Aa
Left femoral neuropathy s/p LTKR
(Grab a coffee... This will be a long one, I apologize in advance) I’m a 45 yo F s/p TLKR in 11/10. I am s/p a 3 level ACDF w/ instrumentation and subsequent implantation of an occipital neuromodulator due to occipital neuralgia, a side effect of the ACDF. I cannot undergo MRIs.
LTKR - I had a spinal epidural and a tourniquet was applied. I did not have a femoral block. Tourniquet time 101 mins. I had the immediate inability to bend my leg (I could not "dangle" my leg in any way the morning after) or lift my leg. I had an ultrasound which showed possible musculotendinous partial tear of the vastus medialis component. I started PT the day after surgery and continued with home PT. My PT felt right away there was something wrong, as I could not, even with intense PT, bend my leg more than 60 degrees. I was scheduled for an EMG/NCS on 12/21. This was the most painfully horrific thing I have EVER experienced. Findings -
- Likely left femoral neuropathy proximal to the motor branch of the iliopsoas; w/ approx 50% motor axon loss to the vastus medialis. Evidence of left sided focal femoral mononeuropathy of the left iliopsoas, vastus medilis. This is clouded somewhat by the abnormalities throughout the rest of the left lower limb and in the right as below. Side to side CMAP amplitude comparisons of the vastus medialis from the femoral nerve indicate approx 50% motor axon loss.
- Possible left and right L5 or S1 radiculopathy, plexoapthy, cannot rule out left lumbosacral panplexopathy.
Clinical Impression - Left femoral neuropathy w approx 50% motor axon loss to the vastus medialis. If this was related to a one-trauma the prognosis for functional recovery is good, which usually takes place at 1 inch per month as a rough estimate, and therefore could take 6-12 months or even longer. There was no current evidence of axonal sprouting or regrowth, but serial limited EMGs could be done in the future to see if this is occurring. Imaging of the spine is recommended.
I underwent a CT myelogram which was WNL.
I continued with the inability to bend my leg, lift my heel off the ground when sitting with my foot resting on the ground, and was now only bending to approx 40 degrees with PT. Also of note, I have not had feeling in the top portion of the front of my thigh since my surgery. On 2/22/11 I underwent manipulation. After asleep, drop and dangle was 50 degrees. He manipulated me and ROM was 110 degrees in the OR. Before I left the hospital the next morning I was at 85 degrees. Discharged home on a CPM machine for 20 hrs/day x 3 weeks.
As I write this, my issues continue. I remain in PT. If I am standing and bend my leg at the knee I can get to maybe 60 degrees, with help or bracing my foot on the floor, I can bend to 80 degrees. This has remained unchanged for months. My left thigh and left calf are significantly smaller than my right - even immediately after surgery when the PT was coming to the house, my L calf measured 1" smaller than the R - it is approx 2" smaller now. I have profound weakness and my knee buckles/gives out frequently. Sitting in a hard chair with an edge pressing on the back of my thigh causes a sharp pain from my low back/hip down my leg. I use a crutch to keep me from falling when walking. I am nowhere near able to walk up/down stairs normally, and do them one at a time, the top of the front of my thigh is completely numb, my knee is swollen, it basically doesn't function properly as the muscle doesn't track the kneecap correctly, which causes intense pressure and pain in the knee (my PT pushes my kneecap in as far as he can and tapes it there for PT – this helps alleviate a bit of the pressure), I cannot lift my leg more than an inch or so while sitting in a recliner, I need to use a leg lifter to get my leg in the car when I drive, I have leg pain/deep ache throughout my entire L leg, moderately severe to severe knee pain 24/7 that persists despite the low dose of pain meds I take to help me function through the day - if I take more I can't function sharply and my job requires that I'm coherent. (The list goes on)
I have been seen by a local neurosurgeon who didn't feel there was anything he could do, I've seen a pain mgt doc who wanted to diagnosis me with Complex Regional Pain Syndrome and put long needles into my back for some diagnostic study (no more needles in the back for me!!), I went to NYC to see an orthopedic specialist who felt my new knee was placed "okay" and that there was nothing he could do to help except get me more ROM, which would be a detriment at this point. The general consensus of all I have seen is either - the tourniquet was too tight/on for too long causing damage to the femoral nerve, or something went wrong with the spinal epidural anesthesia. Whatever happened… caused the damage, but has since repaired itself, leaving behind the damage to the femoral nerve. I am currently trying to get into a local neurologist to have him look over my studies and get his opinio although getting doctors to see me, or "take on another doctor's difficult case" isn't always as easy as making a phone call.
