Peroneural neuropathy after total hip arthroplasty with combined neural block: a case report
A 46-year-old woman, 157 cm 58 kg, underwent left total hip arthroplasty after lumbar plexus block and sciatic nerve block via the parasacral approach. Postoperative X-ray revealed 20-mm leg extension. After surgery, both legs had movement disorder and sensory disturbance, which improved within a fe...
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| Published in | Journal of Japan Society of Pain Clinicians Vol. 28; no. 9; pp. 194 - 198 |
|---|---|
| Main Authors | , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
Japan Society of Pain Clinicians
25.09.2021
一般社団法人 日本ペインクリニック学会 |
| Subjects | |
| Online Access | Get full text |
| ISSN | 1340-4903 1884-1791 |
| DOI | 10.11321/jjspc.21-0029 |
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| Abstract | A 46-year-old woman, 157 cm 58 kg, underwent left total hip arthroplasty after lumbar plexus block and sciatic nerve block via the parasacral approach. Postoperative X-ray revealed 20-mm leg extension. After surgery, both legs had movement disorder and sensory disturbance, which improved within a few hours. Lumbar plexus block was considered to be an epidural block. Thereafter, sensory and motor disorders slightly improved, but recovery of dorsiflexion movement of the left ankle joint was delayed and mild peroneal neuropathy at the level of the peroneal head was diagnosed by electromyography 28 days after surgery. Thirty-two days after surgery, the patient was discharged with stable walking using a cane. The neurological symptoms were suspected to be caused by physical factors, such as hyperextension of the peroneal nerve, because the neuropathy was at the level of the peroneum. We also cannot exclude the possibility that this nerve block affected paralysis. |
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| AbstractList | A 46-year-old woman, 157 cm 58 kg, underwent left total hip arthroplasty after lumbar plexus block and sciatic nerve block via the parasacral approach. Postoperative X-ray revealed 20-mm leg extension. After surgery, both legs had movement disorder and sensory disturbance, which improved within a few hours. Lumbar plexus block was considered to be an epidural block. Thereafter, sensory and motor disorders slightly improved, but recovery of dorsiflexion movement of the left ankle joint was delayed and mild peroneal neuropathy at the level of the peroneal head was diagnosed by electromyography 28 days after surgery. Thirty-two days after surgery, the patient was discharged with stable walking using a cane. The neurological symptoms were suspected to be caused by physical factors, such as hyperextension of the peroneal nerve, because the neuropathy was at the level of the peroneum. We also cannot exclude the possibility that this nerve block affected paralysis. A 46-year-old woman, 157 cm 58 kg, underwent left total hip arthroplasty after lumbar plexus block and sciatic nerve block via the parasacral approach. Postoperative X-ray revealed 20-mm leg extension. After surgery, both legs had movement disorder and sensory disturbance, which improved within a few hours. Lumbar plexus block was considered to be an epidural block. Thereafter, sensory and motor disorders slightly improved, but recovery of dorsiflexion movement of the left ankle joint was delayed and mild peroneal neuropathy at the level of the peroneal head was diagnosed by electromyography 28 days after surgery. Thirty-two days after surgery, the patient was discharged with stable walking using a cane. The neurological symptoms were suspected to be caused by physical factors, such as hyperextension of the peroneal nerve, because the neuropathy was at the level of the peroneum. We also cannot exclude the possibility that this nerve block affected paralysis. 【症例】46歳女性，身長157 cm，体重58 kg．20歳ごろより両股関節痛を生じ，変形性関節症と診断され保存的に加療していた．当院整形外科紹介受診し，左人工股関節置換術施行予定となった．腰神経叢ブロックと傍仙骨部の坐骨神経ブロックを施行後，全身麻酔導入し，手術を行った．術後のレントゲンで脚延長は20 mmであった．覚醒後，両下肢に運動障害と感覚障害があった．症状は数時間以内に改善し，腰神経叢ブロックが硬膜外ブロックになったと考えられ，画像検査で血種による神経圧迫などを除外した上で経過観察となった．その後，感覚障害と運動障害は改善傾向であったが左足関節の背屈運動のみ回復が遅れ，術28日後の筋電図検査にて腓骨頭レベルでの軽度腓骨神経障害と診断された．術32日後，杖歩行安定し退院した．【まとめ】本症例の神経症状は，腓骨頭レベルでの神経障害であることから，腓骨神経の過伸展等の物理的因子に起因することが推察されるが，腰神経叢ブロックが硬膜外ブロックになったことにより麻痺症状が初期段階ではマスクされた．また今回の神経ブロックが麻痺に影響した可能性も否定できない． |
