Upper lumbar plexus lesions demonstrate various combinations of deficits in the iliohypogastric, ilioinguinal, genitofemoral, femoral and obturator nerve distributions. Weakness is seen in hip flexion, knee extension (concomitant inability to lock the leg on standing) and adduction of the thigh. Sensory loss is noted in the lower abdominal wall, inguinal, labial, and scrotal areas as well as the thigh and medial lower leg. An absent or a depressed knee reflex is noted.
Lower lumbar sacral plexus lesions cause deficits within the innervation territories of the gluteal, sciatic, tibial, and peroneal nerves. Weakness occurs in hip extension, and abduction, knee flexion, and all intrinsic foot musculature. Sensory loss occurs in the posterior thigh, anterior and posterior aspects of the lower leg below the knee and most of the foot. There are diminished or absent ankle reflexes. Gluteal and sciatic nerve weakness localizes a lesion to the sacral plexus.
Plexopathies are recognized when motor, sensory, and reflex deficits occur in multiple nerve and segmental distributions that affect one extremity.
Localization is often difficult due to the pathologies of the region, but usually in a broad sense can be divided into:
1.Lumbar plexopathy
2.Sacral plexopathy
3.Lumbosacral trunk lesions
4.Pan-plexopathy
In general, lumbar plexopathies evolve in a stepwise and dissociated manner.
In localization of lumbosacral plexopathies pathology of the cauda equina and conus medullaris has to be considered. Rarely, motor neuron disease may simulate plexopathy if deficits are without pain or sensory loss. Intraspinal lesions (lower spinal cord) tend to be bilateral with early bowel and bladder dysfunction rather than motor weakness. Cauda equina lesions are painful, and bladder dysfunction is seen early.
Differential points in the history or examination include:
i.Inversion of the foot is normal
ii.Toe flexion and hip abduction are normal
iii.The ankle reflex is preserved
i.The lumbar trunk is formed primarily by the L5 spinal nerve with a contribution from L4; peroneal sensation is normal which favors a trunk lesion.
ii.If the pattern of weakness is hip adductors, iliopsoas, and quadriceps a lumbar plexopathy rather than femoral or obturator nerve lesions is more likely
1.The L1, L2, L3 ventral rami are the primary components of the lumbar plexus with contributions from T11 and T12.
a.They traverse the posterior portion of the psoas muscle anterior to the vertebral transverse processes:
i.Femoral nerve (L2-L4 primary spinal nerves) also supplies sensation to the thigh and leg by:
1.Medial and intermediate nerve of the thigh
2.Saphenous nerve which provides sensation to the medial calf
2. Obturator nerve (L2-L4 spinal nerves):
a. Innervates the adductor muscles of the thigh
b. Provide cutaneous innervations to the medial thigh
3. Muscular branches that derive directly from the plexus:
a. Iliopsoas (L1-L3 spinal nerves)
b. Iliacus (L2-L3 spinal nerves)
4. Sensory nerves of the lumbar plexus:
a. Iliohypogastric (L1 spinal root)
b. Ilioinguinal nerve (L1 root) innervates:
i. Upper medial thigh
ii. Base of the penis and labia majora
c. Genitofemoral nerve (L1-L2 root):