My OS had me undergo another EMG/NCS on 8/2/11 to see how much improvement has been made since December. While showing improvement, it was still abnormal.
- Left femoral neuropathy. There is evidence of a left sided focal femoral mononeuropathy as shown by the abnormalities on needle EMG of the vastus lateralis and the decreased left femoral CMAP to the vastus medialis when compared to the right. This is improved since the previous study and no longer are abnormalities seen on the EMG of the iliopsoas or vastus medialis. There is no evidence of wide highly polyphasic low amplitude nor high amplitude motor unit action potentials to suggest axonal regrowth or collateral sprouting. It may be that the normal motor units seen are evidence of mature axonal regrowth. This may account for the decreased abnormal spontaneous activity. Side to side CMAP amplitude comparisons are similar to the previous study. Saphenous SNAP is approx 50% amplitude on the contralateral limb showing evidence of sensory axon loss as well.
There is no longer evidence of a left lumbosacral radiculopathy or plexopathy.
Clinical Impression: Test shows evidence of some improvement. However, clinically she does not seem to have had improvement in motor function. There remains a significant decrease in the amplitude in the motor study to the vastus medialis when compared to the right. This can be due to both neurogenic and disuse atrophy and may be a combination of both.
My f/u with my OS is in a week, where we will discuss my latest EMG/NCS results. My PT is an amazing person (a friend for years) and I trust him implicitly when it comes to my health issues. He obtained the results of the EMG, but wasn't comfortable interpreting beyond... there is improvement, but there are still significant issues.
It has been nine months since this all began, and from what I have been told, a nerve can regenerate for up to 18 months. Where I am at that point is where I will most likely remain. I would sincerely appreciate an honest opinion as to what you think is going on, what my most recent EMG/NCS test results mean, and what you think my long-term prognosis might be. I just need to know. If it isn't great... it isn't great. I can deal. Seems everyone is dancing around it... and really talking more about the best case scenarios. The fact that there does not appear to be any signs to suggest axonal regrowth or collateral sprouting over the last 9 months... I'm guessing isn't a good sign?
Thank you soooo much for taking the time and making it through this. I appreciate in advance any light you may shed on this for me. Also, Is there a website where I can find reputable neurosurgeons in my area?
Fondly,
~J
LTKR - I had a spinal epidural and a tourniquet was applied. I did not have a femoral block. Tourniquet time 101 mins. I had the immediate inability to bend my leg (I could not "dangle" my leg in any way the morning after) or lift my leg. I had an ultrasound which showed possible musculotendinous partial tear of the vastus medialis component. I started PT the day after surgery and continued with home PT. My PT felt right away there was something wrong, as I could not, even with intense PT, bend my leg more than 60 degrees. I was scheduled for an EMG/NCS on 12/21. This was the most painfully horrific thing I have EVER experienced. Findings -
- Likely left femoral neuropathy proximal to the motor branch of the iliopsoas; w/ approx 50% motor axon loss to the vastus medialis. Evidence of left sided focal femoral mononeuropathy of the left iliopsoas, vastus medilis. This is clouded somewhat by the abnormalities throughout the rest of the left lower limb and in the right as below. Side to side CMAP amplitude comparisons of the vastus medialis from the femoral nerve indicate approx 50% motor axon loss.
- Possible left and right L5 or S1 radiculopathy, plexoapthy, cannot rule out left lumbosacral panplexopathy.
Clinical Impression - Left femoral neuropathy w approx 50% motor axon loss to the vastus medialis. If this was related to a one-trauma the prognosis for functional recovery is good, which usually takes place at 1 inch per month as a rough estimate, and therefore could take 6-12 months or even longer. There was no current evidence of axonal sprouting or regrowth, but serial limited EMGs could be done in the future to see if this is occurring. Imaging of the spine is recommended.
I underwent a CT myelogram which was WNL.
