Analysis of lumbar plexopathies and nerve injury after lateral retroperitoneal transpsoas approach: diagnostic standardization

A review

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Object

The minimally invasive lateral transpsoas approach has become an increasingly popular means of fusion. The most frequent complication is related to lumbar plexus nerve injuries; these can be diagnosed based on distribution of neurological deficit following the motor and/or sensory nerve injury. However, the literature has failed to provide a clinically relevant description of these complications. With accurate clinical diagnosis, spine practitioners can provide more precise prognostic and management recommendations to include observation, nerve blocks, neurodestructive procedures, medications, or surgical repair strategies. The purpose of this study was to standardize the clinical findings of lumbar plexopathies and nerve injuries associated with minimally invasive lateral retroperitoneal transpsoas lumbar fusion.

Methods

A thorough literature search of the MEDLINE database up to June 2012 was performed to identify studies that reported lumbar plexus and nerve injuries after the minimally invasive lateral retroperitoneal transpsoas approach. Included studies were assessed for described neurological deficits postoperatively. Studies that did attempt to describe nerve-related complications clinically were excluded. A clinically relevant assessment of lumbar plexus nerve injury was derived to standardize early diagnosis and outline prognostic implications.

Results

A total of 18 studies were selected with a total of 2310 patients; 304 patients were reported to have possible plexus-related complications. The incidence of documented nerve and/or root injury and abdominal paresis ranged from 0% to 3.4% and 4.2%, respectively. Motor weakness ranged from 0.7% to 33.6%. Sensory complications ranged from 0% to 75%. A lack of consistency in the descriptions of the lumbar plexopathies and/or nerve injuries as well as a lack of diagnostic paradigms was noted across studies reviewed. Sensory dermal zones were established and a standardized approach was proposed.

Conclusions

There is underreporting of postoperative lumbar plexus nerve injury and a lack of standardization of clinical findings of neural complications related to the minimally invasive lateral retroperitoneal transpsoas approach. The authors provide a diagnostic paradigm that allows for an efficient and accurate classification of postoperative lumbar plexopathies and nerve injuries.

Abbreviations used in this paper:ASIS = anterior superior iliac spine; EMG = electromyographic; LFCN = lateral femoral cutaneous nerve; SDZ = sensory dermal zone.

Article Information

Address correspondence to: Juan Uribe, M.D., Department of Neurosurgery, University of South Florida, 2 Tampa General Circle, 7th floor, Tampa, Florida 33606. email: juansuribe@gmail.com.

Please include this information when citing this paper: published online December 21, 2012; DOI: 10.3171/2012.11.SPINE12755.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Illustration showing SDZs for clinical examination: SDZ I—iliohypogastric, illioinguinal, genitofemoral, and subcostal nerves; SDZ II—LFCN; SDZ III—femoral nerve; and SDZ IV—obturator nerve.

  • View in gallery

    Photographs showing clinical lumbar plexus injuries. A: Anterior views demonstrating a lateral abdominal hernia found 6 weeks postoperatively. Findings were associated with anesthesia of the superior-lateral portion of SDZ I. B: Anterior view demonstrating significant muscle atrophy of the right lower extremity evident 18 months postoperatively, with associated anesthesia of SDZ III consistent with complete femoral nerve injury. C: Lateral view outlining postoperative anesthesia (SDZ II) consistent with LFCN injury. D: Anterior view outlining complex combined lumbar plexus injury with dermal anesthesia of SDZ II, paresthesia of SDZ III (sparing the saphenous dermatome), and neuropathic inguinal allodynia and regional anesthesia of SDZ I. E: Lateral view demonstrating anesthesia of the lateral portion of SDZ I consistent with injury to the lateral cutaneous branch of the iliohypogastric nerve.

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    Diagnostic paradigm for lumbar plexopathy. Interval electrodiagnostic studies for weakness without clinical recovery are performed at 6 weeks and 3 months (asterisks), and then at intervals thereafter to evaluate for reinnervation. Motor deficits with initial strength greater than antigravity have the potential for good functional recovery with physical therapy (suspected partial neurapraxia). No definitive conclusion on prognosis can be made from initial plegia. A degree of improvement is expected within 3 months with neurapraxia as opposed to axonotmesis or neurotmesis. FN = femoral nerve; LFC = LFCN; ON = obturator nerve.

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