Search

Meralgia paraesthetica is an entrapment neuropathy of the lateral femoral cutaneous nerve, usually due to compression at the inguinal ligament as the nerve passes from the pelvis into the thigh. Surgical decompression of the lateral femoral cutaneous nerve is a simple and effective treatment option, but the surgical anatomy of the area is not always familiar to neurosurgeons and neurosurgical trainees alike. This paper is a simple review of the relevant surgical anatomy and the surgical steps of lateral femoral cutaneous nerve decompression, with the aim of providing the busy surgeon and trainee a quick and easy reference guide to the procedure.

Objective Suprainguinal re-resection of the proximal nerve stump can be performed in case of persistent or recurrent symptoms of meralgia paresthetica after previous transection of the lateral femoral cutaneous nerve (LFCN). Currently, no long-term results for this procedure have been reported in the literature. Methods In this study, 20 consecutive patients with persistent (13 cases) or recurrent (7 cases) symptoms of meralgia paresthetica were reoperated at a mean interval of 16 months after the first transection of the LFCN. The proximal nerve stump was sent for histopathologic analysis of a potential traumatic neuroma. Outcome was assessed using a 5-point Likert scale, which was obtained at a mean interval of 3.5 years after the suprainguinal re-resection. Results The proximal stump of the LFCN was identified in 90% of the cases. Successful pain relief (Likert 1 or 2) was obtained in 65% of the patients. A neuroma was found in 11 cases (55%), mostly in recurrent cases after a pain-free interval. The indication for recurrence of symptoms more frequently resulted in successful pain relief (71%) compared with results for the indication for persistence of symptoms (62%). There was no correlation between the presence of a neuroma and the chance for pain relief. Conclusions Suprainguinal re-resection of the LFCN can be a successful procedure, both for persistence and recurrence of symptoms of meralgia paresthetica after previous transection, with long-lasting pain relief. Several factors, however, should be considered before performing this relatively new technique in patients that are discussed in this article.

Obesity and a prolonged surgical duration are reported risk factors for meralgia paresthetica (MP) after prone position surgery; however, this fails to explain why MP seldom occurs after prone position craniotomy. We reviewed the incidence of MP after spinal surgery and craniotomy in the prone position and investigated whether unidentified factors are involved in the mechanism of postoperative MP. Between January 2014 and March 2020, we performed 556 prone position surgeries. We excluded patients aged ≤16 years and those who were comatose or who required redo-surgery, and reviewed 446 eligible patients (124 who underwent craniotomies and 322 who underwent posterior spinal surgeries). Postoperative MP occurred in 46 (10.3%) patients with a higher incidence after spinal surgery than after craniotomy (13.7% vs. 1.6%, p 0.001). Among the 322 patients who received posterior spinal surgery, thoracic and lumbar laminectomies were associated with a higher incidence of MP than cervical laminectomy. Analyses limited to those patients who received thoracic and lumbar laminectomies revealed that the preoperative thoracic kyphosis (TK) angle was significantly greater in patients with MP than in those without MP (average TK angle, 38.9° vs. 23.1°; p 0.001), and that the preoperative lumbar lordosis angle did not significantly differ between the two groups. Apart from the known predisposing factors, we found that thoracolumbar-sacral laminectomy in patients with a greater TK angle is also a risk factor for MP after prone position surgery.

Background Femoral neuropathy is a rare complication of vaginal delivery that is often under-reported. It is marked by weakness and sensory loss in the lower limbs. This report presents 3 cases to outline possible prevention strategies, as well as to describe the process of diagnosis, management, and recovery for this injury. Cases Diagnosis is made clinically, and prognosis is determined by clinical follow-up along with nerve conduction studies and electromyography. Management involves interdisciplinary efforts with physiotherapy. Prevention includes frequent repositioning and avoidance of hip hyperflexion during labour. The expected recovery period ranges from 2 to 24 months. Conclusion Femoral neuropathy after vaginal delivery is under-reported. Though prognosis is often excellent, special attention to positioning during labour, prompt clinical diagnosis, and interdisciplinary management are essential for this rare injury.

