial peroneal nerve
        • focal slowing, temporal dispersion, or conduction block when recording from extensor digitorum brevis or tibialis anterior while stimulating the common peroneal nerve above and below fibular neck
        • electrical abnormality of short head of the biceps suggests lesion proximal to popliteal fossa
    • magnetic resonance imaging may be helpful in identifying local inflammation that is contributing to neuropathy(4)
  • tibial nerve injury
    • diagnosis is based on clinical presentation, which may include(1,2,3)
      • numbness of toes and plantar foot surface
      • weakness of toes and plantar flexion of ankle
      •  cavus deformity foot due to imbalance between foot muscles
    • physical exam may reveal
      • heel and arch tenderness to palpitation along course of posterior tibial nerve
      • positive Hoffman-Tinel sign (pain into mid-calf with percussion of tibial nerve or branches at site of injury)
      • Reference – Foot (Edinb) 2015 Dec;25(4):244
    • physical exam maneuvers include
      • dorsiflexion-eversion test
        • ankle is maximally everted and dorsiflexed passively, while metatarsophalangeal joints are maximally dorsiflexed passively
        • position is held for 5-10 seconds
        • positive test if worsening of symptoms
        • Reference – Foot (Edinb) 2015 Dec;25(4):244
      • Phalen-type provocative test (plantar flexion-inversion or Trepman test)
        • examine patient in seated position with foot and ankle relaxed
        • start with foot and ankle in neutral position
          • passively hold foot and ankle in mild plantarflexion position (about 20 degrees) and neutral eversion-inversion
          • note location and intensity of symptoms
        • perform eversion test
          • move foot and hold mild plantarflexion, full eversion, and abduction
          • positive test with increase in pain and paresthesias over posterior tibial nerve distribution
          • pain and paresthesias should subside upon returning foot and ankle to neutral position
        • perform inversion test
          • move foot and hold in mild plantarflexion, full inversion, and adduction
          • positive test indicated by increase in pain and paresthesias over posterior tibial nerve distribution
          • pain and paresthesias should subside upon returning foot and ankle to neutral position
        • Reference – Foot Ankle Int 1999 Nov;20(11):721
      • triple compression stress test, in which ankle is placed in full plantar flexion and foot in inversion, with constant pressure applied over posterior tibial nerve to provoke signs of entrapment (Foot (Edinb) 2012 Sep;22(3):146)
    • for additional information, see
      • Pes Cavus
      • Posterior Tarsal Tunnel Syndrome

Upper Extremity Nerve Injuries

  • brachial plexus nerve injury
    • suspect diagnosis if history and physical exam suggests a pattern of muscle or sensory disturbances which match with a known branch or branches of the brachial plexus (such as trunk, division, cord)
    • diagnosis may be confirmed with imaging and electrodiagnostic testing if indicated
  • radial nerve injury
    • diagnosis is based on clinical presentation, which varies by site of radial nerve compression but generally characterized by weakness in wrist and finger extensors(6)
    • physical exam for suspected radial neuropathy includes assessment of(6)
      • motor weakness of finger extension, wrist extension, brachioradialis, and triceps
      • sensory loss in dorsal lateral hand, posterior forearm, and posterior upper arm
      • reflex changes of brachioradialis and triceps
    • imaging studies, including ultrasound or magnetic resonance imaging may be useful in workup and diagnosis of radial nerve injury, especially posterior interosseous nerve syndrome(4)
    • electrodiagnostic testing may confirm clinical findings if conduction block or slowed conduction velocity observed across spiral groove of humerus(6)
  • ulnar nerve injury

Management

General Management Considerations for Peripheral Nerve Injury

  • most neuropathies will resolve spontaneously with minimal intervention(2)
  • symptom management typically begins with nonoperative treatment which may include
  • surgical management of ligation or transection nerve injuries may require specialist to realign epineural sheath and neural fascicles, such as in microsurgical tension-free end-to-end anastomosis(2)