i.Innervates the upper anterior thigh
ii.Scrotum and labia majora
d. Lateral cutaneous nerve of the thigh (L2-L3)
5. Lesions of the entire lumbosacral plexus:
a.Are rare; most are incomplete
b.Paralysis or paresis of the entire lower extremity with hypo or areflexia
c.Sensory abnormalities that involve the entire lower extremity
6. Lesions of lumbar segments:
a.Usually are incomplete
b.Paresis and atrophy in the distribution of the femoral and obturator nerves:
i. Iliopsoas:
1) Weakness of thigh flexion
ii. Quadriceps:
1) Weakness of leg extension
iii. Sartorius:
1) Weakness of thigh eversion
iv. Adductor muscles:
1) Weakness of thigh adduction
i.Sensory loss in the inguinal area and over the genitalia
1.Iliohypogastric, ilioinguinal, and genitofemoral nerves are involved
ii.Lateral thigh:
1.Lateral femoral cutaneous nerve
iii.Medial thigh:
1.Obturator nerve
iv.Anterior thigh:
1.Femoral nerve
v.Medial part of the lower leg:
1.Saphenous nerve that is derived from the femoral nerve
a.Femoral nerve
a.Genitofemoral nerve
i.The cuneal branch innervates the posterior upper thigh and inferior buttock
i.“Flail foot” from paralysis of both the dorsal and plantar foot musculature
i.Knee flexion:
1.Hamstrings
ii.Foot eversion:
1.Peroneal
i.Tibialis anterior and posterior tibial nerve
i.Medial plantar nerves (II – V digits)
ii.Tibial nerve innervates the flexor hallucis longus
i. Peroneal nerve innervates the extensor hallucis longus; L5-S1 roots
ii. Deep fibular nerve (Extensor hallucis longus muscle – EHL)
f. Abduction and internal rotation of the thigh:
i. Superior gluteal nerve
g. Hip extension:
i.Inferior gluteal nerve
1.Loss of sensation in the sciatic nerve distribution:
a.Outer leg
b.Dorsum, sole and inner aspect of the foot
2.Posterior thigh and popliteal fossa:
a.Posterior femoral cutaneous nerve
1.Decreased Achilles reflex:
a.Sciatic nerve
2.Depressed bulbocavernosus reflex
1.Loss or dysfunction of bladder and bowel control:
a.Pudendal nerve
1.Positive mechanical signs favor a root lesion:
a.Straight leg raising test (sciatic nerve and S1 root)
b.Reverse SLR (places traction on the femoral nerve); the leg is extended with the patient lying on his stomach
c.Valsalva maneuver that causes pain:
i.Root greater than plexus involvement
2.Warm, dry and red foot:
a.Indicative of a plexus lesion
b.Involvement of the retroperitoneal lumbar sympathetic nerves
3.Proximal > distal leg muscle weakness suggests a plexus lesion
4.Gluteus muscle innervations arise directly from the plexus
5.Iliopsoas muscle is not involved in a femoral nerve lesion because its innervation is directly from the plexus
a.Double fracture dislocation
b.Traction injury from dislocation of the hip joint
i.Surgical retraction (medially)
ii.Injured laterally by a hematoma between the iliacus fascia and the nerve
a.Pelvis brim by the fetal head
b.Obstetric forceps
a.Angulation under the inguinal ligament
b.Prolonged flexion abduction of the thigh (dorsal lithotomy position under anesthesia)
i.50% of patients suffer neurologic deficits
i.Primarily L4 and L5 spinal nerves (L5 primarily)
ii.The spinal nerves are contiguous with the sacrum adjacent to the sacroiliac joint.
