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Femoral nerve and lumbar plexus injury after minimally invasive lateral retroperitoneal transpsoas approach: electrodiagnostic prognostic indicators and a roadmap to recovery

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Abstract

Injury to the lumbosacral (LS) plexus is a well-described complication after lateral retroperitoneal transpsoas approaches to the spine. The prognosis for functional recovery after lumbosacral plexopathy or femoral/obturator neuropathy is unclear. We designed a retrospective case-control study with patients undergoing one-level lateral retroperitoneal transpsoas lumbar interbody fusion (LLIF) between January 2011 and June 2016 to correlate electrodiagnostic assessments (EDX) to physiologic concepts of nerve injury and reinnervation, and attempt to build a timeline for patient evaluation and recovery. Cases with post-operative obturator or femoral neuropathy were identified. Post-operative MRI, nerve conduction studies (NCS), electromyography (EMG), and physical examinations were performed at intervals to assess clinical and electrophysiologic recovery of function. Two hundred thirty patients underwent LLIF. Six patients (2.6%) suffered severe femoral or femoral/obturator neuropathy. Five patients (2.2%) had immediate post-operative weakness. One of the six patients developed delayed weakness due to a retroperitoneal hematoma. Five out of six patients (83%) demonstrated EDX findings at 6 weeks consistent with axonotmesis. All patients improved to at least MRC 4/5 within 12 months of injury. In conclusion, neurapraxia is the most common LS plexus injury, and complete recovery is expected after 3 months. Most severe nerve injuries are a combination of neurapraxia and variable degrees of axonotmesis. EDX performed at 6 weeks and 3, 6, and 9 months provides prognostic information for recovery. In severe injuries of proximal femoral and obturator nerves, observation of proximal to distal progression of small-amplitude, short-duration (SASD) motor unit potentials may be the most significant prognostic indicator.

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Authors and Affiliations

  1. Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA

    Naomi A. Abel, Jacob Januszewski, Andrew C. Vivas & Juan S. Uribe

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  1. Naomi A. Abel
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  2. Jacob Januszewski
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  3. Andrew C. Vivas
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  4. Juan S. Uribe
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Correspondence to Jacob Januszewski.

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Funding

This study does not incorporate any sources of external funding or support.

Conflict of interest

Juan S. Uribe is a consultant for NuVasive, Inc. All other authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Ethical approval

This study is an institutional review board (IRB)-approved retrospective review of a prospectively collected database. The study protocol was approved by the IRB. All patient identifiable protected health information has been removed from the database used for the study.

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Due to the retrospective nature for the study, formal consent is not required.

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Abel, N.A., Januszewski, J., Vivas, A.C. et al. Femoral nerve and lumbar plexus injury after minimally invasive lateral retroperitoneal transpsoas approach: electrodiagnostic prognostic indicators and a roadmap to recovery. Neurosurg Rev 41, 457–464 (2018). https://doi.org/10.1007/s10143-017-0863-7

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  • DOI: https://doi.org/10.1007/s10143-017-0863-7

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