Management Considerations for Specific Nerve Injuries

Abdominopelvic Nerve Injuries

  • ilioinguinal and iliohypogastric nerve injury
    • conservative management involves symptomatic treatment of neurologic pain, which may persist for months or years(1)
    • management options may include(4)
      • nerve block
      • transcutaneous electrical nerve stimulation
      • anti-inflammatory medications
      • pulsed radiofrequency therapy applied to higher lumbar nerve roots
      • gabapentin
    • surgical management with ilioinguinal neurectomy may be indicated for intractable forms of nerve injury(4)
  • genitofemoral nerve injury(4)
    • initial management is typically medical, as in ilioinguinal and iliohypogastric nerve injury
    • pain that is unresponsive to medical management may require surgical management with genitofemoral neurectomy
  • femoral nerve injury
    • pain management may include nonsteroidal anti-inflammatory drugs and/or acetaminophen, and antiseizure medications for neuropathic pain, including(3)
      • carbamazepine
      • phenytoin
      • gabapentin
    • management of motor impairment may include
      • physical therapy(3)
      • knee bracing or cane(3)
      • orthoses
    • mild femoral neuropathies may improve within days to weeks, whereas more severe nerve injuries may take months to improve(3)
  • lateral femoral cutaneous nerve injury
    • nonoperative management is first-line therapy and usually successful
      • initial medications to consider include
        • nonsteroidal anti-inflammatory drugs (NSAIDs)
        • topical treatments including capsaicin, lidocaine, or tacrolimus for epidermal dysesthesia or cutaneous hypersensitivity
        • tricyclic antidepressants, antiarrhythmics, or antiseizure medications for neuropathic pain
      • if symptoms refractory to initial medical therapy, consider local injection of corticosteroids
    • reserve surgery for failure of nonoperative management
  • obturator nerve injury
    • for patients with intermittent symptoms of obturator nerve entrapment who have sought care early on, it is unclear if conservative management (such as physical therapy, massage, stretching, and ultrasound) can prevent irreversible entrapment (Prim Care 2005 Mar;32(1):163)
    • most cases of obturator entrapment respond poorly to conservative management and surgery generally warranted (Prim Care 2013 Jun;40(2):313)
    • external neurolysis of obturator nerve may be considered(4)
  • hypogastric plexus, hypogastric nerve, and pelvic splanchnic nerve injuries (not specific to injury associated with gynecologic surgery)
  • pudendal nerve injury
    • conservative management may include physical therapy and/or nerve block(4)
    • surgery should be reserved for symptoms refractory to conservative management; options for surgical pudendal nerve decompression may include(4)
      • superior transgluteal approach, including sectioning of piriformis muscle, which may be appropriate for patients with painful hip adduction/abduction and/or relief with crossed leg traction
      • medial transgluteal approach to ischial spine, which may be appropriate for patients with tenderness on palpation
      • inferior transgluteal approach, which may be appropriate for patients with tenderness at inferomedial sacrotuberous ligaments
  • surgical management of iatrogenic pelvic nerve injury with decompression, neurolysis, or neuroprosthesis implantation reported to reduce neuropathic pain and need for routine use of analgesics at 1-year follow-up in 95 patients with lateral femoral cutaneous, sciatic, pudendal, or obturator nerve injury secondary to surgery for pelvic organ prolapse in case series (Int Urogynecol J 2011 Dec;22(12):1485)
  • good outcome based on motor function achieved in 100% of patients who had end-to-end repair, nerve grafting, or nerve transfer for obturator nerve injury
    •  based on systematic review of case reports and case series
    • systematic review of 20 case reports and 2 case series evaluating functional outcomes after end-to-end repair, nerve grafting, or nerve transfer in 25 patients with obturator nerve injury
      • 60% were treated with end-to-end repair, 36% were treated with nerve grafting, and 4% were treated with nerve transfer
      • 96% had pelvic lymphadenectomy, and 4% had radical cystectomy
    • motor function was assessed on Medical Research Council (MRC) score (range 0-5 points, with higher scores indicating better function), and good outcome defined as score ≥ 3 points
    • mean follow-up 7.6 months
    • mean MRC score was 2.9 points immediately after treatment and 4.77 at final follow-up
    • 100% of patients achieved good outcome (MRC score ≥ 3 points) at final follow-up
    • mean time for full functional recovery was 3.8 months
    • Reference – Int J Gynecol Cancer 2022 Aug 10 early online

