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Ann Thorac Surg 2002;73:119-122
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Injury of the common peroneal nerve after cardiothoracic operations

^a Departments of Thoracic and Cardiovascular Surgery, University Hospital RWTH, Aachen, Germany
^b Department of Neurology, University Hospital Rheinisch Westfälische Technische Hochschule, Aachen, Germany

Accepted for publication August 28, 2001.

* Address reprint requests to Dr Vazquez-Jimenez, Department of Thoracic and Cardiovascular Surgery, University Hospital, Pauwelsstr 30, D-52057 Aachen, Germany
e-mail: jvazquez-jimenez{at}post.klinikum.rwth-aachen.de

	Abstract

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Background. To assess incidence, etiology, and clinical relevance of common peroneal nerve injury (CPNI) in patients after cardiothoracic surgery.

Methods. In an 11-year period, CPNI was detected in 39 out of 20,718 patients (0.19%): 38 times after cardiopulmonary bypass (CPB) (38 of 12,726; 0.30%) and in 1 patient after a non-CPB procedure (1 of 7,992; 0.013%). These patients underwent intensive physiotherapeutic treatment. As the majority of CPNI occurred after CPB (97.4%), data of these patients were compared with a 1-year set of 1,032 patients who underwent CPB procedures.

Results. Patients with CPNI were older, had a higher percentage of subnormal body weight, and had considerable comorbidity such as peripheral arteriosclerotic disease, diabetes mellitus, and arrhythmias. Follow-up was complete (mean: 5.2 years; 0.4 to 10.7 years). Twenty-eight patients were free of symptoms; 10 patients complained of moderate symptoms, but were not limited in their everyday life; 1 patient still suffers from severe sensorimotor symptoms.

Conclusions. CPNI after cardiothoracic surgery is rare. Duration of the operative procedure, an increased comorbidity, and a subnormal body weight are assumed to have an etiologic impact. Prognosis is mostly good, but early physiotherapeutic treatment is crucial for prognosis.

	Introduction

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Nerve injuries after thoracic and cardiovascular surgery have been reported [1, 2], but generally concern the brachial plexus [2, 3], phrenic nerve [4, 5], recurrent laryngeal, and facial nerve [2]. Since 1985, the American Society of Anesthesiologists Closed Claims Study has collected information from 35 U.S. professional liability claims regarding anesthesia settlements. In the total of 4,183 cases, 670 (16%) nerve injury claims have been reported. The most frequent sites of injury were ulnar nerve (28%), brachial plexus (20%), lumbosacral nerve root (16%), and spinal cord (13%). There were no peroneal nerve injuries related to cardiac surgery [6]. The incidence of common peroneal nerve injury after cardiothoracic surgery is unknown.

In our MEDLINE literature review, only 5 patients in two reports from Japan [7, 8] were found. Patients with postoperative lesion of the common peroneal nerve may show severe sensorimotor disturbance with inability of dorsiflexion and eversion of the foot requiring intensive physiotherapy. In order to assess incidence and clinical relevance of this sequela after thoracic and cardiovascular surgery, a retrospective study on more than 20,000 patients was performed.

	Material and methods

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Differential diagnosis of foot elevation palsy
Acute weakness of foot elevation can have different etiologies. Radiculopathy of the L5 root has to be differentiated from acute palsy of the common peroneal nerve injury (CPNI) or palsy of the peroneal portion of the sciatic nerve. Since clinical examination does not always allow a clear differentiation between these entities, electrophysiological examination often is required. It has to be considered that electromyography usually is not performed in anticoagulated patients and that signs of denervation can be detected, at the earliest, 10 to 14 days following peripheral nerve lesion.

Acute radiculopathy of the L5 root results in pain and sensory deficits in the corresponding dermatome. Beside foot and toe elevation palsy, inversion of the foot can be ineffective due to weakness of the tibialis posterior muscle. In differentiating between acute L5 radiculopathy and CPNI, electromyographical examination of this muscle can be very helpful since its innervation runs via the tibial and not the peroneal nerve [8]. Thus the tibialis posterior muscle is spared in CPNI.

