A 58-year-old female patient underwent hip arthroplasty (hip prosthesis surgery) with the administration of a regional anesthesia technique (pain block) for postoperative analgesia and intraoperative comfort. A lumbar epidural was employed to position the patient for surgery while managing her pain, and a lateral femorocutaneous nerve block was performed to manage incision-related pain.

 

Postoperative Symptoms:

 

•Burning sensations in the sciatic nerve territory: This symptom suggested potential involvement or injury to the sciatic nerve, possibly related to surgical traction.

•Weakness and loss of strength on the anterior aspect of the leg: This symptom likely points to involvement of the femoral nerve, with electromyography (EMG) results indicating L2 nerve root involvement.

•Foot drop: The patient presented with this condition, a common sign of peroneal nerve injury. The peroneal nerve, a branch of the sciatic nerve, is particularly vulnerable during surgeries involving hip and knee manipulation due to its fine structure.

 

Analysis of Nerve Injury:

 

•Peroneal nerve injury: The burning sensation and foot drop suggest compression or traction-related injury to the peroneal nerve, which is more prone to damage due to its smaller size compared to the tibial component of the sciatic nerve. This is commonly seen in hip and knee surgeries where excessive traction or poor positioning may lead to compression.

•Femoral nerve involvement: The patient’s weakness in hip flexion suggests femoral nerve injury, likely exacerbated by excessive flexion or traction during surgery, compounded by pre-existing sarcopenia and fatty degeneration of the psoas muscle in this elderly patient.

•L2 root component: The involvement of L2, as detected by EMG, is likely related to a mechanical factor, possibly related to positioning or traction, rather than the spinal anesthesia itself. Spinal anesthesia typically does not selectively affect a single nerve root, making mechanical factors more plausible.

 

Reflection for Students:

 

This case emphasizes the importance of:

 

1.Positioning during surgery: Improper positioning can lead to nerve injuries, particularly in elderly patients with sarcopenia or degenerative muscle conditions.

2.Understanding peripheral nerve vulnerabilities: The peroneal nerve is particularly prone to injury due to its delicate structure, especially in the context of surgeries that require traction or extended manipulation of the lower limb.

3.Multifactorial nature of nerve injuries: Nerve damage may result from a combination of factors, including intraoperative positioning, the use of surgical retractors, and patient-specific vulnerabilities (e.g., muscle degeneration).

4.Postoperative monitoring and early diagnosis: Prompt recognition of symptoms like foot drop or burning sensations is crucial for early intervention, which may help minimize long-term functional deficits.

 

This case can serve as a valuable teaching point in understanding the complexities of nerve injuries in orthopedic surgeries, particularly those involving the hip.