I continued with the inability to bend my leg, lift my heel off the ground when sitting with my foot resting on the ground, and was now only bending to approx 40 degrees with PT. Also of note, I have not had feeling in the top portion of the front of my thigh since my surgery. On 2/22/11 I underwent manipulation. After asleep, drop and dangle was 50 degrees. He manipulated me and ROM was 110 degrees in the OR. Before I left the hospital the next morning I was at 85 degrees. Discharged home on a CPM machine for 20 hrs/day x 3 weeks.
As I write this, my issues continue. I remain in PT. If I am standing and bend my leg at the knee I can get to maybe 60 degrees, with help or bracing my foot on the floor, I can bend to 80 degrees. This has remained unchanged for months. My left thigh and left calf are significantly smaller than my right - even immediately after surgery when the PT was coming to the house, my L calf measured 1" smaller than the R - it is approx 2" smaller now. I have profound weakness and my knee buckles/gives out frequently. Sitting in a hard chair with an edge pressing on the back of my thigh causes a sharp pain from my low back/hip down my leg. I use a crutch to keep me from falling when walking. I am nowhere near able to walk up/down stairs normally, and do them one at a time, the top of the front of my thigh is completely numb, my knee is swollen, it basically doesn't function properly as the muscle doesn't track the kneecap correctly, which causes intense pressure and pain in the knee (my PT pushes my kneecap in as far as he can and tapes it there for PT – this helps alleviate a bit of the pressure), I cannot lift my leg more than an inch or so while sitting in a recliner, I need to use a leg lifter to get my leg in the car when I drive, I have leg pain/deep ache throughout my entire L leg, moderately severe to severe knee pain 24/7 that persists despite the low dose of pain meds I take to help me function through the day - if I take more I can't function sharply and my job requires that I'm coherent. (The list goes on)
I have been seen by a local neurosurgeon who didn't feel there was anything he could do, I've seen a pain mgt doc who wanted to diagnosis me with Complex Regional Pain Syndrome and put long needles into my back for some diagnostic study (no more needles in the back for me!!), I went to NYC to see an orthopedic specialist who felt my new knee was placed "okay" and that there was nothing he could do to help except get me more ROM, which would be a detriment at this point. The general consensus of all I have seen is either - the tourniquet was too tight/on for too long causing damage to the femoral nerve, or something went wrong with the spinal epidural anesthesia. Whatever happened… caused the damage, but has since repaired itself, leaving behind the damage to the femoral nerve. I am currently trying to get into a local neurologist to have him look over my studies and get his opinio although getting doctors to see me, or "take on another doctor's difficult case" isn't always as easy as making a phone call.
My OS had me undergo another EMG/NCS on 8/2/11 to see how much improvement has been made since December. While showing improvement, it was still abnormal.
- Left femoral neuropathy. There is evidence of a left sided focal femoral mononeuropathy as shown by the abnormalities on needle EMG of the vastus lateralis and the decreased left femoral CMAP to the vastus medialis when compared to the right. This is improved since the previous study and no longer are abnormalities seen on the EMG of the iliopsoas or vastus medialis. There is no evidence of wide highly polyphasic low amplitude nor high amplitude motor unit action potentials to suggest axonal regrowth or collateral sprouting. It may be that the normal motor units seen are evidence of mature axonal regrowth. This may account for the decreased abnormal spontaneous activity. Side to side CMAP amplitude comparisons are similar to the previous study. Saphenous SNAP is approx 50% amplitude on the contralateral limb showing evidence of sensory axon loss as well.
There is no longer evidence of a left lumbosacral radiculopathy or plexopathy.
Clinical Impression: Test shows evidence of some improvement. However, clinically she does not seem to have had improvement in motor function. There remains a significant decrease in the amplitude in the motor study to the vastus medialis when compared to the right. This can be due to both neurogenic and disuse atrophy and may be a combination of both.
My f/u with my OS is in a week, where we will discuss my latest EMG/NCS results. My PT is an amazing person (a friend for years) and I trust him implicitly when it comes to my health issues. He obtained the results of the EMG, but wasn't comfortable interpreting beyond... there is improvement, but there are still significant issues.
