Evaluation of iatrogenic lesions in 722 surgically treated cases of peripheral nerve trauma

Restricted access

Object. The purpose of this study was to discover the number and types of iatrogenic nerve injuries that were surgically treated during a 9-year period at a relatively busy nerve center. The specific nerves involved, their sites of injury, and the mechanisms of injury were also documented.

Methods. The authors retrospectively evaluated the surgically treated iatrogenic lesions by reviewing case histories, operative reports, and follow-up notes in 722 cases of trauma. These cases were treated between January 1990 and December 1998 because of pain, dysesthesias, and sensory and/or motor deficits.

Iatrogenic injury was a much larger category of trauma than predicted. One hundred twenty-six (17.4%) of the 722 surgically treated cases were iatrogenic in origin. Most of these injuries occurred during a previous operation. To a major extent, nerves of the extremities were affected, and a relatively large number of injuries occurred in the neck and groin. Incidence was highest in the spinal accessory nerve (14 cases), the common peroneal nerve (11 cases), the superficial radial nerve (10 cases), the genitofemoral nerve branches (10 cases), and the median nerve (nine cases). At least two thirds of the patients did not undergo surgery for the iatrogenic injury within an optimal time interval due to delayed referral. Follow-up data were available in 97 of the 126 patients. Surgical outcomes demonstrated improvement in 70% of patients. Operative results were especially favorable in patients suffering from iatrogenic injuries to the accessory and superficial sensory radial nerves.

Conclusions. Iatrogenic injuries should be corrected in a timely fashion just like any other traumatic injury to nerve.

Article Information

Address reprint requests to: Thomas Kretschmer, M.D., Neurochirurgische Klinik der Universität Ulm am Bezirkskrankenhaus Guenzburg, Ludwig-Heilmeyer-Strasse 2, 89312 Guenzburg, Germany. email: kretschmerthomas@hotmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Intraoperative photographs showing spinal accessory nerve lesions after lymph-node removal. Left: End-bulb neuroma of a transected spinal accessory nerve. Right: Typical operative findings after iatrogenic transection. The accessory nerve (held by the vessel loop) thins out into a neuroma and fibrous tissue on the right side.

  • View in gallery

    Intraoperative photograph depicting a complete lesion of the left common peroneal nerve following vein stripping. Intraoperatively, the nerve was found to be transected. The proximal stump of the common peroneal nerve is on the left side and the tibial nerve on the right side.

  • View in gallery

    Intraoperative photographs. Following a rotation flap plasty and a distal division of the gastrocnemius muscle to relieve spastic contracture of the calf muscles and to lengthen the Achilles tendon (Strayer procedure), there is a complete paresis of the common peroneal nerve. Left: On dissection, the peroneal nerve was found to be transected (arrowhead on proximal stump), with a neuroma and a nerve gap located between the proximal and distal stump. Right: Grouped interfascicular sural nerve grafts have been interposed.

  • View in gallery

    Left: Plain x-ray film revealing the left hip region after operation for a pertrochanteric femoral fracture performed using a gamma nail. Center: Because of pseudarthrosis, a free trochanteric fragment instrumentation was changed to a dynamic hip screw with wire cerclage. Postoperatively, a complete sciatic nerve palsy occurred. Right: Intraoperative view of the sciatic nerve, which is encircled by the wire. The wire indentation (small arrowhead) is visible on the sciatic nerve after the cerclage (large arrowhead) was removed.

  • View in gallery

    Intraoperative photograph obtained in a patient in whom this median nerve presented as grossly distorted and there was a large neuroma following endoscopic carpal tunnel release (palm to the right side). After dissection, the nerve is shown to be partly transected at the wrist level (arrowhead).

  • View in gallery

    Intraoperative photograph of the right superficial radial nerve of a patient with severe pain and paresthesia following a vessel puncture demonstrating a marked neuromatous swelling. After further dissection a monofascicular neuroma was found.

  • View in gallery

    Photograph of a patient with left spinal accessory nerve palsy. As is common, despite marked atrophy of the trapezius muscle, the patient is able to shrug his shoulders.

References

  • 1.

    Birch RBonney GDowell Jet al: Iatrogenic injuries of peripheral nerves. J Bone Joint Surg (Br) 73:2802821991Birch R Bonney G Dowell J et al: Iatrogenic injuries of peripheral nerves. J Bone Joint Surg (Br) 73:280–282 1991

    • Search Google Scholar
    • Export Citation
  • 2.