Objective Sometimes during surgery for meralgia paresthetica, it can be difficult to find the lateral femoral cutaneous nerve (LFCN). The aims of this study were to study the prevalence of different anatomical variations in patients, compare preoperative ultrasound (US) data with intraoperative findings, and investigate the effect of type of anatomical variation on duration of surgery and success rate of localizing the LFCN. Methods Fifty-four consecutive patients with idiopathic meralgia paresthetica who underwent either a neurolysis or neurectomy procedure were included. All patients preoperatively underwent US of the LFCN. Anatomical variations were categorized into type A, B, C, D, and E using the classification of Aszmann and Dellon. The cross-sectional area of the LFCN at the inguinal ligament and the distance of the LFCN to the anterior superior iliac spine were noted. Correlations with intraoperative findings were investigated, as well as the effect on duration of surgery and success rate of finding the LFCN. Clinical outcome was assessed using the Likert scale. Results The most frequent anatomical variant was type B (79%), followed by type C (9%), D (5%), and E (7%). No type A was encountered. Correlation between preoperative US and intraoperative findings was 100%. During surgery, the LFCN could be identified in all cases. Duration of surgery did not significantly vary for the different anatomical variants. Conclusions Preoperative US is reliable in detecting anatomical variations of LFCN. This information can be very helpful in identifying the LFCN more frequently and easily during surgery, especially in more medial variants.

A common entrapment site of the lateral femoral cutaneous nerve (LFCN) is in the vicinity of the inguinal ligament. However the more distal segment of this nerve can also be affected. Electrophysiological evaluation of this nerve is difficult. Additionally, available methods have failed in the lesion localization of LFCN. In this study, we aimed to evaluate nerve conduction study in different segments of the LFCN. Nerve action potentials of the LFCN were recorded with distal surface electrodes from a relatively distant point (about 30 cm caudal to the spina iliaca anterior superior). An electrical stimulus was given both 10 cm distal to the SIAS and at the level of the SIAS. Inguinal segmental and distal sensory nerve conduction studies were performed on the LFCN. Thirty-eight healthy controls and 34 patients with meralgia paresthetica (MP) were analyzed by this method. All patients with MP showed electrophysiological abnormalities. Slowed sensory conduction on the inguinal channel (p:0.0001) and loss of response were the most frequent abnormalities (44.7% and 31.6%). In one patient, the only abnormality was slowed sensory conduction at the distal site. Our findings suggest that this technique can help in diagnosis and lesion localization in MP.

Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve (LFCN) caused by compression around the inguinal ligament. We report a surgical alternative for the treatment of meralgia paresthetica under local anesthesia and its outcomes.We operated on 12 patients with unilateral meralgia paresthetica whose age at surgery ranged from 62 to 75 years. The mean postoperative follow-up period was 19 months. Microsurgical deep decompression of LFCN was performed with the patient under local anesthesia. Clinical outcomes of surgical treatment were assessed based on the patient's most recent follow-up visit and were classified into 3 categories: complete, partial, or no relief of symptoms. Symptoms of pain or numbness in the anterolateral part of the thigh were evaluated, using a visual analog scale, before surgery and after surgery, i.e., at the most recent follow-up visit.All patients reported symptom improvement: complete relief in 9 patients (75%) and partial relief in 3 patients (25%). In the 3 patients with partial relief, the remaining symptoms did not affect their daily living. Overall, the visual analog scale scores were significantly improved in all patients (P0.05), and no patient experienced postoperative recurrence of their symptoms at the time of the last follow-up visit.Symptoms of meralgia paresthetica can resemble those of a lumbosacral disorder. Microsurgical deep decompression under local anesthesia produces good surgical outcomes. The use of local anesthesia contributes not only to reduction of pain during surgery but also eliminates excessive surgical procedures and reduces the duration of hospital stay.

Background Meralgia paresthetica, a pain syndrome that is caused by injury to the lateral femoral cutaneous nerve, is a well-documented complication after anterior hip arthroplasty (THA). Traditional treatment of this peripheral nerve entrapment syndrome can be complicated in patients who have had THA via an anterior approach owing to the presence of scar in the postoperative bed. Case Description In a 70-year-old man, we performed a novel laparoscopic-assisted intra-abdominal approach to treat meralgia paresthetica in the setting of previous anterior THA. Conclusions Minimally invasive intra-abdominal treatment of meralgia paresthetica following anterior THA results in durable pain relief. This approach is a helpful alternative to traditional techniques of decompression or section of the lateral femoral cutaneous nerve below the inguinal ligament.