It has been nine months since this all began, and from what I have been told, a nerve can regenerate for up to 18 months. Where I am at that point is where I will most likely remain. I would sincerely appreciate an honest opinion as to what you think is going on, what my most recent EMG/NCS test results mean, and what you think my long-term prognosis might be. I just need to know. If it isn't great... it isn't great. I can deal. Seems everyone is dancing around it... and really talking more about the best case scenarios. The fact that there does not appear to be any signs to suggest axonal regrowth or collateral sprouting over the last 9 months... I'm guessing isn't a good sign?
Thank you soooo much for taking the time and making it through this. I appreciate in advance any light you may shed on this for me. Also, Is there a website where I can find reputable neurosurgeons in my area?
Fondly,
~J
How are you doin now? I'm 7 months into pain and a skinny leg. I have more mobility than you at this point but the pain & weakness is still worrying me. They say I have a stretched femoral nerve but I'm thinking I might have an issue w my back also because on my initial emg it says femoral neuropathy or lumbosacral plexopathy. I'm currently waiting for a referral to go through so I can see a neurologist. Please let me know how you are doing now pain and mobility wise and if there is hope for me. I'm on gabapentin and tramadol. They take forever to kick in
I live in Australia so i'm not sure of reputable neurosurgeons in NY. I would suggest seeing an injury lawyer as well. As for treatments, there are a quite a few non surgical options that encourage nerve regeneration.
"Asian Mushroom
A recommended treatment for the regeneration of nerves in the brain and spinal cord is the use of Asian mushroom, Hericium erinaceus. It is also called lion's mane or white jelly fungus and can be obtained in liquid or solid extract form. The mushroom contains a natural nerve growth component and the dosage is listed on the labels.
DHA, Docosahexaenoic acid
Research has shown that DHA acid, which is a component of the insulating sheath around nerve cells called myelin, is very good for healing nerve damage. DHA is an omega-3 fatty acid which is found in fish. Hence seafood should be included in the diet to make sure you are getting enough omega-3 fatty acids. The omega acids can also be obtained through the use of walnut or olive oil and flax seed.
Chanca Piedra
Chanca piedra is a tropical plant which is also known as phyllanthus in ayurvedic medicine, and quebra pedra. Though the herb is primarily used to treat diabetes, it also prevents long term complications of the central nervous system. Japanese researchers have discovered the presence of aldose reductase inhibitors in the herb which are very efficient in stopping all processes of damage in nerves. Chanca piedra can be obtained in tincture or tablet form. The tablets are usually labeled by the ayurvedic name phyllanthus while the tinctures are sold as chanca piedra or quebra pedra.
Naturally Fermented Red Wine
Naturally fermented wines have been known to have dietary and therapeutic qualities for the past 4,000 years. By being naturally fermented they retain all their biologically active compounds which include the absorbable B vitamins, minerals and trace minerals like magnesium, potassium, iron, calcium, phosphorous and organic sodium. The quercetin in red wine grapes is a very powerful anticancer agent. The activity of quercetin is further intensified by the process of natural fermentation. Quercetin is a preventative agent in a number of major complications including neuropathy or nerve damage."
Natural Way to Heal Nerve Damage >>>
http://www.ehow.com/way_5660472_natural-way-heal-nerve-damage.html#ixzz1UzyePvPE
* Research shows that the active form of B12 (methylcobalamin) encourages nerve regeneration and regrowth of myelin (protective sheath around the nerves). Recommended usage - 2000mcg daily. Sublingual (under the tongue) is very effective. Available in tablets, lozengers, drops and sprays.
Methylcobalamin increases Erk1/2 and Akt activities through the methylation cycle and promotes nerve regeneration in a rat sciatic nerve injury model >>> http://www.ncbi.nlm.nih.gov/pubmed/20045411
* Qichu Fujin Recipe (QCFJR), a compound traditional Chinese medicine, can stimulate the regeneration and repair of nerve fiber and delay the skeletal muscle atrophy after sciatic nerve injury in rats.
Effects of Qichu Fujin Recipe on regeneration and repair of injured sciatic nerve in rats >>> http://www.ncbi.nlm.nih.gov/pubmed/19747441
* Achyranthes bidentata Blume (ABPP), a commonly prescribed Chinese medicinal plant - results indicated that treatment with ABPP at a dose range (1-16 mg/kg) promoted histological regeneration and functional recovery of the injured sciatic nerve and its target muscle.