Lower Extremity Nerve Injuries

  • saphenous nerve injury
    • conservative management is usually successful and typically includes saphenous nerve block(4)
    • surgical management should be reserved for those who do not respond to conservative treatment; options may include
      • surgical neurolysis with release of all fascial bands along distal aspect of adductor canal (Curr Sports Med Rep 2014 Sep;13(5):299)
      •  surgical excision (neurectomy) if infrapatellar branch neuromas are present on magnetic resonance imaging; however, the patient should be informed of likely postsurgical sensory loss in anteromedial knee region (Curr Sports Med Rep 2014 Sep;13(5):299)
  • sciatic nerve injury
    • conservative management may include(4)
      • physical therapy
      • anti-inflammatory medications
      • corticosteroid injections
    • referral for surgical decompression should generally be limited to patients whose symptoms do not improve with conservative management(4)
  • common peroneal nerve injury
  • tibial nerve injury
    • tibial nerve injury at the knee during gynecologic surgery typically presents with motor symptoms of cavus deformity foot(1,2)
    • management of cavus deformity foot
      • first-line treatment for patients with mild and flexible pes cavus deformities is conservative and may include physical therapy and orthoses
      • operative management may be considered in patients with pain or difficulty with ambulation, recurrent ankle sprains, stress fractures, or with severe, rigid deformities refractory to conservative therapy

Upper Extremity Nerve Injuries

  • brachial plexus nerve injury
    • conservative treatment usually sufficient for postoperative brachial plexopathy (Muscle Nerve 2004 Nov;30(5):547)
    • analgesic options
      • nonsteroidal anti-inflammatory medications (limited effectiveness)
      • gabapentin or pregabalin
      • computed tomography-guided infiltration of chemotherapeutics
      • stellate ganglion block
      • pulsed radiofrequency treatment
      • therapeutic magnetic stimulation
      • Reference – Br J Med Med Res. 2013 Oct-Dec;3(4):928-952PDF
    • decompression surgery may be required for brachial plexus injury due to hematoma (Br J Med Med Res. 2013 Oct-Dec;3(4):928-952PDF)
    • conservative management of postoperative brachial plexus injury with physiotherapy and amitriptyline 10 mg once daily reported to restore motor and sensory function by 6 weeks after surgery in 39-year-old patient who had laparoscopic endometriosis excision in Lloyd-Davis position in case report (BMJ Case Rep 2021 Nov 29;14(11))
  • radial nerve injury
    • conservative management indicated for radial neuropathy at spiral groove (“Saturday night palsy”), as most patients will have complete recovery and few treatment options exist (Semin Neurol 2019 Oct;39(5):549)
    • supportive options include
      • physical therapy to maintain range of motion and avoid disuse
      • dorsal cock-up splint to maintain wrist in position allowing for normal hand muscle function
      • Reference – Med Clin North Am 2019 Mar;103(2):357
  • ulnar nerve injury
    • conservative management indicated for mild-to-moderate ulnar nerve entrapment and may include
      • activity modification
      • padding or splinting (including night splinting)
      • physical or occupational therapy
      • nonsteroidal anti-inflammatory drugs and, occasionally, corticosteroid injections as needed for pain
    • surgical treatment indicated if motor weakness or if no response to conservative treatment; multiple surgical techniques exist, but little consensus on best technique
      • simple decompression may be adequate for most patients
      • ulnar nerve transposition may be indicated if ulnar nerve hypermobility or posttraumatic elbow stiffness