Complete plegia of dorsiflexion and eversion of the foot without any history of pain is most likely due to a lesion of the common peroneal nerve. Since in most cases the lesion site is located in the area of the fibular head where the nerve runs superficially [9], a history of acute compression or chronic exposure to pressure can usually be found. Motor nerve conduction study of the common peroneal nerve reveals a complete or partial conduction block or a significant slowing of motor conduction across the head of the fibula.

If nerve conduction studies do not give any evidence for a lesion of the peroneal nerve at the head of the fibula, a more proximal lesion of the peroneal part of the sciatic nerve has to be considered. In these cases, electromyography typically reveals signs of denervation in the short head of the biceps femoris muscle which is spared in CPNI. The peroneal portion of the sciatic nerve is known to be very sensitive to ischemia or pressure [10]. If no focal lesion can be found, clinical examination, blood tests, and electrophysiological examination have to be performed to look for signs of polyneuropathy (Table 1).

View larger version (18K): [in this window] [in a new window]   Fig 1. Operative procedures in 39 patients with injury of the common peroneal nerve. (CABG = coronary artery bypass grafting.)

Statistics
Since the vast majority of patients with CPNI had undergone CPB, data of these patients were compared with an available set of data of CPB patients of a complete year. In 1996, a total number of 1,032 patients were operated on with CPB. Since the number of patients in both groups differs markedly, no statistical test applies; therefore, the comparison of both groups is rather descriptive.

	Results

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Among all patients with CPNI, 23 (59%) had a unilateral, and 16 (41%) a bilateral, lesion. Paralysis and paresthesia was found in 38 patients (97.4%), and paresthesia only in 1 (2.6%). A proofed peroneal lesion on the basis of electromyography was found in 8 patients (21%). The diagnoses were made clinically in 26 patients (67%): a peroneal and ischiadicus lesion was found in 2 patients (5.2%), and in three patients (7.7%), the localization and extension of the lesion could not be exactly defined. All patients underwent intensive postoperative physiotherapeutic treatment.

Comparison of demographic data revealed that patients with CPNI were older. The percentage of patients with a body weight 10 or more percent below normal (normal [kg] = body height [in cm] - 100) was higher in the CPNI group; in contrast, the percentage of patients with a body weight 10 or more percent above normal was higher in the reference group. The majority of patients with CPNI had a history of heart failure and a higher incidence of peripheral vascular disease, diabetes mellitus, and arrhythmias. At the time of operation, more than 50% of patients with CPNI were in New York Heart Association or Canadian Cardiovascular Society greater than or equal to class III. Operation time and intensive care stay were also longer in the CPNI group (Table 2, Fig 1).

	Comment

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Ischemia due to compression or stretching is thought to be the principal cause of peripheral nerve injury in anesthetized patients [11]. Most of these nerve injuries occur as a result of incorrect positioning during operation. The peroneal nerve is injured most frequently at the level of the fibula head because of its superficial location [7]. A subnormal body weight, more prevalent in the CPNI group, may contribute to this pathomechanism. In our department, all patients operated on with CPB received the same standard leg positioning and protection on the operating table. Although this does not exclude malpositioning, we assume that two additional factors may contribute to this type of nerval lesion: the associated comorbidity and the use of CPB.

Arteriosclerosis makes nerves more susceptible to ischemia [2]. In our study, 59% of patients with CPNI needed coronary surgery and a considerable percentage had peripheral arteriosclerotic disease. Diabetes mellitus, as found in approximately one-third of patients with CPNI, has also been reported to make nerves more vulnerable to ischemia [2]. The majority of the patients had a history of heart failure in the past and were markedly limited by their cardiac disease at the time of operation.

Although cardiopulmonary bypass is associated with hypothermia, hypotension, hemodilution, low-flow perfusion, and absence of pulsatile flow, CPB seems not to play an important role in nerve injury since in our study only 38 of 12,726 (0.30%) had CPNI. In future, it would be of interest to compare these patients with patients who have undergone off-pump cardiac surgery to analyze the influence of CPB on common peroneal nerve injury. The relatively high number of redo operations in the CPNI group (22 out of 38; 58%), associated with a longer operation time, may enhance the probability of CPNI.

