Femoral Nerve Compression Research Articles

Before Diagnosing COVID-19-Associated Femoral Nerve Compression due to psoas Hematoma, Causalities and Pathophysiologies Must Be Established

Before Diagnosing COVID-19-Associated Femoral Nerve Compression due to psoas Hematoma, Causalities and Pathophysiologies Must Be Established

The double-headed accessory iliacus muscle: a case report.

Numerous accessory muscles are present in the human body, many of which are clinically significant. We present a case of an anomalous accessory iliacus composed of two heads, whose occurrence and anatomical location indicate a high probability of causing femoral nerve compression. During a routine dissection of the posterior abdominal wall of a xx-year-old cadaver, a double headed accessory muscle was noted, measured and photographed. In addition to the normal anatomy of dissected structures from the posterior abdominal wall, an accessory iliacus muscle composed of superficial and deep heads was identified. In addition, the inferior roots of the divided femoral nerve located between the heads was found to follow an unusual course. It is important to be aware of morphological variability around structures such as double-headed accessory iliacus muscle presented in this study, due to their association with neurovascular bundles and hip joint. The reported atypical morphology is not widely known in the literature but might be of great clinical significance, therefore knowledge of such variability might be regarded in order to diagnose properly and introduce accurate treatment.

Iatrogenic bilocular femoral artery pseudoaneurysm in a patient with end-stage renal disease undergoing regular hemodialysis: An unexpected occurrence after a common procedure and surgical cure

Introduction: Pseudoaneurysms of the femoral artery can develop as an uncommon complication following penetrating trauma or arterial catheterization for cardiovascular procedures or hemodialysis. It is commonly diagnosed with color duplex imaging and usually a single pseudoaneurysm is present. Case Report: We present a 62-year-old woman with end-stage renal disease who developed a very rare bilocular pseudoaneurysm of the femoral artery caused by inadvertent puncture of the artery during elective hemodialysis which remained uneventful and undiagnosed until the pseudoaneurysm was itself punctured by the dialysis catheter iatrogenically and another large connecting pseudoaneurysm was formed above the initial one. Typical unilocular pseudoaneurysm presents as Yin-Yang sign on color duplex imaging but here bidirectional turbulent flow was seen as double Yin-Yang sign suggestive of bilocular pseudoaneurysm mimicking the shape of a snowman, hence Yin-Yang Snowman sign. The patient presented with signs and symptoms of rapid progression of the pseudoaneurysm resulting in femoral nerve compression with compromised skin viability. Therefore, surgical management was planned and the bilocular pseudoaneurysms were excised with repair of the femoral artery and then covered with vascularized rectus femoris muscle flap. Conclusion: An arterial pseudoaneurysm should be included in the differential diagnosis for a groin mass after femoral catheterization or other vascular procedures. A non-invasive imaging approach using color flow duplex sonography can be used with confidence and safety. But in complicated cases or cases with impending complications, surgical exploration and excision remains the mainstay of treatment.

PC46. MRI Neurography as an Adjunct for the Diagnosis of Meralgia Paresthetica

PURPOSE: Meralgia paresthetica (MP) is a sequela of Lateral Femoral Cutaneous Nerve (LFCN) compression characterized by numbness, tingling, and burning sensation in the outer thigh. Traditional methods of diagnosis are usually extremely limited to provide a certain diagnosis. MRI neurography (MRN) is a tissue-specific imaging that provides excellent characterization of nerve anatomy. We propose MRN as an adjunct for the diagnosis and management of meralgia paresthetica. METHODS: We reviewed 13 consecutive patients who were surgically treated for MP in the last 2 years. Treatment protocol offered patients with VAS scores 3-4 with nerve release, 5-7 either LFCN decompression or resection with regenerative peripheral nerve interface (RPNI), and 8-10 RPNI. Since MRN was only recently introduced into our practice, 7 out of 13 patients had MRN pre-operatively. RESULTS: Patients presented with hypersensitivity and burning pain to the LFCN distribution with an average VAS score of 7.8. Of the 7 patients with MRN, 6 patients had complete resolution of symptoms, 1 patient with history of complex regional pain syndrome still reported improvement of symptoms. The 6 patients that didn’t get MRN were treated according to VAS score, EMG, and clinical assessment. 5 of them had complete resolution of symptoms after surgery with 1 reporting significant improvement. CONCLUSION: MRN is a useful resource for the evaluation of peripheral nerves. The ability to provide a comprehensive evaluation of the regional neuromuscular structures helps the diagnosis and management of MP. Nevertheless, larger prospective studies are still warranted to further investigate its utilization and accuracy.