    Birch RBonney GWynn Parry CB: Surgical Disorders of the Peripheral Nerves. Edinburgh: Churchill Livingstone1998 pp 293333Birch R Bonney G Wynn Parry CB: Surgical Disorders of the Peripheral Nerves. Edinburgh: Churchill Livingstone 1998 pp 293–333

    • Search Google Scholar
    • Export Citation
  • 3.

    Blair JMBotte MJ: Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin Orthop 305:2292381994Blair JM Botte MJ: Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin Orthop 305:229–238 1994

    • Search Google Scholar
    • Export Citation
  • 4.

    Carrozzella JStern PJvon Kuster LC: Transection of radial digital nerve of the thumb during trigger release. J Hand Surg (Am) 14:1982001989Carrozzella J Stern PJ von Kuster LC: Transection of radial digital nerve of the thumb during trigger release. J Hand Surg (Am) 14:198–200 1989

    • Search Google Scholar
    • Export Citation
  • 5.

    Choi PDNath RMackinnon SE: Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: a case report, diagnosis, and management. Ann Plast Surg 37:60651996Choi PD Nath R Mackinnon SE: Iatrogenic injury to the ilioinguinal and iliohypogastric nerves in the groin: a case report diagnosis and management. Ann Plast Surg 37:60–65 1996

    • Search Google Scholar
    • Export Citation
  • 6.

    Dhuńer KG: Nerve injuries following operations: a survey of cases occurring during a six year period. Anesthesiology 11:2892931950Dhuńer KG: Nerve injuries following operations: a survey of cases occurring during a six year period. Anesthesiology 11:289–293 1950

    • Search Google Scholar
    • Export Citation
  • 7.

    Donner TRKline DG: Extracranial spinal accessory nerve injury. Neurosurgery 32:9079101993Donner TR Kline DG: Extracranial spinal accessory nerve injury. Neurosurgery 32:907–910 1993

    • Search Google Scholar
    • Export Citation
  • 8.

    Ducker TB: Pathophysiology of peripheral nerve trauma in Wilkins RHRengachary SS (eds): Neurosurgeryed 2. New York: McGraw-Hill1996 Vol 3 pp 31153120Ducker TB: Pathophysiology of peripheral nerve trauma in Wilkins RH Rengachary SS (eds): Neurosurgery ed 2. New York: McGraw-Hill 1996 Vol 3 pp 3115–3120

    • Search Google Scholar
    • Export Citation
  • 9.

    Gentili FHudson ARMidha R: Peripheral nerve injuries: types, causes, and grading in Wilkins RHRengachary SS (eds): Neurosurgeryed 2. New York: McGraw-Hill1996 Vol 3 pp 31053114Gentili F Hudson AR Midha R: Peripheral nerve injuries: types causes and grading in Wilkins RH Rengachary SS (eds): Neurosurgery ed 2. New York: McGraw-Hill 1996 Vol 3 pp 3105–3114

    • Search Google Scholar
    • Export Citation
  • 10.

    Hochwald NLLevine RTornetta P III: The risks of Kirschner wire placement in the distal radius. A comparison of techniques. J Hand Surg (Am) 22:5805841997Hochwald NL Levine R Tornetta P III: The risks of Kirschner wire placement in the distal radius. A comparison of techniques. J Hand Surg (Am) 22:580–584 1997

    • Search Google Scholar
    • Export Citation
  • 11.

    Huang YChu XZhu Q: [Peripheral nerve injury as a complication from orthopedic operation.] Chung Kuo Hsiu Fu Chung Chien Wai Ko Tsa Chih 11:3433461997 (Chin)Huang Y Chu X Zhu Q: [Peripheral nerve injury as a complication from orthopedic operation.] Chung Kuo Hsiu Fu Chung Chien Wai Ko Tsa Chih 11:343–346 1997 (Chin)

    • Search Google Scholar
    • Export Citation
  • 12.

    Kim DHKline DG: Surgical outcome for intra- and extrapelvic femoral nerve lesions. J Neurosurg 83:7837901995Kim DH Kline DG: Surgical outcome for intra- and extrapelvic femoral nerve lesions. J Neurosurg 83:783–790 1995

    • Search Google Scholar
    • Export Citation
  • 13.

