Management of Iatrogenic Nerve Injuries

Abstract

Iatrogenic peripheral nerve injuries from orthopaedic surgery can occur via many scenarios, including direct injury to the nerve during surgery, indirect injury via retraction or compartment syndrome, and injury from nonsurgical treatments such as injections and splinting. Successful management of iatrogenic nerve injuries requires an accurate diagnosis and timely, appropriate treatment. All orthopaedic surgeons must understand the preclinical study of nerve injury and the evaluation and treatment options for iatrogenic nerve injuries. Although a sharply transected nerve can be repaired immediately in the operating room under direct visualization, many injuries are not appreciated until the postoperative period. Advances in diagnostic studies and nerve repair techniques, nerve grafting, and nerve transfers have improved our ability to identify and treat such injuries.

Hamstring branches of the sciatic nerve as donors for neurotization of the superior gluteal nerve: A cadaveric feasibility study

“…Treatment should be tailored to each individual patient, offering an opportunity for intrinsic recovery in cases where the nerve is believed to be in continuity, as is standard protocol for most closed nerve injuries (Pulos et al, 2019). For cases requiring reconstruction, it is critical to consider the mechanism of injury.…”

Iatrogenic peripheral nerve injury: a guide to management for the orthopaedic limb surgeon

“…The current teaching suggests erroneously that EMG is best performed 6–8 weeks after surgery, and certainly not before 7–10 days since falsely reassuring results may occur due to the fact that Wallerian degeneration has not yet completed. 2 , 15 , 17 Early EMG as soon as the nerve injury is identified may be normal; however, a repeated study at two weeks demonstrating a deterioration with no volitional activity, a reduction in Sensory Nerve Action Potential (SNAP) and Compound Muscle Action Potential (CMAP) with muscle fibrillation is diagnostic of axonopathy and the injury is at best a mixed injury with some axonotmesis or at worst a neurotmesis. 17 Early intervention can then be advised rather than the current teaching where abnormal NCS and EMG findings at 6–8 weeks typically result in further studies at 3–4 months, delaying referral and warranted intervention.…”

“…22 These guidelines are clear that accurate and repeated peripheral nerve history and examination is performed both pre-operatively and throughout follow-up. 15 , 22 , 23 It is notable, however, that in the immediate post-operative period difficulties in diagnosing motor or sensory deficits are common. Regional anaesthetic blocks, intoxication, casts and splints can all make clinical examination extremely difficult or unreliable.…”

“…There may be medicolegal ramifications and a loss of confidence with a sense of guilt, termed the second victim phenomenon. 5 , 6 …”

“…The nerve specialist will help to determine the site of injury, the pathophysiological grade of injury and the need for exploration. 5 Surgical exploration is sometimes required to provide an accurate diagnosis and prognosis. There is limited diagnostic utility in electrophysiological studies and in imaging studies.…”