b.Obturator and or superior gluteal nerves are often concomitantly injured
c.L5-S3 anterior rami may be affected
d.Concomitant vertebral body rupture
a.Injections into the buttock:
i.Ischemic injury due to vasoactive drugs that are injected into the inferior gluteal artery causing ischemia of the sciatic nerve
ii.Weakness, pain, and sensory loss in the sciatic nerve distribution occur minutes to a few hours after the injection
iii.Widespread lumbar plexus injury may occur due to retrograde extension of gluteal artery spasm to branches of the internal iliac artery
iv.Buttock skin may be painfully swollen, cyanotic and develop gangrene
v.Painless lumbosacral plexopathy may follow cisplatin injection into the iliac artery
i.Short women with large babies
ii.Prima gravida
i.Lumbosacral trunk injury (primarily L5 spinal nerve) compression at the pelvic brim over the sacroiliac joint:
1.Cephalic pelvic disproportion
2.Protracted labor
3.Mid pelvic forceps delivery
i.Bilateral in 25% of patients
ii.Concomitant with an obturator neuropathy
d.Causes of peripheral femoral neuropathy:
i.Lithotomy position under anesthesia during vaginal delivery (compression under the inguinal ligament)
ii.Separation of the symphysis pubis with direct compression of the nerve by the fetal head
iii.Epidural anesthesia:
iv.Paracervical block that affects the posterior femoral nerve (pain may be delayed by several days)
v.Lumbosacral plexus compressed at the pelvic brim by a uterine leiomyoma (accelerated growth during pregnancy)
vi.Intrapelvic Schwannoma
1.Usually the sciatic nerve is affected but all components of the lumbosacral plexus may be involved
1.Implantation of endometrial tissue either intra-abdominally or at the sciatic notch
2.Perimenstrual pain in the buttock or posterior thigh (sciatic involvement)
3.Weakness, sensory loss and reflex changes are dependent on the lumbosacral component or the terminal nerve that is affected
1.Endometrial deposits in the sciatic notch may be associated with an out-pouching of a pocket of peritoneum
2.Endometrial perineural spread from the uterus to the sacral plexus along the pelvic autonomic nerves and then distally to the sciatic nerve or proximally to the lumbar plexus
1.MRI:
a.Delineates perineural spread and retrograde menstruation with peritoneal bleeding
i.Preoperative stretch injury due to hip dislocation
ii.Retroperitoneal hemorrhage
3. Other surgical complications:
a.Heat
b.Toxicity from methyl methacrylate bone cement
c.Direct trauma and that from retractor blades
d.Postoperative aneurysm formation
1.Surgical repair has been associated with ischemic plexus lesions
1.Motor, sensory and reflex deficits are evident in multiple nerves or segmental distributions in the affected extremity
2.Rectal examination reveals a firm pulsatile mass
3.Hemorrhage from an aortic, iliac or a hypogastric aneurysm may compress the femoral nerve
4.Retroperitoneal hematoma occurs from abdominal aortic aneurysm leakage that may affect the lumbosacral plexus and femoral nerve
1.Neuropractic and axonometric injury occurs with compression and traction injuries
2.Neuromeric injury is primary with high impact trauma and some surgical procedures
1.Ultrasonography of the plexus
2.MRI (conventional) to evaluate the plexus and soft tissue
3.CT to evaluate the bone at the site of injury
1.Occur in less than 1% of patients with neoplasms
2.Direct extension from an intra-abdominal tumor occurs in 75% of patients while extra-abdominal sites are the source in approximately 25% of patients
3.The lower sacral plexus is involved in approximately 50% of patients followed by the upper plexus in 30% and panplexopathy in 18%
4.Bilateral plexopathy occurs in 25% of patients (usually of the upper extremities by breast cancer)
5.Involvement of the sacral sympathetic nerves occurs in approximately 10% of patients
6.Less commonly plexus invasion occurs from lymph nodes, metastases or bony structures
