Child's Nerv Syst (i993) 9:229-232
m NS
9 Springer-Verlag 1993
Injection injury of the sciatic nerve (370 cases)
Francisco J. Villarejo, Alfonso M. Pascual
Department of Neurosurgery, Nifio Jesus Hospital, Madrid, Spain Received: 24 September 1992
Abstract. Injury to peripheral nerves due to injections o f therapeutic and other agents is common. The postulated mechanisms o f injury include direct needle trauma, sec- o n d a r y constriction by scar, and direct nerve fiber dam- age by neurotoxic chemicals in the injected agent. Neuro- logical sequelae can range from m i n o r transient sensory disturbance to severe sensory disturbance and paralysis with p o o r recovery. The r e c o m m e n d e d treatment has ranged from a conservative a p p r o a c h to immediate oper- ative exposure and irrigation, and has also included early neurolysis or delayed exploration with neurolysis or re- section and anastomosis. We present 370 cases o f injec- tion injury o f the sciatic nerve in children treated during the last 20 years at the Neurosurgical D e p a r t m e n t o f the Hospital La Paz in Madrid, Spain. Pathology, clinical course, treatment, and results are discussed.
Key words: Injection injury -- Peripheral nerve - Nerve injury - Electromyogram - Neurolysis
Introduction
Accidentally produced disability during the course o f treatment o f any illness is a distressing event; an excellent example o f this is injection injury o f a peripheral nerve [1, 4 , 7 , 9 , 10].
The most c o m m o n l y affected nerve is the sciatic, specifically the peroneal component. The reason for this is simple: the buttock is the most frequent site o f injec- tion.
Turner in 1920 [14] reported two patients with sciatic paralysis due to quinine injection. Perret in 1954 [11]
collected 91 cases o f sciatic nerve injury in a 5-year peri- od.
In 1960, Combes and Clark [3] reported 12 children with injection injury to the sciatic nerve. Curtis and Tuck-
Correspondence to: F.J. Villarejo
er [4] in the same year reported 10 cases. Gilles and French [7] in 1961 reported 21 cases in children.
Hochstetter [8] reviewed the various aspects o f injec- tion injury to the sciatic nerve and found that any drug was able to produce damage, but some drugs were more dangerous than others. The site o f drug injection is the crucial factor in determining the degree o f nerve fiber injury. Most moderate or severe injection injuries are the result o f direct intrafascicular injection into the nerve trunk. The nature o f the injection c o m p o u n d is also im- p o r t a n t as certain drugs are m u c h more damaging than others when injected into a peripheral nerve [2, 3, 5].
Postulated mechanisms o f injury have included aller- gic neuritis [10, 15], ischemia [8], needle injury [12, 13], circumferential constriction by scar [3], and direct nerve fiber damage by neurotoxic agents injected into or a b o u t the nerve [2, 7].
Patients and methods
We have reviewed 370 cases of children with injection injury of the sciatic nerve or its peroneal and tibial components by injections into the buttock, treated at the Neurosurgical Department of the Hospi- tal La Paz in Madrid, Spain.
Three hundred and five cases presented motor problems and 65 cases presented sensory loss. We excluded 113 patients out of 305 patients in this report.
The yearly rate of injury was high during the first years and dropped after 1975 (Fig. 1).
The nature of the injected compounds was in most cases antibi- otics, and most of these lesions occurred during the 1st year of life (Table 1).
Children old enough to describe the event suffered onset of the neurological deficit either immediately or within minutes of the injection. Pain was present in the majority and was described as severe, shooting, and localized in the distribution of the nerve.
In the infant group it was difficult to establish the precise onset of injury, because most of the patients received multiple injections.
Motor and sensory disturbance, which could be partial or complete, rapidly followed the initial pain after injection (Fig. 2).
All patients described received injections in the buttocks.
In our 192 patients with motor disturbances, 133 had the com- mon peroneal component of the sciatic trunk at the buttock affect-
230
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Time
Fig. 1. Incidence of sciatic nerve injury by injection in children 1965-1984
Table 1. Age at injury
Age No. of cases
Newborn- 12 months 184
1 year - 2 years 60
2 years-3 years 21
3 years-4 years 15
4 years- 5 years 12
5 years-6 years 7
6 years-7 years 3
7 years-8 years 2
8 years-9 years 1
Table 2. Analysis of 192 cases with motor weakness
Nerve affected Extent of No. of
injury patients
Common peroneal nerve Paralysis 117
(N. fibularis communis) Palsy 16
Tibial nerve Paralysis 5
(N. tibialis) Palsy 10
Sciatic nerve Paralysis 30
(N. ischiadicus) Palsy 14
Fig. 2. Child with right footdrop
ed. Only 15 patients had the tibial component of the sciatic trunk at the buttock affected and 44 patients had both the common per- oneal and the tibial components of the sciatic nerve trunk at the buttock affected (Table 2).
