Bilateral meralgia paresthetica after cesarian section with epidural analgesia

Journal of the Peripheral Nervous System 11:98–99 (2006)

LETTER TOTHE EDITOR

Bilateral meralgia paresthetica after cesarian section with epidural analgesia

Dear Editor, Meralgia paresthetica (MP) is a sensory mononeuropathy of the lateral femoral cutaneous nerve (LFCN) usually caused by an entrapment at the anterior superior iliac spine (Kitchen and Simpson, 1972). Besides idiopathic cases, MP has also been associated with weight changes (pregnancy, possibly obesity), trauma in the pelvic or lower spine area, iatrogenic complications (orthopedic, obstetric, or abdominal surgery), external compression, and strenuous exercise (Van Diver and Camann, 1995; Grossman et al., 2001; van Slobbe et al., 2004; Kho et al., 2005). In most individuals, MP affects only one of both nerves, but 8–12% of patients experience bilateral symptoms (Kitchen and Simpson, 1972). The first description of bilateral MP was by Sigmund Freud who suffered from this condition. Epidural analgesia as well as delivery itself can cause numerous neurological complications, among them MP. However, to our knowledge, a simultaneous bilateral lesion of the LFCN following cesarian section with epidural analgesia in a parturient suffering from vasculitis has not yet been reported. A 30-year-old primipara underwent a routine cesarian section with epidural analgesia. On the second postoperative day, she complained of numbness and paresthesias in the anterolateral part of both thighs. The neurological examination showed normal tendon reflexes of the upper and lower limbs with absence of motor signs but hypalgesia and hypesthesia of the anterolateral part of both thighs in the area of innervation of the LFCN. There were no further sensory disturbances. Electrodiagnostic procedures showed no reproducible sensory nerve action potential of the LFCN; nerve conduction examinations of the peroneal, tibial, and sural nerves were normal. A postpartal magnetic resonance imaging (MRI) of the thoracic and lumbar spine and the abdomen, including the groin, revealed no disc hernia or spinal/epidural

hemorrhaging, no retroperitoneal or subligamental hematoma, and no visible compression of the LFCNs from other etiology. There was only a slight subcutaneous accumulation of postoperative fluid in the suprapubic and groin region. The neurological symptoms improved within several weeks after delivery. The patient had been suffering from a leukocytoclastic vasculitis (histologically proven by skin biopsy) with palpable cutaneous purpura on the thighs for about 2 years and had been on immunosuppressive treatment with cylosporine, azathioprine, and mycophenolate mofetil, which was discontinued because of pregnancy. By the time of delivery, she was taking 30 mg prednisolone daily. Under immunosuppressive treatment, serologic findings of vasculitis were normal (ESR 14/30, negative testing for ANA, p-ANCA, c-ANCA, ENA, anti-gliadin antibodies, smooth-muscle antibodies, thyroid antibodies, anti-ds-DNA antibodies, and anti-phospholipid antibodies), as were infectiological parameters (negative tests for borreliosis, syphilis, hepatitis B and C, and HIV I and II) and the results of cerebrospinal fluid (CSF) analysis. Judging by the clinical findings and normal results of neurographical and electromyographical tests, the vasculitis had so far not affected the peripheral nervous system. There were no neurological disorders in her family history. The occurrence of neurological symptoms after delivery with epidural analgesia requires broad diagnostic considerations; concomitant vasculitis as in our patient makes these even more challenging. Albeit rare, meningitis, spinal/epidural hemorrhaging, spinal ischemia, arachnoiditis, abscess, and toxic or traumatic nerve root irritation or lesion as a complication of epidural analgesia have to be ruled out. The lumbar plexus as well as the femoral nerve, obturator nerve, and the LFCN are at risk of pressure palsy during labor and delivery. During cesarian section, intraoperative procedures can cause irritation or lesion of the nerves of the lumbar plexus. The clinical distinction of symptoms caused by epidural analgesia from those through delivery or cesarian section can be difficult and may require further imaging and electrodiagnostic procedures.

Address correspondence to: Dr Friedemann Paul, Institute of Neuroimmunology, Neuroscience Research Center, Charite´, Humboldt-University, D-10098 Berlin, Germany. Tel: þ49-30-450660162; Fax: þ49-30-450-539906; E-mail: friedemann.paul@ charite.de

 2006 Peripheral Nerve Society

98

Blackwell Publishing

Letter to the Editor

Journal of the Peripheral Nervous System 11:98–99 (2006)

possible differential diagnosis of postpartal neurological symptoms.

Clinical and paraclinical findings in our patient and the timeframe of symptoms suggest bilateral MP. We initially considered a traumatic or toxic effect of epidural analgesia. However, our patient did not experience any paresthesias or pain in the legs during and immediately after epidural analgesia, and MRI of the thoracic and lumbar spine was normal. In addition, the symmetric appearance and the distribution of the sensory disturbances make a traumatic or toxic nerve root lesion very unlikely. In contrast, bilateral nerve root irritation is frequently reported after epidural analgesia, however, improvement of symptoms within weeks and not hours or days argues against this etiology. A lumbar disc herniation was ruled out by MRI, as was a retroperitoneal mass or tumor within the length of the LFCN. The LFCN is not a known target of vasculitis, and the bilateralism of the lesion as first and only sign of an involvement of the peripheral nervous system in the course of our patient’s vasculitis is even more doubtful. We believe MP in this case to be of a mechanic origin after pelvic surgery (i.e., bilateral pulling or manipulation of the nerves during cesarian section), possibly with a predisposition due to an anatomical variation of the LFCN. A bilateral lesion of the LFCN as a rare complication of cesarian section has to be considered as a

Sincerely, Friedemann Paul, Frauke Zipp Institute of Neuroimmunology, Neuroscience Research Center, Charite´, HumboldtUniversity, Berlin, Germany

References Grossman MG, Ducey SA, Nadler SS, Levy AS (2001). Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg 9:336–344. Kho KH, Blijham PJ, Zwarts MJ (2005). Meralgia paresthetica after strenuous exercise. Muscle Nerve 31:761–763. Kitchen C, Simpson J (1972). Meralgia paresthetica. A review of 67 patients. Acta Neurol Scand 48:547–555. Van Diver T, Camann W (1995). Meralgia paresthetica in the parturient. Int J Obstet Anesth 4:109–112. van Slobbe AM, Bohnen AM, Bernsen RM, Koes BW, BiermaZeinstra SM (2004). Incidence rates and determinants in meralgia paresthetica in general practice. J Neurol 251: 294–297.

99

Be first to know with

Blackwell Synergy Alerts Blackwell Synergy E-mail Alerts bring you the information that you want, delivered directly to your desktop as soon as it is published. Sign up for FREE E-mail Alerts today and keep informed with the latest essential research.

To sign up visit www.blackwell-synergy.com and follow these 3 easy steps:

1 2 3

Register with Blackwell Synergy (Already a member? Skip to Step 2) On your ‘My Synergy’ homepage, click the blue tab that says “E-mail Alerts”

Check the box alongside the journals of your choice, choose the format for your e-mail messages and submit the form

Research at your fingertips!