1.In approximately 15% of patients lumbosacral plexopathy is the initial presentation of an intra-abdominal tumor
2.The most frequent presentation in >90% of patients is with pain in the low back, buttock, hip or thigh:
a.In 90% of patients the pain is unilateral in onset and is dull, constant aching and is rarely burning; cramping may occur in a radicular pattern
b.Exacerbation may occur at night
c.Patients find difficulty in achieving a comfortable position
d.Position of comfort is with the legs and hips in flexion if the iliopsoas muscle is involved
e.Pain is exacerbated by walking or sitting
f.A warm and dry foot (often red) may be seen if the sympathetic chain is involved
g.Pain may be present for approximately 3 months prior to the onset of other symptoms and signs
h.Weakness and sensory loss due to involvement of different plexus components is seen in most patients; sensory loss occurs in between 50-75% of patients and is most severe in patients with concomitant weakness
i.Progressive muscle weakness is diffuse and interferes with gait
j.Incontinence and impotence occur in 10% of patients due to bilateral involvement
k.Involvement of the lumbosacral trunk is associated with foot drop
l.Sacral involvement causes weakness of foot flexion and hamstring muscle involvement
m.Sensory deficits are most often unilateral
n.The patellar reflex is depressed with an upper plexopathy and the ankle jerk is depressed with sacral involvement
o.Peripheral edema occurs in 80% of patients with pan plexopathy, in 41% of patients with upper plexopathy and in 37% of patients with lower plexus involvement
p.A rectal mass is found in 43% of patients with lower plexopathy and in 25% of patients with upper plexopathy and 15% with panplexopathy
q.Straight leg raising test occurs (is positive) in greater than 83% of patients with pan plexopathy
r.Pain may be increased with Valsalva maneuvers
1.Intra-abdominal tumor extension to the lumbosacral plexus occurs in approximately 75% of affected patients:
a.Tumor may invade directly
b.May grow along the connective tissue, epineurium of nerve trunks or perineural spread
2.Most prevalent tumors are:
a.Colorectal tumors (20%)
b.Sarcomas (16%)
c.Breast tumors (11%)
d.Lymphoma (9%)
e.Cervical tumors (9%)
f.Other tumors including multiple myeloma account for 37% of intra-abdominal tumors
3.Metastatic lesions are from:
a.Breast
b.Lymphoma
c.Sarcoma
d.Lung
e.Thyroid (rare)
f.Melanoma
g.Testicular
h.Multiple myeloma
4.Primary pelvic plexus tumors are:
a.Neurofibroma
b.Schwannoma
c.Sarcoma (degeneration of a benign Neurofibroma)
5.Benign tumors that affect the lumbosacral plexus
a.Dermoid of the omentum
b.Uterine leiomyoma
1.Dependent on the type of underlying cancer and the extent of its involvement are increased
2.Sedimentation rate and C-reactive protein
3.Alkaline phosphatase
4.Protein electrophoresis
5.Prostate specific antigen
6.Uremia and hydronephrosis are associated with gynecologic malignancies
1.High resolution dedicated MR neurography
2.CT scan and conventional MRI are positive >80% of patients by the time of clinical presentation
3.Sacral bone involvement is often a sign of colorectal cancer
1.Bilateral or unilateral slowly progressive leg weakness
2.Starts distally usually in the L5-S1 roots; muscle wasting and absent reflexes
a.Lymphoma
b.Testicular
c.Ovarian
d.Uterine
e.Cervical
a.Malignant nerve sheath tumors
b.Post-irradiation lower motor neuron syndrome
a.Schwann cells
b.Fibroblasts
c.Vascular and perineural cells
a.External beam photon therapy
b.Intestinal or intracavitary radiation implants
c.Combined photon and proton beam
a.Animal experiments demonstrate that the threshold dose is 20-25 Gy
b.Accumulated doses below 40gy with conventional fractionation of 1.8-2.0 Gy are considered to have a low risk of injury to nervous tissue.
a.Demonstrates thickening of the plexus with tumor and atrophy with X-RT; no enhancement with gadolinium with X-RT.
