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CT scans Fasciculations and myokymia are more likely to be seen in patients with radiation plexopathy, which seemingly occurs more frequently in patients with diabetic neuropathy Reference has already been made to femoral nerve injury during parturition, but other puerperal complications are also observed Back pain in the latter part of pregnancy is common, but there are rare instances in which the patient complains of severe pain in the back of one or both thighs during labor and after delivery has numbness and weakness of the leg muscles, with diminished ankle jerks Parturitional lumbosacral plexus injuries occur with a frequency of 1 per 2000 deliveries This type of plexus injury is usually unilateral and is manifest by pain in the thigh and leg and symptoms and signs of involvement of the superior gluteal and sciatic nerves (Feasby et al) The attribution of these symptoms to pressure of the fetal head on the sacral plexus(es) is conjectural A limited plexopathy, occurring after dif cult vaginal delivery, mainly impairs sensation in the perineum and sphincteric function (Ismael et al) The perineal muscles may show signs of denervation Protrusion of an intervertebral disc may also occur during delivery Idiopathic Lumbosacral Plexitis In addition to a diabetic type, an idiopathic neuralgic amyotrophy or lumbosacral plexitis, analogous to the brachial variety, is observed from time to time Bradley and coworkers have recorded such cases After causing widespread unilateral or bilateral sensory, motor, and re ex changes in a leg, lumbosacral plexitis may leave the patient with dysesthesias as troublesome as those that follow herpes zoster (which may also occur at this level) Some patients have had an exploration of the cauda equina (for ruptured disc), even though loss of sweating and warmth of the feet should have indicated interruption of autonomic bers by lesions in peripheral nerves (Lesions that are con ned to nerve roots spare autonomic functions) The sedimentation rate may be elevated Immunosuppressant drugs were possibly bene cial in 4 of 6 cases (Bradley et al) Sarcoidosis is another cause and may be responsive to corticosteroids Diabetic amyotrophy, due to involvement of the lumbar plexus, has a vascular origin, probably in ammatory as discussed in an earlier section (page 1135), and there are also nondiabetic vascular lesions that give rise to identical lumbar and upper leg pain and weakness in proximal muscles The plexus lesions of polyarteritis nodosa, unilateral or bilateral, may also be manifest as a mononeuropathy multiplex Mononeuropathy multiplex in diabetic patients is more frequent in our experience when there is an associated occlusive vascular disease of the lower extremities Diabetic mononeuropathy multiplex is discussed in an earlier part of this chapter and protruded intervertebral disc syndromes are described in Chap 11 Lateral Cutaneous Nerve of the Thigh This is a sensory nerve that originates from the second and third lumbar roots and supplies the anterolateral aspect of the thigh, from the level of the inguinal ligament almost to the knee The nerve penetrates the psoas muscle, crosses the iliacus, and passes into the thigh by coursing between the attachments of the lateral part of the inguinal ligament to just anterior to the anterior superior iliac spine Compression (entrapment) may occur at the point where it passes between the two prongs of attachment of the inguinal ligament Compression of the nerve results in uncomfortable paresthesias and sensory impairment in its cutaneous distribution, a common condition known as meralgia paresthetica (meros, thigh ) Usually numbness and mild sensitivity of the skin are the only symptoms, but occasionally there is a persistent distressing burning
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pain Perception of touch and pinprick are reduced in the territory of the nerve; there is no weakness of the quadriceps or diminution of the knee jerk The symptoms are characteristically worsened in certain positions and after prolonged standing or walking Occasionally, for an obese person, sitting is the most uncomfortable position Obesity, pregnancy, and diabetes mellitus may be contributory factors Most often the neuropathy is unilateral; Ecker and Woltman found only 20 percent of their cases to be bilateral Most of our patients with meralgia paresthetica request no treatment once they learn of its benign character Weight loss and adjustment of restrictive clothing or correction of habitual postures that might compress the nerve are sometimes helpful A few with the most painful symptoms have demanded a neurectomy or section of the nerve, but it is always wise to perform a lidocaine block rst, so that the patient can decide whether the persistent numbness is preferable In one specimen of nerve obtained at operation, we found a discrete traumatic neuroma Hydrocortisone injections at the point of entrapment may have helped in a few cases Obturator Nerve This nerve arises from the third and fourth and to a lesser extent the second lumbar roots It supplies the adductors of the thigh and contributes to the innervation of the internal and external rotators The adductors have the added function of exing the hip The nerve may be injured by the fetal head or forceps during the course of a dif cult labor or compressed by an obturator hernia Rarely, it is affected with diabetes, polyarteritis nodosa, and osteitis pubis and by retroperitoneal spread of carcinoma of the cervix, uterus, and other tumors (Rogers et al) Femoral Nerve This nerve is formed from the second, third, and fourth lumbar roots Within the pelvis it passes along the lateral border of the psoas muscle and enters the thigh beneath Poupart s ligament, lateral to the femoral artery Branches arising within the pelvis supply the iliacus and psoas muscles Just below Poupart s ligament the nerve splits into anterior and posterior divisions The former supplies the pectineus and sartorius muscles and carries sensation from the anteromedial surface of the thigh; the posterior division provides the motor innervation to the quadriceps and the cutaneous innervation to the medial side of the leg from the knee to the internal malleolus Following injury to the femoral nerve, there is weakness of extension of the lower leg, wasting of the quadriceps muscle, and failure of xation of the knee The knee jerk is abolished If the nerve is injured proximal to the origin of the branches to the iliacus and psoas muscles, there is weakness of hip exion The adductor of the thigh (innervated by the obturator nerve) is spared, distinguishing femoral neuropathy from an L3 radiculopathy The most common cause of femoral neuropathy is diabetes The nerve may also be involved by pelvic tumors Not uncommon is injury of the nerve during pelvic operations Usually this is the result of improper placement of retractors, which may compress the nerve directly or indirectly by undue pressure on the psoas muscle Bleeding into the iliacus muscle or the retroperitoneum, observed in patients receiving anticoagulants and in hemophilia patients, is a relatively common cause of isolated femoral neuropathy (Goodfellow et al) The presenting symptom of iliacus hematoma is pain in the groin spreading to the lumbar region or thigh, in response to which the patient assumes a characteristic posture of exion and lateral rotation of the hip A palpable mass in the iliac fossa and the signs of femoral nerve compression (quadriceps weakness and loss of knee jerk) follow in a day or two Infarction
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