    Kline DG: Surgical repair of peripheral nerve injury. Muscle Nerve 13:8438521990Kline DG: Surgical repair of peripheral nerve injury. Muscle Nerve 13:843–852 1990

    • Search Google Scholar
    • Export Citation
  • 14.

    Kline DGHacket ER: Reappraisal of timing for exploration of civilian peripheral nerve injuries. Surgery 78:54651975Kline DG Hacket ER: Reappraisal of timing for exploration of civilian peripheral nerve injuries. Surgery 78:54–65 1975

    • Search Google Scholar
    • Export Citation
  • 15.

    Kline DGHudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries Entrapments and Tumors. Philadelphia: WB Saunders1995Kline DG Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries Entrapments and Tumors. Philadelphia: WB Saunders 1995

    • Search Google Scholar
    • Export Citation
  • 16.

    Matz PGBarbaro NM: Diagnosis and treatment of iatrogenic spinal accessory nerve injury. Am Surg 62:6826851996Matz PG Barbaro NM: Diagnosis and treatment of iatrogenic spinal accessory nerve injury. Am Surg 62:682–685 1996

    • Search Google Scholar
    • Export Citation
  • 17.

    McAllister RMRGilbert SEACalder JSet al: The epidemiology and management of upper limb peripheral nerve injuries in modern practice. J Hand Surg (Br) 21:4131996McAllister RMR Gilbert SEA Calder JS et al: The epidemiology and management of upper limb peripheral nerve injuries in modern practice. J Hand Surg (Br) 21:4–13 1996

    • Search Google Scholar
    • Export Citation
  • 18.

    McGillicuddy JE: Techniques of nerve repair in Wilkins RHRengachary SS (eds): Neurosurgeryed 2. New York: McGraw-Hill1996 Vol 3 pp 31793192McGillicuddy JE: Techniques of nerve repair in Wilkins RH Rengachary SS (eds): Neurosurgery ed 2. New York: McGraw-Hill 1996 Vol 3 pp 3179–3192

    • Search Google Scholar
    • Export Citation
  • 19.

    Midha RGuha AGentili Fet al: Peripheral nerve injection injury in Omer GE JrSpinner MVan Beek AL (eds): Management of Peripheral Nerve Problemsed 2. Philadelphia: WB Saunders1998 pp 406413Midha R Guha A Gentili F et al: Peripheral nerve injection injury in Omer GE Jr Spinner M Van Beek AL (eds): Management of Peripheral Nerve Problems ed 2. Philadelphia: WB Saunders 1998 pp 406–413

    • Search Google Scholar
    • Export Citation
  • 20.

    Müller-Vahl H: Iatrogene Läsionen peripherer Nerven in der Chirurgie. Langenbecks Arch Chir 364:3213231984Müller-Vahl H: Iatrogene Läsionen peripherer Nerven in der Chirurgie. Langenbecks Arch Chir 364:321–323 1984

    • Search Google Scholar
    • Export Citation
  • 21.

    Murphy RX JrJennings JFWukich DK: Major neurovascular complications of endoscopic carpal tunnel release. J Hand Surg (Am) 19:1141181994Murphy RX Jr Jennings JF Wukich DK: Major neurovascular complications of endoscopic carpal tunnel release. J Hand Surg (Am) 19:114–118 1994

    • Search Google Scholar
    • Export Citation
  • 22.

    Nahabedian MYDellon AL: Outcome of the operative management of nerve injuries in the ilioinguinal region. J Am Coll Surg 184:2652681997Nahabedian MY Dellon AL: Outcome of the operative management of nerve injuries in the ilioinguinal region. J Am Coll Surg 184:265–268 1997

    • Search Google Scholar
    • Export Citation
  • 23.

    Oleksak MEdge AJ: Compression of the sciatic nerve by methylmethacrylate cement after total hip replacement. J Bone Joint Surg (Br) 74:7297301992Oleksak M Edge AJ: Compression of the sciatic nerve by methylmethacrylate cement after total hip replacement. J Bone Joint Surg (Br) 74:729–730 1992

    • Search Google Scholar
    • Export Citation
  • 24.