1. CSF:
a. CSF protein may be slightly elevated
2. EMG:
a. Myokymia may be demonstrated in approximately 60% of patients
1. Rapid onset and progressive course
2. Pain may be the initial symptom
3. Unilateral involvement
4. Proximal weakness (L1-L4 roots)
5. Enhancing mass on MRI (with gadolinium); destruction of bone
1.A heterogeneous group of syndromes has been described after irradiation of the distal spinal cord and cauda equine primarily as treatment for testicular cancer and lymphoma
2.The mean age at irradiation is 33 years of age (literature review)
3.The average irradiation dose is 5,225 cGy (range 3,000-14,600)
4.Latency between irradiation and symptom onset ranged from 3 months to 27 years
5.Also known as Post X-RT Cauda Equina Syndrome
1.Painless wasting and fasciculation of leg muscles
2.Most often a delayed onset from months to years after treatment
3.Mild sensory symptoms in some patients
4.A proportion of patients may develop sphincter involvement
5.Occasional periods of stability
1.One autopsied patient that was uncomplicated by metastatic disease demonstrated:
a.A radiation-induced vasculopathy of the proximal spinal roots
b.Preservation of motor neuron cell bodies and the spinal cord architecture
1.Gadolinium enhancement on MRI of the cauda equine in approximately 50% of patients
1.EMG:
a.Patchy motor nerve root involvement
b.Electrophysiological evaluation by magnetic stimulation:
i.Prolonged cauda equina conduction time that suggests focal demyelination of the nerve roots of the cauda equina
a.Hip flexion
b.Adduction
c.Knee extension
a.Orthostatic hypotension
b.Urinary dysfunction
c.Impotence
d.Constipation or nocturnal diarrhea
1.The sed rate is elevated in 20% of patients
2.CSF:
a.The protein may be elevated (120 % suggests root involvement)
3.EMG:
a.EMG and nerve conduction velocities to evaluate the level and extent of the plexopathy as well as the often concurrent length dependent neuropathy
1.MRI:
a.An early screen of the plexus to rule out other pathologies
b.If malignant infiltration is suspected, CT may be added to imaging parameters as up to 40% of patients have epidural tumor extension with possible bone involvement
1.Motor polyradiculoneuropathies without pain occur in diabetes mellitus
2.Women and men are equally affected; the median age range is 62 years (age range between 36-78)
3.Patients had DM for a median duration of 5 ½ years (most with type 2 DM)
4.Diabetic complications of retinopathy and nephropathy occur in approximately 20% of patients
5.Weight loss is seen in approximately 80% of patients (> 10 pounds)
1.Symmetrical polyradicular pattern with greater distal than proximal involvement (in contrast to canonical diabetic lumbosacral radiculoplexus neuropathy (DLRPN))
2.Proximal segments are involved to the same degree as in DLRPN
3.The upper limb is involved in approximately 80% of patients: this involvement is more widespread and severe than with classical DLPRN
1.Nerve biopsies:
a.Ischemic injury and microvasculitis
b.Focal or multifocal fiber loss
c.Focal perineural degeneration or thickening
d.Epineurial neovascularization
e.Injury neuroma
f.Perivascular and vascular inflammation of small arterioles, venules and capillaries
1.A minority of patients have an elevated sed rate or laboratory results suggestive of an inflammatory process
2.CSF:
a.Elevated protein with a normal cell count
3.EMG:
a.Reduced or absent upper and lower limb sensory and compound muscle action potential amplitudes
b.No temporal dispersion or conduction block
c.Mild slowing of conduction velocities and prolongation of distal and F wave latencies
d.Patchy and widespread involvement of lumbosacral myotomes by needle EMG
a.Prior to age 20 years of age
b.Between 40-60 years of age
1.Abrupt onset of unilateral pain in the anterior thigh (lumbar plexitis) and posterior thigh and buttock (sacral plexitis); some patients have a more prolonged onset with recurrent bouts of pain
2.Muscle weakness is observed within 5-10 days of onset of the pain; it may progress for days to weeks; the pain resolves as the weakness supervenes
3.Muscle weakness of L1-L4 roots is most common and is associated with a positive femoral reverse SLR nerve test and absent quadriceps reflex
4.Lower plexus involvement:
a.Positive Tinel’s sign at the sciatic notch and popliteal fossa
b.Weakness of the anterior and posterior tibialis, everters of the ankle, foot flexors, and extensors
