Obstetrical and Gynecological Procedures and Surgery

The peripheral nervous system can be injured in a variety of ways during pregnancy and delivery. Injury can occur at the level of the nerve roots, lumbosacral plexus, or individual peripheral nerves (...Xa.ble.i.SSilS ).

The risk of injury to spinal cord or nerve roots from spinal or epidural anesthesia used for delivery is 0.1 percent or less. Various types of injury that have been described include epidural hematomas, chemical radiculitis or arachnoiditis, direct needle injury to the root, or spinal infarction secondary to hypotension. [91]

Lumbosacral plexus injuries occur during labor or delivery and can be easily confused with a herniated disc. They occur in fetal-pelvic disproportion or in primiparous patients with large babies that necessitate midforceps delivery. The anterior division of the lumbosacral trunk (L4 or L5) is compressed by the fetal head or the obstetric forceps against the pelvic brim. These patients often complain of buttock or leg pain, which intensifies with uterine contractions. A footdrop or weakness of the tibialis anterior is the most common finding. y

A number of isolated nerve lesions may occur as a complication of obstetrical maneuvers. The obturator nerve may be injured when the patient is in the lithotomy position, because of angulation as the nerve leaves the obturator foramen. Clinically, the patient has weakness of adduction of the thigh and sensory loss over the medial thigh.

The femoral nerve is injured when the thighs are markedly flexed and abducted or the hips are abducted and externally rotated. Results of the injury include impaired extension of the knee, impaired flexion of the thigh, sensory loss over the anterior thigh, and loss of the patellar reflex.

The saphenous nerve can be injured by pressure from leg braces when the patient is in the lithotomy position. The sciatic nerve can be injured when the patient is placed in stirrups on the obstetrical table or with a misplaced deep intramuscular injection. Clinically, the patient experiences sensory loss over the lateral leg and the whole foot, weakness of both dorsal and plantar flexion of the foot, and of the extension of the knee, and loss of the ankle jerk. Isolated tibial injury is uncommon. The common peroneal is usually compressed at the head of the fibula from the leg braces with the patient in the lithotomy position. y Clinically, the patient has footdrop and inversion and sensory loss on the lateral aspect and the dorsum of the foot.

Nerve injury is an infrequent complication of gynecological surgery (see X§.ble,5.5.:13. ). The most frequently reported injury has been to the femoral nerve, followed by the sciatic and the obturator nerves. y Stretch, compression, ligation, and transection are the most commonly reported intraoperative precipitators of symptoms, and postoperative scar formation may lead to entrapment symptoms at anatomical locations remote from the procedure.

Mechanisms of femoral neuropathy include self-retaining retractors, especially in thin patients with low transverse incisions and deep retractor blades; hyperflexion of the thigh; and control of bleeding deep in the pelvis and in the region of the psoas muscle. The clinical presentation is as described earlier.

Sciatic nerve injury can occur as a result of sacroiliac fossa bleeding, intramuscular injections, and the sacrospinus vaginal vault suspension procedure. Obturator nerve injury has been associated with pelvic surgery and specifically with pelvic lymphadenectomy.

Other less commonly encountered nerve injuries that may occur in association with gynecological surgery include

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the genitofemoral nerve, which may be injured during pelvic lymphadenectomy, and can result in numbness or tingling over the labia and the skin over the femoral triangle. The ilioinguinal and iliohypogastric may be severed during an operation using a low transverse abdominal incision. The clinical syndrome consists of numbness or tingling over the suprapubic region, the upper medial thigh, and the anterior part of the labium majus. Finally, the lateral femoral cutaneous nerve may be injured during an inguinal lymphadenectomy and the pudendal nerve may be injured during radical pelvic surgery or during the performance of the sacrospinous vaginal vault suspension. Damage of the lateral femoral cutaneous nerve results in paresthesias over the lateral aspect of the front of the thigh as far as the knee, and damage of the pudendal nerve results in urinary and fecal incontinence and paresthesias of the clitoris, labia, perineum, and anus.

In contrast to brachial plexopathy, radiation-induced neural damage to the lumbosacral plexus is a rare complication. Although a few permanent lumbosacral lesions have been reported in patients treated with conventionally fractionated external beam, this syndrome is more often seen in patients treated with intracavitary irradiation for cervical or endometrial carcinoma. y

Careful surgical technique is probably the most important factor in prevention of the above-mentioned complications. In addition, careful placement of the self-retaining retractor and careful positioning of the patient in stirrups is of paramount importance. With mild injuries, the prognosis for recovery is excellent, but recovery may be prolonged and incomplete if axonal degeneration has occurred. Recovery usually takes 4 weeks for the sensory function and 1 to 4 months for the motor function. Physical therapy, splinting or bracing to prevent contractures, and electrical stimulation are the usual treatment modalities used.

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