Before 1978 we performed 11 neurolyses and treated 64 patients with physical therapy for injuries to the common peroneal nerve. In the patients treated with physical therapy we had 46 excellent re- sults, 7 good results, and 11 bad results. Physical therapy is used to maintain muscle tone and range of motion and to avoid stiffness of joints.
Among the 11 operated patients, 3 had neurolyses without phys- ical therapy with excellent results and 8 had physical therapy prior to neurolysis, but only 4 of these had excellent recovery, those who had some motor power and electrical activity in the EMG (Fig. 3).
Among the 11 patients in whom physical therapy alone proved to be unsuccessful, 5 had a paralysis and absence of efferent poten- tials in the EMG at 3 and 5 months after the injury, and 6 were seen 9 and 12 months after the injury with paralysis and no electrical activity in the EMG.
The 46 patients with excellent recovery after physical therapy and the 7 patients with good recovery after physical therapy had some motor and efferent activities prior to treatment, although they were seen between 2 and 10 months after the injury.
Twelve patients with paralysis of the sciatic nerve trunk did not improve with physical therapy.
Patients treated after 1978 followed a different protocol, and we identified two groups:
1. Patients with a good prognosis, including patients in whom the neurological examination showed some motor power or efferent potentials in the EMG and who had progressive improvement in motor power and EMG in the first 3 months foUowing the injection injury.
2. Patients with a bad prognosis, including patients with complete paralysis, absence of efferent potentials in the EMG, and no im- provement in the 3 months following the injury.
Patients in the first group were treated with rehabilitation and patients in the second group underwent internal neurolysis by mi- crosurgical techniques with liberation of nerve fascicles.
Patients treated after 1978 had a different evolution. Thirty-two neurolyses were performed with excellent results in patients with a bad prognosis, and 10 patients with an initially good prognosis had excellent recovery with physical therapy alone (Fig. 3).
Sixteen patients with palsy of the common peroneal nerve com- ponent had excellent results with rehabilitation (Fig.3).
In five patients with paralysis of the tibial nerve component, two neurolyses were performed with excellent results, and another three patients were treated with physical therapy, with excellent results (Fig. 4).
Ten patients with palsy of the tibial nerve received physical therapy with excellent results (Fig. 4).
In 30 patients with paralysis of the sciatic nerve trunk (both peroneal and tibial components), 5 were treated with neurolysis. In 3 good results were achieved and in 2 the evolution was poor.
Twenty-five patients received physical therapy with 13 good results and 12 bad results (Fig. 5).
In the three patients treated with neurolysis in which we had good results, the neurological evaluation showed absence of motor power and absence of efferent potentials in the EMG examination prior to surgery, but they were operated on between 3 and 6 months after the injury. Two patients with bad results were operated on 10 and 12 months after the injury, and in these the neurological exam- ination and EMG exploration were similar to those in the cases above (Fig. 5).
Twenty-five patients were treated with physical therapy alone.
The 13 patients in whom we saw good results had some motor power in the neurological examination before physical therapy was
80 Before 1978 64
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Neurolysis Rehabilitation
9 Total [ ] Excellent Paralysis [ ] Good
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Neurolysis Rehabilitation
Fig. 3. Outcome in 133 cases of common peroneal nerve paralysis or palsy treated before and after 1978
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Palsy Fig. 4. Outcome of 15 cases of tibial nerve injury
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Paralysis 25 Palsy
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Neurolysis Rehabilitation Neurolysis Fig. 5. Outcome of 44 cases of sciatic nerve injury
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Rehabilitation
started and had efferent potentials at E M G examination. They were seen between 2 and 8 months after the injury.
The 12 patients with bad results had absence of efferent poten- tials in the E M G examination and no motor power at neurological exploration prior to rehabilitation (Fig. 5).
In 14 patients with palsy of the sciatic nerve, 7 neurolysis were performed with excellent results and 7 patients had physical therapy with excellent results. All cases were treated between 2 and 8 months after the injury (Fig. 5).
Discussion
After reviewing our cases, we can say that injection injury of the sciatic nerve is most frequent in children under 1 year of age. The reasons for this are:
231 1. In children weighing 5 kg or less, the distance between the skin of the gluteal region and the sciatic nerve is always less than 2 cm, and if the weight is less than 3 kg, the distance is 1.5 cm.
2. If the needle is introduced perpendicularly anywhere in the gluteal skin, the tip of the needle is always directed to the sciatic nerve because the nerve is the axis or the center of the gluteal sphere [6].
3. I f the injection is done with flexion of the hips and extension of the legs, the sciatic nerve is fixed in this position.
4. The size of the nerve in relation to the volume o f the gluteal region is larger in newborns than in older chil- dren.