The Bridging Infix: a modified, minimally invasive subcutaneous anterior pelvic fixation technique

Various methods for anterior pelvic ring fixation have been described in the literature, each with specific advantages and disadvantages. We describe a modified minimally invasive subcutaneous technique for anterior fixation: the Bridging Infix. It combines the benefits of internal plate fixation with external fixator principles. We merged and modified features of the existing INFIX and Pelvic Bridge techniques during the design. Similar to these techniques, we use plate-rods typically used during occipitocervical fusions. The design changes allow for less discomfort due to prominent hardware in thin patients and eliminate the need for an intact medial pubic rami for fixation. There is also no risk of bladder injury due to accidental screw perforation through the pubic rami. The Bridging Infix is ideal for patients who are physiologically too frail for extensive open reduction and plate osteosynthesis, such as elderly patients with pelvic fragility fractures who are failing to mobilise due to pain. It can also be used for patients in whom external fixators may be impractical or poorly tolerated, such as obese patients or those with increased nursing demands. This technique does not provide adequate posterior pelvic ring stability, thus it requires an intact posterior tension band or the addition of separate posterior fixation. Patients can commence in-bed mobilisation the same day as the procedure, with weight-bearing as tolerated allowed for most cases, and toe-touching reserved for highly unstable injury patterns only. The implants are not routinely removed unless requested by the patient, especially in the elderly to avoid additional anaesthetic exposure. Potential complaints include lateral thigh pain, due to lateral femoral nerve compression, and mechanical discomfort during exercise activities. Level of evidence: Level 5

Peripheral Angioinvasive Aspergillosis in the Setting of End-Stage Liver Disease

Invasive aspergillosis of the peripheral arteries is a rare complication in vascular surgery. Angioinvasion can compromise vascular wall integrity, leading to local and systemic complications. We report the case of peripheral angioinvasive aspergillosis of the common femoral artery (CFA) and superficial femoral artery in a patient with decompensated alcoholic liver cirrhosis. We reviewed the electronic medical records for the patient's medical history, diagnostic imaging, operative reports, and in-hospital course. All information was de-identified. A 58-year-old man with advanced alcoholic liver cirrhosis had presented to our tertiary care center for orthotopic liver transplant evaluation. A part of the workup included coronary angiography, which was performed through a 6F femoral sheath access. Subsequently, the patient developed right groin hematoma with a CFA pseudoaneurysm and evidence of femoral nerve compression. He underwent hematoma evacuation and CFA repair that required endarterectomy. His postoperative course was complicated by a recurring surgical site hematoma requiring transfusions, several groin reexplorations, and creation of a sartorius flap to provide coverage of the femoral vascular bundle. A vacuum-assisted closure device was used for wound dressing. During the ensuing days, sartorius flap necrosis developed, and the patient experienced acute arterial bleeding. On reexploration, the CFA was noted to have sieve-like bleeding with complete disintegration of the arterial wall. Ligation of the CFA, profunda femoris, and superficial femoral artery as lifesaving measures was required. The patient's condition continued to worsen, with liver failure and right leg ischemia. After the goals of care were discussed with the family, they decided for terminal extubation, after which the patient died. Evaluation of samples of the femoral vessels obtained during surgery returned positive for the presence of Aspergillus species on fungal stains within the arterial wall, with large fungal bodies protruding into the vessel segment lumen (Fig). Distorted vessel wall anatomy was also observed with dense infiltration and hyphae and evidence of vessel microperforation. The presence of invasive aspergillosis was most likely responsible for the arterial wall disintegration. Peripheral angioinvasive aspergillosis is a rare infectious complication in vascular surgery and can occur in patients with end-stage liver disease. Angioinvasion is difficult to treat and can result in vascular wall compromise, presenting as life-threatening hemorrhage.