Clinically, ischemic environment during gynecological surgery at lithotomy position is most common causative factor for the development of vasculitic femoral neuropathy (VFN). The present study was designed to induce the clinically relevant rat model of VFN by ischemic-reperfusion (I/R) injury of unilateral external iliac artery (uEIA). The VFN was induced by 3, 4 and 5h occlusion of uEIA followed by reperfusion. The I/R of uEIA induced VFN was evaluated by (i) behavioral parameters i.e., hind limb temperature; weight bearing capacity; (ii) kinematic analysis i.e., paw posture, splay angle, static sciatic index (SSI), and ankle-angle tests; (iii) evaluation of pain perception i.e., plantar and pin prick; (iv) serum biochemical estimation i.e., nitrate, lipid peroxidation, TNF-α and calcium level; (v) evaluation of motor and sensory nerve conduction velocity; and (vi) measurement of nerve fiber density. The 4 and 5h occlusion of uEIA has produced the potential changes in behavioral, functional, electrophysiological, biochemical and histopathological assessment. The 5h occlusion of uEIA has shown to produce the mortality. Whereas, 3h occlusion does not produce the significant changes in the development of VFN. The 4h ischemic occlusion of uEIA has shown potential rat model of VFN due to its close mimicking capacity of VFN in human. Therefore, it can be useful to explore the newer anti-neuralgic medicine and with their pharmacodynamic action in the field of various neurovascular disorders.

Peripheral neuropathy is a rare but important complication of total hip arthroplasty (THA) and has previously been reported in the ipsilateral arm and associated with inflammatory arthritis. The results of 7004 primary hip arthroplasties performed between January 1993 and February 2009 were retrospectively reviewed to identify patients who reported ulnar neuropathy symptoms, with ten patients identified at mean follow-up of 57 months (range = 3-195 months). Eight patients experienced unilateral ulnar nerve symptoms in the contralateral upper limb post-surgery, one patient experienced symptoms in the ipsilateral upper limb and one patient experienced symptoms in both upper limbs. The incidence of post-THA ulnar neuropathy was 0.14%. All patients had a pre-operative diagnosis of osteoarthritis and none had diabetes, a previous history of neuropathy or inflammatory arthritis. All operations were primary arthroplasties and were performed under the care of a single surgeon in a single centre. Two of the ten patients (20%) had a general anaesthetic. The pattern of symptoms reported, i.e. mainly unilateral affecting the contralateral side with variable resolution, contrasts with previous studies and suggests that intraoperative patient positioning may be an important factor influencing ulnar neuropathy following THA. Attention to support and positioning of the contralateral arm may help reduce the incidence of this complication.

Various surgical procedures can be applied in the treatment of meralgia paresthetica. The two main ones are neurolysis and neurectomy of the lateral femoral cutaneous nerve. To date, no prospective or randomized controlled trial has compared the effectiveness of these procedures with standardized outcome measures. In this study we present our results for two prospectively followed cohorts and we present the protocol for a double blind randomized controlled trial (RCT).All patients that had an indication for surgical treatment of idiopathic meralgia paresthetica between August 2012 and April 2014 were included in the study. The patient decided on the type of treatment (neurolysis or neurectomy) after informed consent had been given. Primary outcome was measured using the Likert scale obtained 6 weeks after the surgery. Successful pain reduction was defined as Likert 1 or 2. Secondary outcome measures were the Numeric Rating Scale (NRS) and Bothersomeness Index (BSI). In case of neurectomy the BSI for numbness was also obtained.A total of 22 consecutive patients were included: neurolysis was performed in 8 patients and neurectomy in 14 patients (one bilateral case). Successful pain reduction was observed more frequently after neurectomy (93.3%) than after neurolysis (37.5%, P0.05). Secondary outcome scores (NRS and BSI pain) were also better after neurectomy, although not significantly (respectively P=0.07 and 0.05). Paired analysis of the scores before and after the surgery showed an improvement in both the NRS and BSI after the neurectomy procedure (both P0.001), while scores were not significantly different before and after the neurolysis procedure. Patient's scores for the BSI numbness after the neurectomy procedure were low (mean 1.4, SD±1.0, range 0-3).The results of our prospective study confirm results previous studies reported in the literature in that the percentage pain relief was better after neurectomy than after neurolysis. A RCT is needed to further investigate potential differences in effectiveness. The protocol for such a trial is presented in this article.

Although exceptional, endometriotic lesions of the troncular nerves of the lower limb may occur and are often diagnosed with delay. We report, hereby, the first case of femoral nerve endometriosis the treatment of which consisted of radical resection with femoral nerve transplant. We completed a review of the literature on sciatic nerve endometriotic lesions and discussed the physiopathology and surgical treatment.

Myositis ossificans circumscripta is a benign, self-limiting, ossifying soft-tissue mass that typically occurs in skeletal muscle of the extremities after trauma. Occurrence in the psoas muscle is rare with no reports of this condition presenting as femoral neuropathy. A 54-year-old woman visited our hospital because of progressive left leg pain and weakness, which she had experienced for 2 years. Physical examination indicated left femoral neuropathy, and a 6 cm × 5 cm mass was palpable in the left groin. Plain radiographs showed an irregular calcification over the left hip. Computed tomography of the pelvis showed a fusiform mass within the left psoas muscle. A modified ilioinguinal approach was used to excise the mass, and histologic examination confirmed the diagnosis. After surgery, the patient's symptoms resolved and there was no recurrence at 4 years' follow-up. Excision may be considered when a patient has a large, painful mass with neuropathy and significant functional impairment after conservative treatment.