5. The area for injection in newborns and young children is very small, and it is for this reason and due to lack of skill in injections that there have been so m a n y injuries of the sciatic nerve.
The reason for the higher frequency of damage at the level of the c o m m o n peroneal component of the sciatic nerve at the buttock, is that this nerve is located more laterally than the tibial nerve component.
Figures 3 - 5 show that palsy of these nerves has an excellent prognosis and treatment should be only physi- cal therapy. We believe that the seven operated patients with sciatic nerve palsy would have done well without surgical treatment.
It is important to follow the protocol established after 1978, based on the neurological examination, E M G , and follow-up for the first 3 months after the injury. Patients should be operated on 3 months after injury if motor power and E M G findings do not improve in spite of physical therapy. I f the motor power and E M G findings improve during these 3 months, patients should continue with physical therapy.
Since the above criteria were used after 1978 we have achieved 100% excellent results with surgical treatment.
Regarding physical therapy, before 1978 we had 61%
excellent results, while after 1978 we got 100% excellent results. The difference in these figures is due to the fact that some cases before 1978 should have been operated on but were not, and the other cases were chronic.
Lesions o f the tibial nerve component of the sciatic nerve have a better outcome than lesions o f the c o m m o n peroneal nerve component.
For lesions of the sciatic nerve trunk or tibial nerve component with paralysis, our criteria are similar to those for lesions of the c o m m o n peroneal nerve compo- nent, because excellent or good results were achieved when the patients were operated on between 3 and 6 months after the injury, and most of them did not have any motor power at neurological exploration and did not have efferent potentials at E M G examination.
Most bad results occurred in chronic cases without motor function at the time of the neurological examina- tion and absent efferent potentials on EMG. This applies to treatment with either neurolysis or rehabilitation. For this reason, the diagnosis must be made as soon as possi- ble.
232
W e c o n s i d e r as c h r o n i c cases p a t i e n t s t r e a t e d 6 m o n t h s a f t e r the i n j e c t i o n i n j u r y . M o s t a u t h o r s d o n o t s t a t e a n y r o u t i n e as to w h e n these p a t i e n t s s h o u l d be o p e r a t e d on.
C l a r k [2] p r e f e r r e d to d o t h e o p e r a t i o n 6 m o n t h s a f t e r the i n j u r y . H u d s o n et al. [9] a d v i s e t h a t these lesions s h o u l d be f o l l o w e d closely a n d t h a t c o n s e r v a t i v e m a n a g e m e n t s h o u l d n o t b e p r o l o n g e d in p a t i e n t s w h o d o n o t s h o w r e c o v e r y a t t h e e x p e c t e d t i m e f o l l o w i n g i n j u r y .
References
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2. Clark WK (1970) Injection injury of the sciatic nerve. Clin Neurosurg 17:111 - 125
3. Combes M, Clark WK (1960) Sciatic nerve injury following intragluteal injection: pathogenesis and preventions. Am J Dis Child 199:579
4. Curtis PH Jr, Tucker HJ (1960) Sciatic palsy in premature infants. A report and follow-up study of ten cases. JAMA 174:1586-1588
5. Elkington JSC (1942) Peripheral nerve palsies following intra- muscular injections of sulphonamides. Lancet 2:425-427
6. Esteban Mugica B, Diaz Faes J (1981) Lesiones del nervio cifitico postinyecci6n glfitea. Estudio clinico. Rev Ortop Trau- ma 25:67-80
7. Gilles FH, French JH (1961) Postinjection sciatic nerve palsies in infants and children. J Pediatr 58:195-198
8. Hochstetter A v o n (1955) Ober Probleme und Technik der intragl~ialen Injektion. I. Der EinfluB des Medikaments Indi- vidualit~it des Patienten auf die Entstehung yon Spritzen.
Schweiz Med Wochenschr 85:1138-1140
9. Hudson FP, McCandless A, O'Malley AG (1950) Sciatic paral- ysis in newborn infants. Br Med J 1:223-225
10. Kolb LC, Gray SJ (1946) Peripheral neuritis as a complication of penicillin therapy. JAMA 132:323-325
11. Perret W (1954) Injection paralysis disorders of sensorimotor function of the leg following intramuscular injections in the gluteal regio. Schweiz Arztez 35:59-62
12. Scheimberg L, Allensworth M (1957) Sciatic neuropathy in infants related to antibiotic injections. Pediatrics 19:261-269 13. Selander D, Dhuner KG, Lundborg G (1977) Peripheral nerve
injury due to injection needles used for regional anaesthesia: an experimental study of the acute effects of needle point trauma.
Acta Anaesthesiol Scand 21:182-188
14. Turner GG (1920) The site for intramuscular injections. Lancet 2:819-825
15. Young F (1932) Peripheral nerve paralysis following the use of various serums: report of a case and review of the literature.
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