c.Absent Achilles reflex
5. The process may be bilateral
6. Recovery is often prolonged (over months) and is often incomplete
1.Impaired glucose tolerance has been reported in some patients
2.Nerve biopsy demonstrates demyelination and axon loss similar to diabetic patients
3.Probable microvasculitis; possibly immune-mediated
a.To rule out compressive or invasive lesions
b.Gadolinium-enhanced lumbar and sacral roots, and trunks may be demonstrated
1.EMG/NCV:
a.To delineate the location and severity of the process
2.HbA1c (must be negative)
3.Sed rate elevated in some patients
4.CSF:
1.Usually a necrotizing vasculitis
1.Develops acutely
2.Painful; weakness with fixed sensory loss
3.Progresses in a step-wise manner
4.Constitutional symptoms are associated that include:
i.Granulomas of the respiratory tract
ii.Retinitis
iii.Purpura
iv.CNS involvement
v.Eosinophilia
i.Diabetic microvasculitis
ii.SLE
iii.Periarteritis nodosa
iv.Sarcoid
v.Steroid responsive lumbosacral plexopathy
vi.Wegener’s granulomatosis
1.Bacterial abscess whose origin is in the psoas or paraspinal musculature
2.Perirectal abscess:
a.Immunocompromised patients
b.Prior rectal surgery
c.Fever in association with groin, abdominal or back pain
i.Usually sciatic nerve radiation
ii.L4-S2 motor/sensory deficits
c.HS type 2 greater than type 1
d.The primary anogenital lesion may be on the cervix
e.Rare plexopathy with recurrent attacks
2.Clinical features:
a.Dermatomal leg weakness and sensory loss
b.Paresthesias and sensory loss in the perineum, buttocks, and posterior thigh
c.Urinary retention, constipation, and erectile dysfunction
d.Reduced tone of the anal sphincter; sensory loss in sacral dermatomes; loss of the bulbocavernosus reflex
e.May involve lower motor neurons of the sacrococcygeal plexus
f.Mild meningeal irritation
g.Symptoms and signs last 10 days to 3 weeks often with good recovery
3.Neuropathology:
a.HS type 2 > than type 1
4.Laboratory evaluation:
a.Diagnosis is confirmed by PCR
b.CSF may demonstrate a lymphocytic pleocytosis
1.Upper roots of the lumbar plexus
2.Characteristic iliopsoas spasm
3.Hyperalgesia (mechanical of the lower abdomen)
1.L5 root most often affected
1.L5 root is most often affected
1.Dorsal root entry zone; meninges are inflamed and involve the cervical roots
2.Pachymeningitis cervicalis
3.HIV-associated
1.Surgery
2.Catheters (anesthesia for pain)
3.Osteomyelitis
1.Pyogenic organisms
2.Staph aureus is most common
3.Affects the disc space (end arterial supply)
a.Severely painful (vibration of the bed causes pain)
b.Very positive meningeal stretch signs
4.MRI:
a.Involvement of both the anterior and posterior longitudinal ligaments
b.Enhancement of the disc space, the nerve roots, and the paravertebral muscle
5.Contiguous spread of infection to nerve roots from osteomyelitis is the most common route of infections
1.Upper lumbar plexus involvement most commonly affected
1.The lumbar plexus may be compressed within the iliopsoas muscle
2.Femoral nerve in isolation may be compressed by an iliacus hematoma or hemorrhage (trauma or retractor)
1.Femoral nerve involvement
a.The iliacus fascia is tighter than the psoas fascia; smaller hematomas produce femoral compression more frequently than diffuse lumbar plexopathy
2.Pain in the groin radiating to the anterior thigh and medial lower leg (primarily L3-L4 roots and the saphenous nerve)
3.Position of comfort is a flexed upper leg
4.Positive reverse straight leg raising test
5.Minimally painful Patrick’s maneuver (internal/external rotation of the upper leg)
6.Weakness of the quadriceps; loss of sensation in the femoral nerve territory; loss of the quadriceps reflex
7.Grey-Turner’s is sign in approximately 5-10 days over the costovertebral angle (purple blood breakdown products)
8.Clinical manifestations of psoas muscle hematoma:
a.Severe groin and lower abdominal pain
b.The upper leg is not usually flexed at the hip:
c.Negative reverse SLR test (forced upper leg extension)
d.Rarely hip flexion with external rotation of the leg is painful
e.No palpable hematoma; rarely a groin mass in palpable
f.Thigh adductor muscle weakness (obturator nerve)
1.Iliacus and psoas hemorrhage; occur most often in anticoagulated patients
a.May be associated with an abrupt drop in hemoglobin
b.Rarely bilateral
c.Heparin has a greater incidence than coumadin; the newer anticoagulants have not yet been reported.