Iatrogenic femoral nerve injury is an uncommon but recognised complication of abdominal and gynaecological surgery. There have been several reported cases following colorectal surgery which specifically report transient femoral nerve neuropathies with variable but often full recovery. To our knowledge, this is the first documented case of femoral nerve reconstruction after iatrogenic resection during right hemicolectomy. We present a case report of complete femoral nerve transection following abdominal surgery and discuss our management.

© 2011 Mayo Foundation for Medical Education and Research A 73-year-old woman presented to the Saint Marys Hospital emergency department for anterior thigh pain. This pain began 2 weeks before presentation when she noticed difficulty lifting her right leg into her car. She noticed progressive worsening of these symptoms such that she could not put on her socks and shoes. On the day of presentation, while attempting to raise her right leg into bed, she developed severe burning pain in the anterior aspect of her thigh. The severity of the pain, 10 on a 10-point scale, prompted her to seek evaluation in the emergency department. She denied trauma, change in activity level, back pain, bladder or bowel dysfunction, and saddle anesthesia. Her medical history was notable for coronary artery disease with placement of a drug-eluting stent in the distal circumflex coronary artery 6 months previously via the right radial artery, paroxysmal atrial fibrillation, diabetes mellitus with a recent glycated hemoglobin concentration of 6.0%, and chronic lower extremity lymphedema. Her medications included aspirin, clopidogrel, diltiazem, lisinopril, simvastatin, metoprolol, warfarin, and glyburide. She had no recent changes in medications, was receiving a stable warfarin dose, and her international normalized ratio (INR) was within normal limits. She denied tobacco, ethanol, and intravenous drug use. In the emergency department, radiography of the femur and lumbar spine were performed, showing no evidence of fracture. On admission, her vital signs were as follows: temperature, normal; pulse, 72 beats/min; and blood pressure, 126/68 mm Hg. Findings on cardiac and pulmonary examinations were within normal limits. Her abdomen was soft, obese, and nontender; no masses were palpable. Both lower extremities were warm and well perfused; dorsalis pedis and posterior tibial pulses were palpable. Musculoskeletal examination revealed intact internal and external rotation of her right hip. She was unable to do a straight leg raise or flexion/extension of both the hip and knee because of the severe pain. The spine and sacroiliac joints were not tender to palpation, but she did have tenderness to palpation over the greater trochanter of the right leg. She was able to perform transfers, but her ability to do so was limited by severe pain. During sensory testing, the patient noted a subjective difference in fine touch of the right vs the left anterior thigh.

Objective Femoral neuropathy is a rare but disabling complication following renal transplantation and pelvic surgery in general. In a retrospective review, we analyzed the incidence, clinical presentation, and outcome of this complication after renal transplantation in our center. In addition, we conducted a literature search on this complication. Materials and Methods Five cases of isolated femoral neuropathy after renal transplantation were encountered at our center, out of 3,448 renal transplantations performed over a 47-year period. Results All of these patients presented with a weakness of hip flexion (iliopsoas muscle) and knee extension (quadriceps muscle) starting immediately after surgery. Atrophy of the quadriceps became apparent in severe and prolonged cases. In addition, numbness and paresthesia located in the anteromedial part of the thigh were present in 3 patients. Conclusion Isolated neuropathy of the femoral nerve is a rare but disabling complication after renal transplantation. The etiology of isolated femoral neuropathy often results from direct compression of the femoral nerve or from indirect compression on the psoas muscle by application of self-retaining retractors placed during pelvic surgery. Other factors that can play a role in the pathogenesis are related to direct ischemia of the nerve by clamping of the iliac artery, thus interrupting the pelvic blood supply to the femoral nerve during the vascular anastomosis or vessel dissection, or by postoperative hematoma in the retroperitoneum or psoas muscle. Meticulous surgery and careful positioning of the self-retaining retractors during surgery are pivotal to avoid this complication which transplant surgeons should be aware of.