Femoral nerve compression caused by a hibernoma in the right thigh: a case report and literature review

BackgroundA hibernoma, also known as a brown fat tumor, is a rare benign soft tissue tumor, which originates from brown adipose tissue remaining in the fetus after the gestational period. It is often detected in adult men, presenting as a painless slow-growing mass. Hibernomas of the thigh have been reported; however, motor and sensory disorders caused by the tumors compressing the femoral nerve have not been reported. We report a case of a histopathologically proven hibernoma that induced femoral mononeuropathy.Case presentationA 26-year-old man was admitted to the hospital due to a mass, approximately 11.0 × 9.0 × 4.0 cm in size, that had developed 5 years ago in the anterolateral aspect of the proximal thigh. Furthermore, he had a history of hypoesthesia 1 month prior to his admission. He had signs and symptoms of both a motor and sensory disorder, involving the anterior aspect of the right thigh and the medial aspect of the calf, along the distribution of the femoral nerve. During surgery, the femoral nerve was found to be compressed by the giant tumor. The resultant symptoms probably caused the patient to seek medical care. Marginal resection of the mass was performed by careful dissection, and the branches of the femoral nerve were spared. Histopathology examination showed findings suggestive of a hibernoma. At the 4-month follow-up, no femoral nerve compression was evident, and local tumor recurrence or metastasis was not found.ConclusionsAsymptomatic hibernomas do not require treatment; however, in cases of hibernomas with apparent symptoms, complete marginal surgical excision at an early stage is a treatment option because it is associated with a low risk of postoperative tumor recurrence.

Psoas Quintus: A Novel Muscle Variant of the Posterior Abdominal Wall

Anatomical variations of the psoas muscles are rare, with only a few examples reported in the literature. Typical musculature consists of two psoas muscles on the posterior abdominal wall. These include the psoas major, which is universally present in the human population, and the psoas minor, an inconsistent, but commonly occurring muscle. Other rarely reported psoas variants include the psoas tertius and psoas quartus muscles. Both are predicted to play a role in femoral nerve compression due to their proximity to the femoral nerve and their location on the posterior abdominal wall. Here we report the presence of both psoas quartus and psoas tertius muscles, as well as the discovery of a previously unreported psoas variant, which we have named psoas quintus. The muscle was discovered during a routine dissection of the left posterior abdominal wall of a 57‐year‐old Caucasian male. The psoas quintus had a proximal attachment via a slender tendon to the body of the L3 vertebrae and spread to the area of the anterior superior iliac spine by a relatively broad tendon. Its muscles fibers were oriented distinctly from those of the iliacus muscle below and the psoas quartus medially.

Macroscopic observations of muscular bundles of accessory iliopsoas muscle as the cause of femoral nerve compression

Compression of the femoral nerve (FN) to the iliac fossa has been reported as a consequence of several pathologies as well as due to the aberrant muscles. The purpose of this research was to investigate the patterns of the accessory muscles of iliopsoas muscles and the relationship of the FN in fifty semi pelvis. Accessory muscular slips from iliacus and psoas, piercing or covering the FN, were found in 19 specimens (7.9%). Based on the macroscopic structure, the muscle was categorized into two types. Pattern 1 as the more frequent variation, was sheet muscular type covering the FN (17 specimens, 89.5%). Pattern 2, the less frequent variation was found on a muscular slip covering the FN (2 specimens, 10.5%). Iliac and psoas muscles and their variants on both types were defined. Appraising the relation between the muscle and the nerves, each disposition of the patterns may be a potential risk for nerve entrapment. The knowledge about the possible variations of the iliopsoas muscle complex and the FN may also give surgeons confidence during pelvic surgery. Recognition of these variations in normal anatomy may be useful to the clinicians when treating patients with refractory leg pain.

