A 37-year-old male who in January 2009 suffered a severe abdominal polytrauma secondary to a motorcycle accident.
Axial tomography (ACT) evidences the presence of a significant hematoma in the left psoas muscle, hematoma in the left glatio muscle, iliac fracture, fracture of the transverse palatal sacral fracture to left branch, fracture
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After initial stabilization of the patient and admission to the Intensive Care Unit (ICU), the Traumatology Service performs emergency pelvic external fixation.
During the intervention, 3 units of blood were drained and a transfusion of 10 units was performed.
Two weeks later, osteosynthesis reduction was performed with vertical plates in both iliac palas due to vertical pelvic instability.
In the subsequent evolution, the patient is unable to extend the hip, knee and ankle, and after electromyographic examination four weeks after the trauma, severe muscle neuropathy of the left femoral nerve is diagnosed with distal axonotmesis very superficial nerve.
There is also neuropathic pain in the limb treated with opioids and right side anesthesia.
The patient came to our hospital 6 months after the accident for evaluation by the Neurology Department, who diagnosed traumatic left crural monoparesis in relation to multiple mononeuropathy and/or lumbar interconsultation surgery.
At 8 months after the accident, the patient was able to maintain hip extension and ankle extension, difficulty with the use of an external bitutor. The assessment of muscle strength was based on the Medical Research Council classification 0/5 knee flexion:
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After serial electromyographic examination in which no reinnervation of the reinnervation was observed, and a magnetic resonance imaging (MRI) in which no avulsions of the left lumbar plexus were located, important signs of surgical exploration were observed.
We believe that recovery of the proximal muscles dependent on the lumbar plexus was a priority to achieve efficient standing and gait, in view of the recovery of the distal muscles dependent on the sacral plexus.
Based on this, we propose only an exploratory surgery of the lumbar plexus, since the expectation of recovery of the muscles of the sciatic nerve external popliteus was minimal.
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We performed a retroperitoneal lateral approach until reaching the lumbar plexus, where we observed very intense fibrosis, stroke type, femoral nerve and fibrosis of the rest of the branches of the lumbar plexus.
Neurolysis was performed with epineurectomy of the femoral nerve and neurolysis of the genitofemoral, obturator, iliohypogastric nerve.
After surgery, the patient required admission to the ICU for 5 days and as an analgesic treatment intravenous corticosteroids were administered for 2 weeks, with a subsequent descending oral regimen for 4 additional weeks.
Postoperative rehabilitation treatment lasted for 12 months.
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Five years after the intervention, the following function was evidenced based on the classification of the Medical Research Council: hip extension 5/5, hip extension 5/5 4, knee flexion/ extension 5/5, knee flexion/ extension 5/5, hip adduction 5/5.
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The patient has recovered his/her job prior to the accident, does not need to use the guardian week and performs a normal activity for daily life that allows him/her even to practice activities such as Nordic walking 15 km, 3.
The only exception is that it should carry an anti-equine splint because there has been no recovery of muscles dependent on the external popliteal sciatic nerve.
Sensory level refers pain from the groin to the ankle at the external edge of the limb, with paresthesias in the area of the internal twin, but it is treated as indicated by tolerable pain for which no treatment is given.