Complications

  •  advanced nerve injury may be associated with muscle atrophy and/or contractures (J Hand Surg Am 2010 Jan;35(1):153)
  • complications of surgical management of nerve injuries may include
    • nerve or tendon damage
    • vascular injury
    • hypertrophic and/or painful scar formation
    • complex regional pain syndrome
    • other types of chronic pain
    • postoperative wound infection
    • impaired wound healing

Prognosis

  • prognosis depends on the severity of nerve injury
    • most postoperative nerve compression injuries resolve spontaneously over the course of several weeks to months with minimal intervention(2,3)
    • sensory neuropathies typically resolve within 5 days after surgery(2)
    • motor neuropathies and deficits may require up to 10 weeks to recover(2)
    • rarely, postoperative neuropathies can persist > 1 year, which is often the result of nerve transection injuries(2)
  • most patients with mild or intermittent ulnar neuropathy or meralgia paresthetica improve spontaneously or with nonoperative therapy
  • nerve conduction studies may be helpful for predicting prognosis of entrapment mononeuropathies(5,6)
    • conduction block on nerve conduction studies (implying demyelination rather than axonal loss) reported to be associated with better prognosis for ulnar and radial mononeuropathies
    • > 50% reduction in motor response amplitude comparing affected side of nerve to unaffected side (suggestive of axonal loss) reported to be associated with incomplete or delayed recovery in patients with femoral neuropathy
  • 67% muscle function recovery at 3-8 months reported in adults with femoral nerve injury with both sensory and motor neuropathy after gynecologic laparotomy
    •  based on case series
    • 785 patients who had surgery (including lymph node dissection) under general anesthesia for gynecologic cancer between 2012 and 2016 in single center in Japan were assessed
    • all surgeries were performed with epidural anesthesia in lithotomy position and using self-retaining retractors and electrical instruments
    • 6 patients (0.76%) aged 43-74 years had femoral nerve injury with both sensory and motor neuropathy after gynecologic laparotomy
      • all patients had score of ≤ 3 points on Medical Research Council (MRC) scale (score range 0-5 points, with lower scores indicating decreased function)
      • 1-year postoperative outcomes
        • muscle function recovery at 3-8 months in 4 patients (67%), including 3 patients who had physical therapy
        • 2 patients (33%) died
    • Reference – Int Cancer Conf J 2023 Oct;12(4):294full-text