The development of CPNI is probably the result of the coincidence of several risk factors. Preoperative medical history and careful neurological examination can be helpful to identify patients at risk, since preoperative neurological lesions, even when completely recovered, tend to reoccur after CPB [2]. After operation, accurate neurological examination is necessary to assess the true incidence of this complication, because, as reported by Keates and colleagues [2], many neurological lesions remain unnoticed by the patients and may only be discovered after selective neurological examination.

Differential diagnosis of CPNI requires specific neurological examination. Electromyography is the method of choice, however, if the patient is under anticoagulation treatment, as many patients in our institution are, this examination cannot be made safely and, therefore, diagnosis is made on the basis of clinical examination and neurography.

In summary, CPNI is a rare complication after cardiothoracic operations. We assume that the duration of the operative procedure, an increased comorbidity, and a subnormal body weight may increase the risk for this sequelae. Differential diagnosis of CPNI requires specific neurological examination; electromyography is the method of choice. However, the prognosis of this postoperative complication is good, although long-lasting moderate-to-severe impairment of the nerval function is observed. Early diagnosis and physiotherapeutic treatment is crucial for recovery.

	References

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1. Parks B.J. Postoperative peripheral neuropathies. Surgery 1973;74:348-357.[Medline]
2. Keates J.R.W., Innocenti D.M., Ross D.N. Mononeuritis multiplex: a complication of open heart surgery. J Thorac Cardiovasc Surg 1975;69:816-819.[Abstract]
3. Honet J.C., Raikes J.A., Kantrowitz A., Pursel S.E., Rubenfire M. Neuropathy in the upper extremity after open-heart surgery. Arch Phys Med Rehabil 1976;57:264-267.[Medline]
4. Kohorst W.R., Schonfeld S.A., Altmann M. Bilateral diaphragmatic paralysis following topical cardiac hypothermia. Chest 1984;85:65-68.[Abstract/Free Full Text]
5. Brown K.A., Hoffstein V., Bryck R.J. Bedside diagnosis of bilateral diaphragmatic paralysis in a ventilator-dependent patient after open-heart surgery. Anesth Analg 1985;64:1208-1210.[Abstract/Free Full Text]
6. Cheney F.W., Domino K., Caplan R.A., Posner K.L. Nerve injury associated with anesthesia. Anesthesiology 1999;90:1062-1069.[Medline]
7. Hatano Y., Arai T., Iida H., Soneda J. Common peroneal nerve palsy: a complication of coronary artery bypass grafting surgery. Anaesthesia 1988;43:568-569.[Medline]
8. Saitoh K., Kamata J., Ueshima K., et al. Supervised cardiac rehabilitation for patients with the disturbance of the motor function after cardiac surgery: the significance of physical therapists’s participation. Kyobu Geka 1998;51:1090-1094.[Medline]
9. Stewart J.D., Aguayo A.J. Compression and entrapment neuropathies. In: Dyck P.J., Thomas P.K., Lambert E.H., eds. Peripheral neuropathy, Vol II. Philadelphia: WB Saunders, 1984:1435-1457.
10. Sunderland S. The relative susceptibility to injury of the medial and lateral popliteal divisions of the sciatic nerve. Br J Surg 1953;41:300-303.[Medline]
11. Britt B.A., Joy N., Mackay M.B. Positioning trauma. In: Orking R.K., Cooperman L.H., eds. Complications in anesthesiology. Philadelphia: JB Lippincott, 1983:647-670.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jaime F. Vazquez-Jimenez Oliver J. Liakopoulos Georg Wendt Bruno J. Messmer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vazquez-Jimenez, J. F. Articles by Messmer, B. J. Search for Related Content PubMed PubMed Citation Articles by Vazquez-Jimenez, J. F. Articles by Messmer, B. J. Related Collections Cardiac - other Related Article