We investigated the relationship between the mode and duration of iliac artery anastomosis and acute femoral neuropathy (AFN).A retrospective analysis was performed for 83 AFN cases from 6 transplantation centers in China. The incidence and nature of dysfunction of AFN were classified based upon the duration of iliac arterial anastomosis. No prisoners were used, and no organs from prisoners were used to obtain the data.The incidence of AFN was 3.6% (53/1,449) in internal iliac anastomosis (group 1), 3.1% (11/346) in external iliac anastomosis (group 2) (P.05 vs. group 1), and was 54.2% (19/35) in internal iliac ligation with external iliac anastomosis (group 3 P.01 vs. groups 1 and 2). In group 1, the duration of the arterial anastomosis wasor=20 minutes in 1 case (1.9%), and20 minutes in 52 cases (98.1%). In group 2, the duration of arterial anastomosis wasor=20 minutes in 1 case (9.0%) and20 minutes in 10 cases (91%). In group 3, the duration of the arterial anastomosis was20 minutes in all cases; 20 cases showed injury to the iliolumbar or deep iliac circumflex artery.The incidence of AFN was associated with the selection of iliac arteries, the duration of the arterial anastomosis, and an injury to the iliolumbar or deep iliac circumflex artery.

A 9-year old miniature poodle and a 6-year old American Staffordshire terrier were evaluated for slowly progressive lameness and atrophy of the left pelvic limb. Neurological examinations of both animals were consistent with femoral nerve lesions. In both cases, neoplastic masses were identified within the left psoas muscle, invading the left femoral nerve or, in one case, its nerve roots. Ultrasound-guided fine needle aspirate and histopathological examination of the masses revealed that these were malignant sarcomas. Femoral mononeuropathies are very rare in dogs, and most descriptions of femoral nerve lesions are caused by traumatic injuries. Descriptions of neoplastic processes affecting the femoral nerve are limited to peripheral nerve sheath tumours (PNST). These cases provide the first descriptions of malignant neoplasms other than PNSTs that infiltrate the femoral nerve or its nerve roots and cause unilateral femoral mononeuropathy and lameness of obscure origin.

Meralgia paresthetica is an entrapment neuropathy involving the lateral femoral cutaneous nerve of the thigh. Patients complain of a persistent burning sensation, tingling and aching pain, and hypersensitivity or hyposensitivity in the anterolateral aspect of the thigh. Numerous direct and indirect causes for the disease have been suggested in the literature.We present 12 cases that were diagnosed to have meralgia paresthetica due to tight new fashion low cut trousers (‘taille basse’). The diagnosis was confirmed by injecting a small amount of a short acting local anesthetic around the lateral femoral cutaneous nerve which alleviated the symptoms for several hours. Electrophysiologic studies were sensitive in 83.3% of the cases.All cases were treated successfully using conservative methods, namely avoiding tight trousers, local steroid infiltration and weight reduction.

Autotomy behavior is frequently observed in rats and mice in which the nerves of the hindlimb are severed, denervating the paw. This is the neuroma model of neuropathic pain. A large body of evidence suggests that this behavior reflects the presence of spontaneous dysesthesia and pain. In contrast, autotomy typically does not develop in partial nerve injury pain models, leading to the belief that these animals develop hypersensibility to applied stimuli (allodynia and hyperalgesia), but not spontaneous pain. We have modified the widely used Chung (spinal nerve ligation [SNL]) model of neuropathic pain in a way that retains the fundamental neural lesion, but eliminates nociceptive sensory cover of the paw. These animals performed autotomy. Moreover, the heritable across strains predisposition to spontaneous pain behavior in this new proximal denervation model (SNN) was highly correlated with pain phenotype in the neuroma model suggesting that the pain mechanism in the two models is the same. Relative reproducibility of strain predispositions across laboratories was verified. These data indicate that the neural substrate for spontaneous pain is present in the Chung-SNL model, and perhaps in the other partial nerve injury models as well, but that spontaneous pain is not expressed as autotomy in these models because there is protective nociceptive sensory cover.

Resume L'histiocytose de Langerhans est une pathologie rare de l'enfant et de l'adulte jeune qui provoque aussi bien des lesions focales que des atteintes de plusieurs organes mimant une vascularite ou une hemopathie maligne, par proliferation et accumulation tissulaire d'histiocytes. L'atteinte osseuse ou granulome eosinophile est la plus frequente. Les circonstances de decouverte de telles lesions sont le plus souvent la douleur, une tumefaction, une fracture, fievre et parfois otorrhee, hypoacousie ou exophtalmie en cas d'atteinte des os de la face. Les radiculalgies sont rarement decrites meme en cas d'atteinte du squelette axial. Nous reportons quatre cas de radiculagies liees a une histiocytose langerhansienne : deux cruralgies tronquees associees a une atteinte cotyloidienne chez deux hommes de 25 et 34 ans, ainsi que deux lombosciatiques chez une jeune femme presentant une atteinte corporeale de L5 et chez un homme de 41 ans chez qui existe une localisation sacree.