| Author | KINUKAWA, Tomoaki Alex SEKI, Taisuke TAMURA, Takahiro TAKEGAMI, Yasuhiko NISHIWAKI, Kimitoshi |
| Author_FL | 絹川 友章 関 泰輔 竹上 靖彦 西脇 公俊 田村 高廣 |
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| References | 4) Gadsden JC, Lindenmuth DM, Hadzic A, et al. Lumbar plexus block using high-pressure injection leads to contralateral and epidural spread. Anesthesiology 2008; 109: 683–8. 9) Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain 1951; 74: 491–516. 11) 河野俊介, 北島 将, 園畑素樹, 他. 人工股関節全置換術後腓骨（坐骨）神経麻痺合併症例の検討. 整形外科と災害外科 2014; 63: 722–3. 5) Gadsden JC, Choi JJ, Lin E, et al. Opening injection pressure consistently detects needle-nerve contact during ultrasound-guided interscalene brachial plexus block. Anesthesiology 2014; 120: 1246–53. 13) Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973; 2: 359–62. 3) Stevens RD, Van Gessel E, Flory N, et al. Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Anesthesiology 2000; 93: 115–21. 7) Moldaver J. Tinel's sign. Its characteristics and significance. J Bone Joint Surg Am 1978; 60: 412–4. 2) 石倉亮介, 佐倉伸一. 整形外科領域の麻酔と術後鎮痛. 佐倉伸一編集. 周術期超音波ガイド下神経ブロック. 改訂第2版. 東京, 真興交易医書出版部, 2001, pp558–81. 6) 桑原 聡. 脱髄と軸索変性はどのように見分けるのでしょうか？ 鈴木則宏監修. 神経内科Clinical Question & Pearls 末梢神経障害. 東京, 中外医学社, 2018, pp2–6. 8) 阿部まり子. 症例検討 周術期神経障害2. 回復術後の下肢麻痺―リスクはあちこちに潜んでいる. LiSA 2016; 23: 560–5. 12) Pollock JE. Neurotoxicity of intrathecal local anaesthetics and transient neurological symptoms. Best Pract Res Clin Anaesthesiol 2003; 17: 471–84. 1) Højer Karlsen AP, Geisler A, Petersen PL, et al. Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain 2015; 156: 8–30. 10) Enocson A, Hedbeck CJ, Tidermark J, et al. Dislocation of total hip replacement in patients with fractures of the femoral neck. Acta Orthop 2009; 80: 184–9. |
| References_xml | – reference: 8) 阿部まり子. 症例検討 周術期神経障害2. 回復術後の下肢麻痺―リスクはあちこちに潜んでいる. LiSA 2016; 23: 560–5. – reference: 4) Gadsden JC, Lindenmuth DM, Hadzic A, et al. Lumbar plexus block using high-pressure injection leads to contralateral and epidural spread. Anesthesiology 2008; 109: 683–8. – reference: 3) Stevens RD, Van Gessel E, Flory N, et al. Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Anesthesiology 2000; 93: 115–21. – reference: 11) 河野俊介, 北島 将, 園畑素樹, 他. 人工股関節全置換術後腓骨（坐骨）神経麻痺合併症例の検討. 整形外科と災害外科 2014; 63: 722–3. – reference: 12) Pollock JE. Neurotoxicity of intrathecal local anaesthetics and transient neurological symptoms. Best Pract Res Clin Anaesthesiol 2003; 17: 471–84. – reference: 13) Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973; 2: 359–62. – reference: 5) Gadsden JC, Choi JJ, Lin E, et al. Opening injection pressure consistently detects needle-nerve contact during ultrasound-guided interscalene brachial plexus block. Anesthesiology 2014; 120: 1246–53. – reference: 6) 桑原 聡. 脱髄と軸索変性はどのように見分けるのでしょうか？ 鈴木則宏監修. 神経内科Clinical Question & Pearls 末梢神経障害. 東京, 中外医学社, 2018, pp2–6. – reference: 9) Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain 1951; 74: 491–516. – reference: 10) Enocson A, Hedbeck CJ, Tidermark J, et al. Dislocation of total hip replacement in patients with fractures of the femoral neck. Acta Orthop 2009; 80: 184–9. – reference: 2) 石倉亮介, 佐倉伸一. 整形外科領域の麻酔と術後鎮痛. 佐倉伸一編集. 周術期超音波ガイド下神経ブロック. 改訂第2版. 東京, 真興交易医書出版部, 2001, pp558–81. – reference: 1) Højer Karlsen AP, Geisler A, Petersen PL, et al. Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain 2015; 156: 8–30. – reference: 7) Moldaver J. Tinel's sign. Its characteristics and significance. J Bone Joint Surg Am 1978; 60: 412–4. |
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| Snippet | A 46-year-old woman, 157 cm 58 kg, underwent left total hip arthroplasty after lumbar plexus block and sciatic nerve block via the parasacral approach.... |
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| SubjectTerms | lumbar plexus block perioperative neuropathy peroneal neuropathy sciatic nerve block total hip arthroplasty 人工股関節全置換術 周術期神経障害 坐骨神経ブロック 腓骨神経麻痺 腰神経叢ブロック |
| Title | Peroneural neuropathy after total hip arthroplasty with combined neural block: a case report |
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