Prevention of Nerve Injury During Gynecologic Surgery

  • Lateral and frontal views of prone, reverse Trendelenburg, Trendelenburg, supine, beach chair (Fowler), lithotomy, and lateral positions.Surgery and anesthesia patient positioning – Lateral and frontal views of prone, reverse Trendelenburg, Trendelenburg, supine, beach chair (Fowler), lithotomy, and lateral positions.Copyright ©2022 EBSCO Information Services.
  • patient positioning considerations for prevention of perioperative nerve injury
    • proper lower-extremity placement in lithotomy position may include
      • positioning legs in boots to prevent common peroneal nerve injury(1)
      • thigh-trunk angle of 170 degrees to protect obturator nerve and lumbar spine(1)
      • knee flexion of 90-120 degrees to protect sciatic nerve(1)
      • hip flexion of 60-170 degrees to protect femoral, obturator, and sciatic nerves; assess for hyperflexion by palpitating popliteal pulses to check for compression of the femoral artery in the inguinal canal(1,3)
      • hip abduction ≤ 90 degrees to protect femoral and obturator nerves; correct angle can typically be found by aligning the long axis of lower extremity with umbilicus and contralateral shoulder(1,3)
      • use of padding around the knee and lateral fibular head, which may help protect the common peroneal nerve from compression against stirrups or supporting pole(1)
    • proper upper extremity placement in Trendelenburg position to protect brachial plexus, ulnar, and radial nerves, including
      • proper arm position and support, consisting of
        • supinated position for extended arms, with trunk-arm angle ≤ 90 degrees(1)
        • pronated position for tucked arms, avoiding prolonged or extreme elbow flexion(1,2)
        • adequate padding of posteromedial elbow(1,2)
        • positioning arm away from edge of arm board(1)
      • placing head in central position(1)
      • avoiding posterior displacement of the shoulder(1)
      • limiting angle of inclination to 30 degrees(1)
      • avoiding use of shoulder braces when possible(1)
        • when needed, braces should be positioned directly at acromioclavicular joint and adequate padding should be used at pressure points
        • alternatives to prevent patient sliding may include gel pads, egg crate, or foam mattress pads
      • avoiding use of wrist straps when possible(1)
  • prevention of nerve injury during laparoscopic gynecologic surgery(1)
    • patient should be placed in low lithotomy position with thigh-trunk angle of 170 degrees
    • side-port trocars should be ≤ 5 mm diameter when possible
    • trocar ports should be placed above anterior superior iliac spine and not in abdominal wall nerve courses
    • fascial wound closure may not be necessary if side-port trocar ≤ 5 mm diameter but if needed, sutures should not be tightened
  • prevention of ilioinguinal and iliohypogastric nerve injury during placement and closure of low abdominal incisions(2)
    •  low abdominal incision should not be extended beyond lateral margin of rectus muscle as to not transect nerves
    • use of upward curving incision should be considered when wide margins are needed which may avoid path of underlying nerves
    • incorporating tissue > 1.5 cm from fascial edge during fascial incision closure should be avoided to reduce risk of nerve entrapment
  • prevention of nerve injury during placement of self-retaining retractor blades
    • most shallow retractor blade that is sufficient to provide adequate exposure should be used(2)
    • self-retaining retractor blades should be positioned such that the retractor cradles the rectus muscle without compressing the underlying psoas muscle(2,3)
    • visual check and direct palpation should be performed to ensure that psoas muscle is not entrapped between retractor blades and pelvic side wall(2,3)
    • retractor blade position should be monitored throughout surgery and repositioned as needed, especially for lengthy procedures(2)
    • laparotomy pads may be rolled and used as cushion between retractor blades and muscle wall(2,3)
    • hand-held retractors may be preferred over self-retaining retractors to limit pressure on retracted tissue(2)

Guidelines

Review Articles

Patient Information

References

  1. Abdalmageed OS, Bedaiwy MA, Falcone T. Nerve Injuries in Gynecologic Laparoscopy. J Minim Invasive Gynecol. 2017 Jan 1;24(1):16-27.
  2. Kuponiyi O, Alleemudder DI, Latunde-Dada A, Eedarapalli P. Nerve Injuries Associated with Gynaecological Surgery. TOG. 2014 Jan 13;16(1):29-36.
  3. Clarke-Pearson DL, Geller EJ. Complications of hysterectomy. Obstet Gynecol. 2013 Mar;121(3):654-673, commentary can be found in BJOG 2016 Dec;123(13):2189.
  4. Toussaint CP, Perry EC 3rd, Pisansky MT, Anderson DE. What’s new in the diagnosis and treatment of peripheral nerve entrapment neuropathies. Neurol Clin. 2010 Nov;28(4):979-1004.
  5. Bowley MP, Doughty CT. Entrapment Neuropathies of the Lower Extremity. Med Clin North Am. 2019 Mar;103(2):371-382.
  6. Doughty CT, Bowley MP. Entrapment Neuropathies of the Upper Extremity. Med Clin North Am. 2019 Mar;103(2):357-370.

Related Posts

Related Posts:

15585

Sign up to receive the trending updates and tons of Health Tips

Join SeekhealthZ and never miss the latest health information

15856