Resume Nous rapportons six hematomes du psoas diagnostiques durant les cinq dernieres annees, afin de determiner l'incidence de cette pathologie et les circonstances de survenue. Cinq hemophiles A, quatre severes et un modere avec antecedent d'inhibiteur, âges de 13 a 33 ans, ont presente six hematomes du psoas post-traumatique (2) ou spontane (4) compliques de deux atteintes tronculaires du nerf crural et de quatre rechutes. Deux patients beneficiaient d'un traitement prophylactique au long cours par concentres de facteur VIII, interrompu a l'initiative du patient dans un cas. Le traitement a consiste en des concentres de facteur VIII recombinant, une corticotherapie courte pour les patients dont le nerf crural etait atteint, un alitement avec traction du membre inferieur pour trois patients associe a une prise en charge de reeducation. La frequence des hematomes du psoas a ete de 2,9 pour mille patients atteints d'hemophilie A severe ou moderee par an. La realisation de la prophylaxie par facteur VIII et le respect des recommandations par rapport aux activites contraignantes pour les muscles flechisseurs de hanche sont sans doute a l'origine de la faible frequence des hematomes du psoas en France. Le faible nombre de recidives et d'atteintes crurales depend de la precocite du diagnostic qui conditionne la mise en œuvre du traitement adapte par facteur VIII.

Intra-aortic balloon pump (IABP)-related neuropathy is an infrequent complication, and the development of motor deficits is even rarer in such cases. We report a 37-year-old man with anterior ST-elevation myocardial infarction who received emergent percutaneous coronary intervention and IABP counterpulsation. Weakness and numbness developed after IABP removal despite lack of evidence of ischemia in the involved extremity. Nerve conduction velocity study and electromyogram led to the diagnosis of femoral nerve neuropathy. The neurologic deficits recovered after 6 months of rehabilitation. This case illustrates the importance of bedside neurologic examination of the involved extremity for early detection of possible injury to the femoral nerve in patients after IABP treatment and insertion of larger bore catheter. [J Formos Med Assoc 2007;106(3 Suppl):S29-S32]

Compression of the lateral femoral cutaneous nerve (LFCN) in the thigh, commonly referred to as meralgia paresthetica, may be due to obesity, tight clothing and other external factors. We report two cases of meralgia paresthetica due to compression of the LFCN by portable electronic or "smart" devices.

Objectives To report on five serious intraoperative damages to nonprocedure-related organs during 10 years of experience with the Bookwalter device. Self-retaining retractors are helpful devices, particularly during major transperitoneal and retroperitoneal operations. Various retractors are available and allow the use of all combinations of blades to maintain exposure during each step of an operation. Furthermore, by using these devices, most operations can be performed by two surgeons only. Methods With the help of the operation protocols, more than 4000 applications of the Bookwalter device between January 1992 and December 2001 were retrospectively reviewed. Four cases with damage to the large bowel and one of femoral neuropathy were documented. Results In one transperitoneal and three retroperitoneal approaches, serious damage to the large bowel occurred. None was recognized before postoperative days 2 and 7. One femoral neuropathy was noted. Conclusions The Bookwalter self-retaining retractor is a helpful and safe device in exposing the intraoperative situs. However, care must be taken in patients with risk factors, such as immunosuppression and diverticulitis, and particularly in retroperitoneal operations when tightening the blades. When the intra-abdominal cavity is not exposed, damage to other organs may not be directly noted, which could explain the delay of several days to the onset of symptoms.

Lower extremity mononeuropathies are less common than those affecting the upper limb. Yet, they are often challenging and more difficult to diagnose. The electrodiagnostic (EDX) studies play a pivotal role in diagnosis. Well planned and executed studies are very useful, although limiting factors such as age, foot swelling or prior lumbar spine surgery may hinder making a definite diagnosis. In this section, the author emphasizes the EDX studies of most lower extremity mononeuropathies and discusses, briefly, their anatomical and clinical aspects.

Extreme lateral interbody fusion (XLIF) is a relatively new procedure for the treatment of degenerative disc disease avoiding the morbidity of anterior approaches. Ipsilateral L2-5 nerve root irritation and injury are well-described complications. We describe two patients with contralateral extremity symptoms, not reported so far. In the first patient the injury was caused by a displaced endplate fragment compressing the contralateral nerve root; in the second patient, the injury resulted from a far-lateral herniation after the XLIF procedure. Both patients experienced resolution of their symptoms after being reoperated. Overall, this complication was encountered in 2/32 levels treated during the study period. Overzealous endplate removal and breaking of the osteophytes in the opposite corner of the intervertebral disc, although desirable for maximal coronal deformity correction, may lead to irritation of the contralateral nerve roots. Attention is needed especially where the interbody cage is placed posteriorly or diagonally towards the neuralforamen.

