|Year : 2017 | Volume
| Issue : 1 | Page : 52-54
Lumbosacral plexopathies associated with acetabular fracture
Department of Rehabilitation, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
|Date of Web Publication||20-Mar-2017|
Department of Rehabilitation, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen 40002
Source of Support: None, Conflict of Interest: None
Lumbosacral plexopathies are of considerably less epidemiologic common prevalence than brachial plexus. The most common form of trauma resulting in lesions affecting the lumbosacral plexus is injuries to sacroiliac region. The symptoms which are caused by compressing lumbosacral plexus are sensory disturbance and weakness in an affected leg. The author reports a case of a 65-year-old male with a history of right acetabular fracture status post open reduction and internal fixation by plate and screw who complained weakness and numbness in the right leg. Four months later, he still had difficulty in walking and felt paresthesia at the right lateral thigh and entire of the right foot. His further investigation which was electrodiagnostic study was diagnosed as right lumbosacral plexopathies.
Keywords: Acetabular fracture, electrodiagnostic study, lumbosacral plexopathies
|How to cite this article:|
Sirasaporn P. Lumbosacral plexopathies associated with acetabular fracture. J Sci Soc 2017;44:52-4
| Introduction|| |
Lumbosacral plexopathies are of considerably less epidemiologic common prevalence than brachial plexus. This is due to the relatively guarded position of these neural structures and their decreased accessibility to injury. The simplest classification of lumbosacral plexopathies is categorized into two groups: structural and nonstructural. The structural causes are trauma, tumor, and surgical damage whereas the nonstructural etiologies are radiation, vasculitis, diabetes related, and infection., Nevertheless, the most common form of trauma resulting in lesions affecting the lumbosacral plexus is high-speed deceleration injuries to sacroiliac region.,, The incidence of lumbosacral plexopathies from sacral fracture which is significantly more common is about 2.03% whereas the incidence of lumbosacral plexopathies from acetabular fracture is about 0.7%.
The symptoms which are caused by insulting lumbosacral plexus vary according to the structures involved such as sensory disturbance and muscles weakness in an affected leg. Unfortunately, because of initial orthopedic stabilization and limitation by patient's pain, neurological assessment in acute phase is difficult to detect and is generally diagnosed during follow-up.
| Case Report|| |
A 65-year-old man with no underlying disease became persistent of the right leg weakness 4 months ago. He had sudden right leg weakness after he had fallen from the roof. After his accident, he also felt numbness of the right leg. The pelvic radiograph showed fracture of the right acetabulum with medial displacement [Figure 1]. Computed tomography scan of pelvis with three-dimensional reconstruction revealed fracture of the right acetabulum, and the fracture lines are extended into latero-superior, superomedial acetabular wall, and acetabular roof [Figure 2]. He underwent open reduction and internal fixation by plate and screw [Figure 3]. After few days postoperation, his symptoms were not improved. His muscle power of the right leg could not be precisely evaluated due to pain. Therefore, an orthopedic surgeon first ignored his symptoms.
|Figure 1: The pelvic radiograph showing fracture of the right acetabulum with medial displacement|
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|Figure 2: Computed tomography scan of the pelvis showing fracture of the right acetabulum and the fracture lines are extended into latero-superior, superomedial acetabular wall, and acetabular roof|
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|Figure 3: The pelvic radiograph showing acetabulum internal fixation by plate and screw|
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However, 4 months postoperatively, his symptoms did not recover and still had paresthesia at the right lateral thigh and entire of the right foot. He still had difficulty in walking. He must use an axillary crutch for helping his ambulation. The orthopedic surgeon reevaluated the patient and noticed abnormality of neurological system of the right leg. The patient was referred on to a rehabilitation clinic for further investigation. Therefore, electrodiagnostic study was performed to confirm and localize the lesion. At the rehabilitation clinic, physical examination revealed mild muscle atrophy at the right leg. Surgical scar at lateral of the right hip was detected. Motor power of the right iliopsoas, gluteus maximus, gluteus medius, adductor, and gastrosoleus muscles was Grade 2. Motor power of the right quadriceps was Grade 5. Motor power of the right hamstring was Grade 3 whereas motor power of the right tibialis anterior and extensor hallucis longus was Grade 0. Impaired pinprick sensation and light touch sensation at the right lateral thigh and entire of the right foot were noted. Tinel's sign was negative at the right popliteal fossa and the fibular head. Deep tendon reflex at the right ankle was absent.