55. Minimally invasive lateral transpsoas approach: Comorbidity in our cases

The minimally invasive lateral transpsoas approach to the lumbar spine is a valid and recent alternative to interbody placement at levels L1–L5 in the setting of degenerative disc disease, spondylolisthesis, and scoliotic or kyphotic deformity. The benefits over traditional open surgery include reduced blood loss, decreased postoperative pain and narcotics use, shorter hospital length of stay, faster recover and quicker return to work and normal activity. The most common complications following this procedure include anterior thight numbness, lower extremity radiculopathy with weakness, iliopsoas and/or quadriceps weakness, and pseudoarthrosis. Papanastassiou et al. reported on two patients unusual complication of controlateral femoral nerve compression. The direct lateral approach requires the patient to be in lateral decubitus position. The technique utilizes specialized retractors allowing for direct visualization of the surgical approach corridor. Electrophysiological monitoring is believed to be critical in localizing the lumbosacral plexus during positioning of the retractor system. In according to the recent guidlines SINC-NeuroSIAARTI-SINCh, Intraoperative Stimulation (Clip and Probe), Free-Run EMG, PES and PEM of the both Legs are used. We monitorized 21 patients: 5 pazients had a postoperative temporary weakness of the Iliopsoas muscle, and only one patient with impaired diabete had a post operative spondilodiscitis.

Bilateral iliopsoas hematoma: Case report and literature review

Background:Clinically significant spontaneous bilateral iliopsoas hematoma is a rare complication of anticoagulation therapy. Definitive treatment of spontaneous iliopsoas hematomas is not well-established and varies between observation and surgical intervention. The intramuscular hematoma causes severe pain, muscle dysfunction, and occasionally nerve palsy with the femoral nerve most commonly affected. Most patients are neurologically normal but when a significant neurological deficit is associated with iliopsoas hematoma, optimal treatment recommendations vary. We report a case of spontaneous bilateral iliopsoas hematomas causing significant bilateral femoral nerve dysfunction.Case Description:The authors present the case of a 63-year-old female who developed bilateral femoral nerve palsy due to anticoagulation bleeding complication. Magnetic resonance imaging demonstrated large bilateral intramuscular psoas hematomas causing femoral nerve compression. Surgical evacuation and decompression of the femoral nerves was performed with rapid neurological improvement.Conclusion:Management recommendations depend on the volume and cause of the hematoma, timing of diagnosis, and the degree of neurological impairment. A conservative approach with bed rest and correction of bleeding abnormalities to allow the hematoma to spontaneously resorb has been utilized for patients with small hematomas and little to no neurological symptoms. In contrast, more aggressive recommendations have been made for patients with large hematomas, severe motor function deficits, or hemodynamic instability.

Femoral Nerve Compression After Migration of Bone Cement to the Groin After Hip Arthroplasty

Although often a benign complication of total hip arthroplasty, cement extrusion can cause nerve, vessel, and organ compression. We report the case of a 70-year-old male patient in whom an extruded cement mass migrated anteriorly and compressed the femoral nerve and impinged on the femoral artery producing acute, severe groin pain with neuralgia 9 years postoperatively. Paresthesia of the anterior and medial thigh was found on examination. Radiographic, ultrasound, and computed tomographic studies confirmed a 6 × 1.5-cm mass of bone cement in the right groin compressing the femoral nerve that was removed successfully at surgery. Six months postoperatively, the patient's pain had resolved, but hyperesthesia of the medial thigh remained.