Resumen La hemorragia del musculo iliaco es una infrecuente causa de neuropatia femoral, apareciendo habitualmente en sujetos con coagulopatias. Descrita por primera vez en un hemofilico, su frecuencia ha aumentado considerablemente con la extension de los tratamientos anticoagulantes. Constituye una complicacion importante, ya que puede producir tanto alteraciones hemodinamicas graves como secuelas neurologicas severas. Es importante el conocimiento de esta entidad para establecer un rapido diagnostico diferencial con las ciaticas anteriores de origen vertebral. Un diagnostico y un tratamiento precoces son esenciales para mejorar el pronostico funcional de la neuropatia femoral, amen de permitir una temprana correccion de las alteraciones hemodinamicas y hematologicas que conlleva.

This is a case report of pelvic pain caused by a large retroperitoneal femoral nerve schwannoma. A 31-year-old woman, gravida 2 para 2, was referred for surgical treatment of her chronic right lower quadrant pain. Laparoscopy revealed normal pelvic anatomy and a 7- × 5-cm mass overlying the right psoas muscle and involving the right femoral nerve. A combination of laparoscopic and laparotomy dissection allowed complete excision of the mass. Pathological analysis of the mass revealed a benign schwannoma of the femoral nerve sheath. Transient right femoral neuropathy complicated her postoperative course. Nongynecologic causes of pelvic pain are common and may include neurologically derived causes. Retroperitoneal schwannomas are uncommon and occur in about 0.5% of schwannomas. Complete surgical excision is recommended and results in an excellent cure rate.

A 60-year-old man presented with intense right knee and thigh pain as well as weakness in his right lower extremity. Two months prior, he had sudden onset of severe low back pain and presented to his local physician, where he was diagnosed with lumbar spondylolisthesis. The back pain remitted soon thereafter, but he subsequently developed right knee and thigh pain. Upon presentation to our hospital, he denied having lower back pain or abdominal pain and had intact pulses in his lower extremities. His abdomen was soft and without tenderness, but a pulsating mass was palpated in the periumbilical region. Computerized tomography scan revealed an abdominal aortic aneurysm (AAA) with a large pseudoaneurysm (11-cm maximum diameter) posterior to the AAA (A, Cover). Magnetic resonance imaging showed destruction of the L3 and L4 vertebral bodies by the pseudoaneurysm (B). During open surgical repair, a large defect (6 cm 4 cm) of the posterior wall of the AAA was seen, and the eroded vertebral bodies were visualized through this defect (C). Orthopedic surgeons were consulted and deemed that vertebral repair was not required. Aneurysm repair was elected, using a knitted Dacron bifurcated graft, 16 mm 8 mm in size. The patient’s right knee and thigh pain remitted postoperatively, and the patient had an uneventful postoperative course. Contained retroperitoneal rupture is a rare presentation of ruptured AAA and can present with a variety of symptoms, including femoral neuropathy. The femoral nerve arises within the psoas major and emerges from its lateral border to run between the psoas major and the iliacus behind the iliac fascia. Thus, the location of the femoral nerves makes it vulnerable to compromise in the context of retroperitoneallycontained abdominal aortic rupture and may therefore result in symptoms of femoral neuropathy. Vertebral erosion is also reported as a complication of contained retroperitoneal rupture, usually accompanied by lower back pain. In this case, lower back pain was not prominent. Clinicians should consider this rare etiology in patients with isolated lower limb neuropathy of unexplained origin.

The authors present a 15-year-boy with meralgia paresthetica caused by the recurrence of a diffuse congenital hemangiomatosis in the pelvic region. Relief of the patient's symptoms was achieved by neurolysis of the lateral femoral cutaneous nerve in the thigh and partial excision of the tumor. To our knowledge, hemangiomatosis has never been suggested as a cause of meralgia paresthetica.

Seventy-eight patients who had undergone a total of 82 free vascularised iliac crest tissue transfers were reviewed to determine the incidence of donor site complications. The most frequent problems encountered were early postoperative pain and long term sensory changes. Major complications such as femoral neuropathy and incisional hernia formation were encountered infrequently. More serious potential complications are discussed. In general, the functional loss associated with the free vascularised iliac crest tissue transfer was found to be acceptable, but the inclusion of a skin paddle was noted to be associated with a greater incidence of sensory changes, hernia formation and contour abnormalities.