The protective effects of Achyranthes bidentata polypeptides in an experimental model of mouse sciatic nerve crush injury >>> http://www.ncbi.nlm.nih.gov/pubmed/19646511
* Ginsenoside Rg1 (GRg1) is one of the bioactive compounds extracted from ginseng which is capable of promoting nerve regeneration.
Ginsenoside Rg1 promotes peripheral nerve regeneration in rat model of nerve crush injury >>> http://www.ncbi.nlm.nih.gov/pubmed/20438804
"Asian Mushroom
A recommended treatment for the regeneration of nerves in the brain and spinal cord is the use of Asian mushroom, Hericium erinaceus. It is also called lion's mane or white jelly fungus and can be obtained in liquid or solid extract form. The mushroom contains a natural nerve growth component and the dosage is listed on the labels.
DHA, Docosahexaenoic acid
Research has shown that DHA acid, which is a component of the insulating sheath around nerve cells called myelin, is very good for healing nerve damage. DHA is an omega-3 fatty acid which is found in fish. Hence seafood should be included in the diet to make sure you are getting enough omega-3 fatty acids. The omega acids can also be obtained through the use of walnut or olive oil and flax seed.
Chanca Piedra
Chanca piedra is a tropical plant which is also known as phyllanthus in ayurvedic medicine, and quebra pedra. Though the herb is primarily used to treat diabetes, it also prevents long term complications of the central nervous system. Japanese researchers have discovered the presence of aldose reductase inhibitors in the herb which are very efficient in stopping all processes of damage in nerves. Chanca piedra can be obtained in tincture or tablet form. The tablets are usually labeled by the ayurvedic name phyllanthus while the tinctures are sold as chanca piedra or quebra pedra.
Naturally Fermented Red Wine
Naturally fermented wines have been known to have dietary and therapeutic qualities for the past 4,000 years. By being naturally fermented they retain all their biologically active compounds which include the absorbable B vitamins, minerals and trace minerals like magnesium, potassium, iron, calcium, phosphorous and organic sodium. The quercetin in red wine grapes is a very powerful anticancer agent. The activity of quercetin is further intensified by the process of natural fermentation. Quercetin is a preventative agent in a number of major complications including neuropathy or nerve damage."
Natural Way to Heal Nerve Damage >>>
http://www.ehow.com/way_5660472_natural-way-heal-nerve-damage.html#ixzz1UzyePvPE
* Research shows that the active form of B12 (methylcobalamin) encourages nerve regeneration and regrowth of myelin (protective sheath around the nerves). Recommended usage - 2000mcg daily. Sublingual (under the tongue) is very effective. Available in tablets, lozengers, drops and sprays.
Methylcobalamin increases Erk1/2 and Akt activities through the methylation cycle and promotes nerve regeneration in a rat sciatic nerve injury model >>> http://www.ncbi.nlm.nih.gov/pubmed/20045411
* Qichu Fujin Recipe (QCFJR), a compound traditional Chinese medicine, can stimulate the regeneration and repair of nerve fiber and delay the skeletal muscle atrophy after sciatic nerve injury in rats.
Effects of Qichu Fujin Recipe on regeneration and repair of injured sciatic nerve in rats >>> http://www.ncbi.nlm.nih.gov/pubmed/19747441
* Achyranthes bidentata Blume (ABPP), a commonly prescribed Chinese medicinal plant - results indicated that treatment with ABPP at a dose range (1-16 mg/kg) promoted histological regeneration and functional recovery of the injured sciatic nerve and its target muscle.
The protective effects of Achyranthes bidentata polypeptides in an experimental model of mouse sciatic nerve crush injury >>> http://www.ncbi.nlm.nih.gov/pubmed/19646511
* Ginsenoside Rg1 (GRg1) is one of the bioactive compounds extracted from ginseng which is capable of promoting nerve regeneration.
Ginsenoside Rg1 promotes peripheral nerve regeneration in rat model of nerve crush injury >>> http://www.ncbi.nlm.nih.gov/pubmed/20438804
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