d.Often there is no preceding trauma
e.Most often a neuropractic nerve injury
1.Loss of the psoas shadow on a routine abdominal flat plate
2.MRI demonstrates the hemorrhage
1.Athletic injury; hyperextension and avulsion of the iliacus muscle from the ileum
2.Localized blunt trauma; pelvic fracture
3.Disseminated intravascular coagulation
4.Hemophilia and other clotting disorders
5.Leukemia
6.Aneurysmal rupture
7.Anticoagulation
i.May have a delayed onset of symptoms and signs (1-2 days after infusion)
ii.Diffuse lower extremity pain
iii.Minimal weakness or sensory loss
iv.Pain clears prior to recovery of motor function
1.There is a large arterial network with collaterals in the pelvis that usually permits ligation of an internal iliac artery with no adverse effects
2.The arterial network arises from anterior and posterior divisions of the internal iliac arteries which supply blood to the sciatic nerve and the gluteal musculature
3.The inferior gluteal artery supplies:
a.A branch of the anterior division
b.The pelvic viscera
c.The lower hip
d.Back of the thigh
4.The posterior division:
a.Gives origin to the superior gluteal artery that supplies:
i.The gluteal musculature
ii.The femoral nerve
iii.Sciatic nerve roots
1.Bilateral ischemic lumbosacral plexopathy from chronic aortoiliac occlusion:
a.Presentation with progressive paraplegia
2.Gluteal muscle necrosis and lumbosacral plexopathy after renal transplantation:
a.Diabetic patients may be at extreme risk
b.Paraplegia has been reported following renal transplantation after ligation of the hypogastric artery
c.Lumbosacral plexopathy has been reported after dual kidney transplantation and after pseudoaneurysm of the iliac artery in transplanted patients
d.Mortality is extremely high in patients with gluteal necrosis
e.Aortic aneurysms with hypogastric artery ligation during repair may be complicated by:
i.Gluteal necrosis and pain
ii.Rectal ischemia and pain
iii.Anal and bladder sphincter dysfunction
1.Atherosclerotic aortoiliac occlusion
2.Severe diabetic vasculopathy of the internal iliac arteries
3.Following pelvic vessel embolization for post-partum hemorrhage
a.May be associated with uterine necrosis
1.Arteriography to evaluate the aorto0iliac circulation and to delineate aneurysm of these arteries
2.Recognition of gluteal necrosis:
a.Occurs in approximately 3% of patients following internal iliac artery embolization performed in a traumatic situation
b.Gluteal necrosis often misdiagnosed as a contusion or pressure ulcer; often extremely painful
1.Carcinomatous meningitis
2.AIDP
3.CIDP
4.Arachnoiditis
5.Infections (CMV in particular)
6.Sarcoid
7.Leukemia/lymphoma
8.Tumor invasion
1.Level of the lesion may be:
a.Conus medullaris
b.Cauda equina
c.Proximal nerve trunks
d.Lumbosacral plexus
2.Clinical manifestation:
a.Acute lower extremity monoplegia
1. Undergrowth of the affected limb
2. Primarily in the sciatic nerve:
a.Progressive neuropathy
b.Shortened atrophic limb
c.Pes cavus
3. Undergrowth of bone with hip dysphasia
1. Normal differential muscle within the affected nerve or plexus