Femoral neuropathy is an uncommon yet debilitating complication of total hip arthroplasty (THA). Over a 1-year period, in 440 consecutive THAs performed at Pennsylvania Hospital, 10 (2.3%) femoral neuropathies occurred. Among primary arthroplasties, all neuropathies were associated with the Hardinge anterolateral approach. A retrospective case review as well as a detailed anatomic cadaveric study highlighted the characteristics of the femoral nerve that make it susceptible to injury. In addition, a review of the existing literature on this subject was performed. Placement and management of acetabular retractors were the factors most commonly associated with injury of the femoral nerve. All affected patients had significant initial disability. However, full femoral nerve. All affected patients had significant initial disability. However, full functional recovery occurred within 1 postoperative year. Clear understanding and awareness of the anatomy of the femoral triangle as well as accurate placement of anterior acetabular retractors can minimize the incidence of this complication.

Sealed rupture of abdominal aortic aneurysms, even if uncommon, deserves particular attention for the possibility of misdiagnosis and for the deleterious effects of such a misdiagnosis. Sixteen patients (mean age 72 years; range 65 to 84 years) with chronic sealed rupture of abdominal aortic aneurysms are reported. Two patients had acute rupture of the aneurysm, and at operation chronic contained rupture was found along with the recent hemorrhage. One patient died after surgery. The remaining patients underwent successful resection with long-term survival and regression of symptoms. Consideration of sealed abdominal aortic aneurysm rupture should be included when examining elderly patients with history of unexplained back pain or femoral neuropathy. Computed tomography is a useful aid in the diagnosis of sealed rupture. Ultrasonography is less accurate; in three patients ultrasonography failed to diagnose the presence of the rupture. (J VASC SURG 1990;11:430-5.)

Se presentan cuatro casos de neuropatía femoral secundarios a cirugía urológica, el primero tras lumbotomía derecha hace más de 20 años y los otros tres en los últimos cuatro años, con incisión iliaca. Se comentan los mecanismos de producción de la lesión, evolución, tratamiento y prevención de esta infrecuente complicación neurológica y se revisa la literatura sobre dicha patología en la actividad urológica.

Dengue fever is a debilitating mosquito-borne disease caused by dengue virus. We reported a case of femoral compression neuropathy due to iliopsoas hematoma complicating dengue hemorrhagic fever. Iliopsoas muscle hematoma can cause femoral neuropathy with resultant pain and paralysis. Such manifestations are not well documented in the literature. The pathogenesis of hematoma and compressive neuropathy with its appropriate management is discussed.

Traumatic native hip dislocations are usually high energy injuries. The patient is commonly young, male, and has been involved in a road traffic accident. Posterior dislocations are the most common, making up in excess of 85% of all traumatic dislocations and are often associated with a posterior wall fracture. Sciatic nerve injury is a well described complication and is present in approximately 10% of adult patients. We present an extremely unusual case of femoral nerve palsy following traumatic posterior dislocation of the native hip which to our knowledge has never previously been reported.

We describe a rare anatomical variation of the lateral femoral cutaneous nerve (LFCN) in a 29-year old female patient discovered during a surgical decompression of the LFCN for meralgia paresthetica. Anatomical variations of the LFCN must always be considered at the time of surgery to maximize success rate and avoid nerve damage during surgical dissection.

Background Ilio-inguinal nerve block is commonly used in children to provide analgesia after surgery in the groin. Several case reports and clinical studies have described leg weakness after this technique and suggest that it may caused by inadvertent femoral nerve block. No prospective studies describing the incidence of this complication have been published. Methods We carried out a prospective, observational study to find out how many children had leg weakness after ilio-inguinal nerve block. We studied 200 children having day-case surgery in the groin under a general anaesthetic with an ilio-inguinal nerve block. All children performed a simple leg-raising test with each leg before induction of general anaesthesia with a standardized ilio-inguinal nerve block on the side of surgery. When the child was awake and comfortable after surgery, they repeated the leg-raising test. Results Sixteen of 182 children (8.8%) had leg weakness after surgery on the side of the nerve block only, as detected by a leg-raising test. Conclusions Leg weakness consistent with a femoral nerve block occurs after ilio-inguinal nerve block in approximately one in nine children.

Iliacus hematoma associated with femoral nerve palsy is a very rare but considerable complication of hip arthroplasty. A 76-year-old woman had femoral nerve palsy 6 months after revision hip arthroplasty using a reinforcement plate. Computed tomography and selective angiography revealed the pseudoaneurysm on an extension of one of the screws fixing the hardware. Transcatheter arterial embolization proximal to the aneurysm was performed to resolve the aneurysm and to prevent further bleeding. Surgical removal of the hematoma was successfully achieved, as was full functional recovery. This case report describes our diagnosis and treatment of this rare condition and also the therapeutic usefulness of the radiologic intervention to control further bleeding before and after surgical removal of the hematoma.