Microanatomy Of The Lateral Femoral Cutaneous Nerve In Relation To Inguinal Ligament

AimMeralgia paresthetica is a painful mononeuropathy resulting from compression or focal entrapment of lateral femoral cutaneous nerve (LFCN) as it passes deep to or through the inguinal ligament (IL). There are no reports available on cross‐sectional microanatomy of LFCN. The aim of the study was an attempt to find the changes in non‐fascicular components (Adipose (FAT) and non‐adipose tissue (connective tissue) (nFAT)) of LFCN just above IL (LFCN‐1), at IL (LFCN‐2) and below IL (LFCN‐3).MethodsWe studied 21 human cadaveric LFCN‐1, LFCN‐2 and LFCN‐3 samples. Paraffin sections of these nerves were processed by Masson's trichrome stain for connective tissue. FAT and nFAT areas were calculated from the non‐fascicular areas of these nerves.ResultsFascicles was found to be more in LFCN‐3 when compared to LFCN‐1 and LFCN‐2. There was more nFAT in LFCN‐2 when compared to LFCN‐1 and LFCN‐3. The comparison of the nFAT and FAT between LFCN‐1 and LFCN‐2 (p<0.001), LFCN‐1 and LFCN‐3 (p<0.001), and LFCN‐2 and LFCN‐3 (p<0.001) were statistically significant.ConclusionsMore nFAT when compared to FAT was found in LFCN‐2. These results of the study might help to explain Meralgia paresthetica resulting from compression or focal entrapment of the LFCN as it passes deep to or through the IL. Microanatomical knowledge of the LFCN is essential for decompression and neurolysis of the nerve in the treatment of meralgia paresthetica.

Short- and Long-Term Donor Outcomes After Kidney Donation: Analysis of 601 Cases Over a 35-Year Period at Japanese Single Center

The lack of deceased donors in Japan means that living-donor kidney transplantation is necessary in as many as 80% of cases. However, there are few data on perioperative complications and long-term outcome for live kidney donors. To determine associated perioperative morbidity and long-term mortality among live kidney donors, we reviewed 601 donor nephrectomies performed at our institution between 1970 and 2006 and attempted to contact all of the donors (or their families) to ascertain their present physical status. The survival rate and causes of death were compared with an age- and gender-matched cohort from the general population. Although three donors (0.5%) experienced major perioperative complications, that is, femoral nerve compression, pulmonary thrombosis, and acute renal failure, all of the donors recovered and left hospital without complications. Among 481 donors (80%) for whom details were available at the time of inspection, 426 (88.5%) were still surviving. Donor survival rates at 5, 10, 20, and 30 years were 98.3%, 94.7%, 86.4%, and 66.2%, respectively. The mean interval between kidney donation and death was 183+/-102 (7-375) months, and the mean age at death was 70+/-11 years. The survival rate of kidney donors was better than the age- and gender-matched cohort from the general population, and the patterns and causes of death were similar. Our data suggest that continuation of living-donor kidney transplantation programs is justified in short- and long-term donor safety.

Femoral nerve compression secondary to a ganglion cyst arising from a hip joint: a case report and review of the literature

IntroductionFemoral nerve compression due to a cystic lesion around the hip joint is rare and only a few cases have been described in the literature. Among these, true ganglion cysts are even more rare.Case presentationWe report the case of a 57-year-old woman with femoral nerve compression caused by a true ganglion cyst of the hip joint.ConclusionA high index of suspicion is required to predict a non-palpable cystic lesion around the hip joint as it may mimic different disorders and should be kept in mind in the differential diagnosis of unusual groin pain, radicular pain and peripheral vascular disorders.

Bilateral iliopsoas intramuscular bleeding following anticoagulant therapy with heparin: a case report

Iliopsoas haematoma is an uncommon complication that may arise during anticoagulant therapy, especially with heparin and warfarin. Besides determining patient distress secondary to femoral nerve compression, this event may progress to life-threatening complications and require expensive treatments. We describe the case of a 70-year-old healthy man complaining of severe bilateral groin, lumbar and thigh pain, and paralytic ileus after therapy with heparin. The angio-computed tomography scan observed bilateral iliopsoas haematomas. In view of the clinical and radiological scenarios, we ordered a diagnostic and therapeutic angiography of the bleeding vessels by trans-catheter arterial embolization of the fourth right lumbar artery trunk. The treatment proved to be beneficial from a clinical, radiological and laboratory point of view. To the best of our knowledge, this is the first reported case of bilateral iliopsoas haematoma occurring in a male treated with therapeutic levels of heparin alone.

