|Year : 2014 | Volume
| Issue : 3 | Page : 278-279
Bilateral common peroneal nerve injury after pediatric cardiothoracic surgery: A case report and review of the literature
G Setty, R Saleem, P Harijan, A Khan, N Hussain
Department of Paediatric Neurology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
|Date of Web Publication||23-Dec-2014|
George Eliot Hospital, Nuneaton CV10 7DJ, Warwickshire
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nerve injuries after thoracic and cardiovascular surgery have been reported but generally concern the brachial plexus, phrenic nerve, recurrent laryngeal, and facial nerve. Common peroneal nerve injury (CPNI) following cardiopulmonary bypass has been reported in adults (4); however bilateral injury is extremely uncommon. Age, low body weight, co-morbidities such as peripheral arteriosclerotic disease, diabetes mellitus, and arrhythmias were associated with CPNI following cardiothoracic surgery in adults. Common peroneal nerve injury (CPNI) following cardiopulmonary by-pass has been reported in adults; however, bilateral injury is extremely uncommon. The superficial course of CPN makes it vulnerable to traction or compression. We report a 5-year-old girl manifesting with bilateral CPNI following prolonged cardiopulmonary by-pass. To the best of our knowledge, she is the first pediatric patient presenting with bilateral CPNI following cardiothoracic surgery and cardiopulmonary by-pass.
Keywords: Bilateral peroneal nerve, cardiac surgery, children, injury
|How to cite this article:|
Setty G, Saleem R, Harijan P, Khan A, Hussain N. Bilateral common peroneal nerve injury after pediatric cardiothoracic surgery: A case report and review of the literature. J Pediatr Neurosci 2014;9:278-9
|How to cite this URL:|
Setty G, Saleem R, Harijan P, Khan A, Hussain N. Bilateral common peroneal nerve injury after pediatric cardiothoracic surgery: A case report and review of the literature. J Pediatr Neurosci [serial online] 2014 [cited 2019 Nov 12];9:278-9. Available from: http://www.pediatricneurosciences.com/text.asp?2014/9/3/278/147594
| Introduction|| |
Nerve injuries after thoracic and cardiovascular surgery have been reported but generally concern the brachial plexus, phrenic nerve, recurrent laryngeal, and facial nerve. Common peroneal nerve injury (CPNI) following cardiopulmonary by-pass has been reported in adults;  however, bilateral injury is extremely uncommon. Age, low body weight, co-morbidities such as peripheral arteriosclerotic disease, diabetes mellitus, and arrhythmias were associated with CPNI following cardiothoracic surgery in adults. The common peroneal nerve (CPN) courses lateral to the surgical neck of fibula around the knee. The superficial course of CPN makes it vulnerable to traction or compression. Hypo-perfusion, femoral artery lines and traction of blood pressure cuffs and stockings can lead to hypoxia and pressure related injury to nerves of lower extremities. We report a 5-year-old girl manifesting with bilateral CPNI following prolonged cardiopulmonary by-pass and review relevant literature. To the best of our knowledge, she is the first pediatric patient presenting with bilateral CPNI following cardiothoracic surgery and cardiopulmonary by-pass. 
| Case Report|| |
Five-year-old girl had a corrective surgery for double outlet right ventricle with transposition of great arteries. Postoperatively, she developed bilateral foot drop following a stormy intraoperative course with increased bleeding and a prolonged cardio pulmonary by-pass time of around 272 min.
On examination, she was conscious and alert. She was extremely thin weighing between 2 nd and 9 th centile. Cranial nerve examination was normal. There was significant bilateral foot drop with weakness of dorsiflexion and eversion. There was sensory loss on the anterior aspect of leg and dorsum of both feet. There was no specific sensory level. The tone was normal and deep tendon reflexes were reduced at the ankle. Both the plantars were down going. Bladder and bowel function were normal.
Nerve conduction studies showed severe damage to the left common peroneal nerve with motor axonal loss, but no evidence of sensory involvement in the superficial peroneal nerve. There was also moderately severe motor axonal damage in the right common peroneal nerve, which showed relatively less severe acute axonal loss, so there was greater potential for the earlier recovery on this side. Electromyography on the right provided good evidence that the site of injury to the peroneal nerve to be at the knee. She made a good recovery after 3 months of intensive physiotherapy treatment.
| Discussion|| |
Acute weakness of foot elevation can have different etiologies. Radiculopathy of the L5 root has to be differentiated from CPNI or palsy of the peroneal portion of the sciatic nerve.  Clinical examination does not always allow a clear differentiation between these entities; electrophysiological examination is often required for diagnosis and localizing the nerve lesion.  Tibialis posterior muscle was spared in our child, making CPNI the cause of her difficulties.
Compression or stretching resulting in ischemia has been thought to be the main cause of peripheral nerve injury in anesthetized patients.  In our patient, the area of the fibular head where the nerve runs superficially was the site of injury due to its anatomy and superficial course. , The stormy postoperative course and prolonged cardiac by-pass may have contributed to the nerve injury, which manifested as bilateral foot drop. The mechanism of injury was possibly hypo-perfusion and compression with blood pressure cuffs used during the surgery. Our child was very thin, and this would have been an additional risk factor. Study by Vazquez-Jimenez et al. has shown that subnormal body weight and leg malpositioning were associated with the nerve injury. 
Study by Saidha et al. has shown that the duration of the procedure has a direct correlation to the postoperative neuropathy, especially after the cardio-thoracic surgery with neuropathy being remote from operative sites. Increased procedure duration causes prolonged periods of nerve compression, which increases the risk for development of neuropathy.  In our case, prolonged duration of surgery may have a causative role for the nerve injury.
Neurophysiology study showed that there was moderate to severe axonal loss on both sides (axonotemesis, axonal loss with intact nerve sheaths), which got better after intensive physiotherapy treatment. Early diagnosis and physiotherapeutic treatment were crucial for her recovery.
| Conclusion|| |
Paediatric CPNI is extremely rare after cardiothoracic surgery, and bilateral CPNI in children has not been reported. Prolonged cardiopulmonary by-pass, compression during by-pass and subnormal weight were major contributory factors for CPNI in our case. Prompt recognition by clinical and neurophysiological tests will guide further management.
| References|| |
Durmaz B, Atamaz F, On A. Bilateral common peroneal nerve palsy following cardiac surgery. Anadolu Kardiyol Derg 2008;8:313-4.
Miller G, Eggli KD, Contant C, Baylen BG, Myers JL. Postoperative neurologic complications after open heart surgery on young infants. Arch Pediatr Adolesc Med 1995;149:764-8.
Vazquez-Jimenez JF, Krebs G, Schiefer J, Sachweh JS, Liakopoulos OJ, Wendt G, et al.
Injury of the common peroneal nerve after cardiothoracic operations. Ann Thorac Surg 2002;73:119-22.
Saidha S, Spillane J, Mullins G, McNamara B. Spectrum of peripheral neuropathies associated with surgical interventions. A neurophysiological assessment. J Brachial Plex Peripher Nerve Inj 2010;5:9.
Britt BA, Joy N, Mackay MB. Positioning trauma. In: Orking RK, Cooperman LH, editors. Complications in Anesthesiology. Philadelphia: JB Lippincott; 1983. p. 647-70.
Kim DH, Murovic JA, Tiel RL, Kline DG. Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Science Center. Neurosurgery 2004;54:1421-9.
Beery M, Bannister LH, Standring SM. Nervous system. In: Williams PL, editor. Gray's Anatomy. London: Churchill Livingstone; 1995. p. 1255-397.