    Oppikofer CTschopp H: Die Problematik der übersehenen und iatrogenen Nervenläsionen in der Chirurgie. Helv Chir Acta 57:9239291991Oppikofer C Tschopp H: Die Problematik der übersehenen und iatrogenen Nervenläsionen in der Chirurgie. Helv Chir Acta 57:923–929 1991

    • Search Google Scholar
    • Export Citation
  • 25.

    Parks BJ: Postoperative peripheral neuropathies. Surgery 74:3483571973Parks BJ: Postoperative peripheral neuropathies. Surgery 74:348–357 1973

    • Search Google Scholar
    • Export Citation
  • 26.

    Piza-Katzer HEBalogh BHerczeg Eet al: Introgene Nervenläsionen und ihre mikrochirurgische Behandlung. Chirurg 66:114611531995Piza-Katzer HE Balogh B Herczeg E et al: Introgene Nervenläsionen und ihre mikrochirurgische Behandlung. Chirurg 66:1146–1153 1995

    • Search Google Scholar
    • Export Citation
  • 27.

    Piza-Katzer HEHerczeg EBalogh Bet al: Intra- und postoperative Nervenläsionen und ihre Behandlung. Nervenarzt 65:3753801994Piza-Katzer HE Herczeg E Balogh B et al: Intra- und postoperative Nervenläsionen und ihre Behandlung. Nervenarzt 65:375–380 1994

    • Search Google Scholar
    • Export Citation
  • 28.

    Schmalzried TPAmstutz HCDorey FJ: Nerve palsy associated with total hip replacement. Risk factors and prognosis. J Bone Joint Surg (Am) 73:107410801991Schmalzried TP Amstutz HC Dorey FJ: Nerve palsy associated with total hip replacement. Risk factors and prognosis. J Bone Joint Surg (Am) 73:1074–1080 1991

    • Search Google Scholar
    • Export Citation
  • 29.

    Seddon HJ (ed): Peripheral Nerve Injuries. Medical Research Council Special Report Series No. 282. London: HM Stationery Office1954Seddon HJ (ed): Peripheral Nerve Injuries. Medical Research Council Special Report Series No. 282. London: HM Stationery Office 1954

    • Search Google Scholar
    • Export Citation
  • 30.

    Stöhr M: Iatrogene Nervenläsionen. Injektion Operation Lagerung Strahlentherapieed 2. Stuttgart: Thieme1996Stöhr M: Iatrogene Nervenläsionen. Injektion Operation Lagerung Strahlentherapie ed 2 . Stuttgart: Thieme 1996

    • Search Google Scholar
    • Export Citation
  • 31.

    Tackmann WRichter H—PStöhr M: Kompressionssyndrome peripherer Nerven. Berlin: Springer-Verlag1989 pp 234–237 328Tackmann W Richter H—P Stöhr M: Kompressionssyndrome peripherer Nerven. Berlin: Springer-Verlag 1989 pp 234–237 328

    • Search Google Scholar
    • Export Citation
  • 32.

    Vastamäki MSolonen KA: Accessory nerve injury. Acta Orthop Scand 55:2962991984Vastamäki M Solonen KA: Accessory nerve injury. Acta Orthop Scand 55:296–299 1984

    • Search Google Scholar
    • Export Citation
  • 33.

    Villarejo FJPascal AM: Injection injury of the sciatic nerve (370 cases). Childs Nerv Syst 9:2292321993Villarejo FJ Pascal AM: Injection injury of the sciatic nerve (370 cases). Childs Nerv Syst 9:229–232 1993

    • Search Google Scholar
    • Export Citation
  • 34.

    Warner MAWarner MEMartin JT: Ulnar neuropathy. Incidence, outcome, and risk factors in sedated anesthetized patients. Anesthesiology 81:133213401994Warner MA Warner ME Martin JT: Ulnar neuropathy. Incidence outcome and risk factors in sedated anesthetized patients. Anesthesiology 81:1332–1340 1994

    • Search Google Scholar
    • Export Citation
  • 35.

    Wilbourn AJ: Iatrogenic nerve injuries. Neurol Clin 16:55821988Wilbourn AJ: Iatrogenic nerve injuries. Neurol Clin 16:55–82 1988

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 191 191 27
Full Text Views 214 214 3
PDF Downloads 106 106 1
EPUB Downloads 0 0 0

PubMed

Google Scholar