Bilateral Femoral Nerve Compression and Compartment Syndrome Resulting from Influenza A–Induced Rhabdomyolysis: A Case Report

Bilateral femoral nerve compression neuropathy caused by primary iliopsoas muscle pathology is rare. We report a case of extensive compartment syndrome of the right arm and both legs associated with bilateral femoral nerve palsy resulting from severe muscle swelling secondary to influenza A infection. Our objective is to alert physicians to the possible development of compartment syndrome in patients with influenza and severe myalgia. We also reviewed the literature on the pathophysiology and management of femoral nerve compression neuropathy.

Iliopsoas hematoma in patients with hemophilia: A single-center study

Six cases of iliopsoas hematoma were diagnosed in 5 patients with hemophilia over the last 5 years at our hemophilia center. We reviewed these cases to determine the incidence and precipitating factors of iliopsoas hematoma in hemophilia. Of the 5 patients, 4 had severe hemophilia A and 1 had moderate hemophilia A with a history of inhibitors to factor VIII concentrates. The age range was 13 to 33 years. The hematoma was posttraumatic in 2 cases and spontaneous in 4 cases. Femoral nerve compression developed in 2 cases. There were four recurrences. At the time of the hematoma, 2 patients were receiving long-term prophylactic factor VIII concentrate therapy but one of them had stopped the injections of his own accord. The treatment consisted of recombinant factor VIII concentrates, a brief course of glucocorticoid therapy in the 2 cases with femoral nerve involvement, lower limb traction in 3 patients, and rehabilitation therapy. The annual incidence rate of iliopsoas hematoma was 2.9/1000 patients with severe or moderate hemophilia A. The use of prophylactic factor VIII therapy and compliance with recommendations about avoiding activities that put strain on the hip flexor muscles probably explain the low rate of iliopsoas muscle hematoma in patients with hemophilia in France. An early diagnosis allows early Factor VIII therapy, which decreases the risk of femoral nerve involvement and recurrence.

Iliacus stretching for symptomatic relief of femoral mononeuropathy

Summary A case of a middle-aged, long-term insulin-dependent diabetic gentleman with an acute onset of hip and thigh pain and quadriceps weakness after sneezing is presented. Following an initial differential diagnosis of nerve root and/or femoral nerve compression, magnetic resonance imaging (MRI) failed to reveal any evidence of nerve root compression or intrapelvic pathology. On this basis, the diagnosis was subsequently modified to femoral mononeuropathy. As his symptoms were relieved by iliopsoas stretching, the possibility exists that he was suffering primarily from proximal femoral nerve entrapment by iliacus, and a post-mortem example of this anatomical variant is shown. Gentle stretching of hip flexors, especially if it alleviates symptoms, might therefore be considered amongst other conservative measures, where proximal femoral nerve entrapment is suspected.

Femoral Nerve Palsy As a Complication of Anterior Iliac Crest Bone Harvest: Report of Two Cases and Review of the Literature

There are many documented neurological complications of anterior iliac crest bone harvest. Until now, these have included injuries to the iliohypogastric, subcostal and lateral femoral cutaneous nerves. Femoral nerve palsy as a direct surgical complication of anterior iliac crest bone harvest has never been cited in any surgical literature, although it has been reported in deep pelvic and abdominal surgeries in which improper retraction and/or prolonged hyperextension of the hip may have caused a nerve compression syndrome. In addition, surgical patients on antithrombolytic therapy have experienced hemorrhage within the iliacus and iliopsoas muscles, resulting in hematoma and secondary femoral nerve compression. The classic motor and sensory deficits reported in femoral nerve palsies are reduced or absent patellar reflex, weak hip flexion, quadriceps muscle weakness, and anesthesia of the anterior thigh and medial aspect of the leg. Two cases of femoral nerve palsy with different etiologies are presented.