Nerve conduction studies (NCS) and needle electromyography were conducted. NCS showed no electrical response at the right sural nerve [Table 1]. Needle electromyography showed increased insertional activity, variable of spontaneous activity, and impairment of recruitment at gluteus maximus, gluteus medius, long head of the right biceps femoris, tibialis anterior, and gastrocnemius muscles. There were normal insertional activity and no sign of spontaneous activity at the right adductor and paravertebral L5 level muscles [Table 2]. This result was summarized to the right lumbosacral plexopathies. He was advised for a range of motion exercise and strengthening exercise of the right leg muscles. In addition, ankle foot orthosis which helps to easily walk was advised to the patient.
Two months later, there was some improvement in the right tibialis anterior and extensor hallucis longus muscles. The numbness of the right leg diminished and there was no other complication.
| Discussion|| |
Lumbosacral plexopathies were significantly more common among patients with sacral fractures than among patients with acetabular fractures. Patients with lumbosacral plexopathies present frequently with varying degrees of lower extremity weakness and sensation changes which should be differentiated from sciatic neuropathy. Neurological findings of lumbosacral plexopathies include not only weakness of ankle dorsiflexion and plantar flexion, but also there is variable weakness of the gluteus and hamstring muscles. The hallmarks of electrodiagnostic study for lumbosacral plexopathies are spontaneous activity in peroneal, tibial, sciatic, superior gluteal and inferior gluteal innervated muscles. The motor and sensory NCS of an affected lower limb reveal diminished or no electrical response.
This report showed lumbosacral plexopathies from acetabular fracture. The causes of lumbosacral plexopathies in this patient may be a result of high-speed deceleration injuries to acetabulum and bony elements compromised to lumbosacral plexus.
The exact incidence of lumbosacral plexus injury associated with acetabular fracture is not accurately known. When an injury to sacroiliac or hip regions is observed, the patient should be cautiously evaluated for injury to lumbosacral plexus because it places directly over this area and any force sufficient to damage the bony parts may have been destroyed this neural structure. Nevertheless, the majority of traumatic lesions affecting the lumbosacral plexus are incomplete and the symptoms can achieve recovery.
| Conclusion|| |
Physicians should become aware of lumbosacral plexus injury, especially in acetabular fracture. Neurological evaluation is important during assessment of the patient. Lumbosacral plexus can be tested through sensation over lower extremity area and lower limb motor function. Due to the relative clinical presentations of lumbosacral plexopathies and peripheral nerve lesion, electrodiagnostic study is a crucial key in confirming diagnosis.
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| References|| |
Goodell CL. Neurological deficits associated with pelvic fractures. J Neurosurg 1966;24:837-42.
Sirasaporn P. Lumbosacral plexopathies: Causing by femoral head fracture. J Med Cases 2014;5:404-7.
Strakowski JA. Electrodiagnosis of plexopathy. PM R 2013;5 5 Suppl:S50-5.
Sugimoto Y, Ito Y, Tomioka M, Tanaka M, Hasegawa Y, Nakago K, et al
. Risk factors for lumbosacral plexus palsy related to pelvic fracture. Spine 2010;35:963-6.
Jang DH, Byun SH, Jeon JY, Lee SJ. The relationship between lumbosacral plexopathy and pelvic fractures. Am J Phys Med Rehabil 2011;90:707-12.
Chiodo A. Neurologic injury associated with pelvic trauma: Radiology and electrodiagnosis evaluation and their relationships to pain and gait outcome. Arch Phys Med Rehabil 2007;88:1171-6.
Yuen EC, Olney RK, So YT. Sciatic neuropathy: Clinical and prognostic features in 73 patients. Neurology 1994;44:1669-74.
Kutsy RL, Robinson LR, Routt ML Jr. Lumbosacral plexopathy in pelvic trauma. Muscle Nerve 2000;23:1757-60.
Goldberg G, Goldstein H. AAEM case report 32: Nerve injury associated with hip arthroplasty. Muscle Nerve 1998;21:519-27.
Stoehr M. Traumatic and postoperative lesions of the lumbosacral plexus. Arch Neurol 1978;35:757-60.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]