Yue John K, Oh Jun Yeop, Aabedi Alexander A, Chen Jia-Shu, Probst Kenneth X, Shah Vinil N, Wustrack Rosanna L, Jacques Line G
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA.
Neurotrauma Rep. 2025 Jan 30;6(1):128-135. doi: 10.1089/neur.2024.0156. eCollection 2025.
Sciatic nerve injury associated with total hip arthroplasty (THA) confers chronic and progressive disability. Mechanisms of injury are heterogeneous and management nuances are often case-specific. We discuss a Sunderland Type 4 sciatic nerve transection by femoral cerclage wire from prior THA to highlight optimal clinical strategies when approaching complex cases. A 65-year-old woman presented to the neurosurgery clinic with worsening, medically refractory right sciatic sensorimotor neuropathy that began 1 year after ipsilateral hip arthroplasty. Neurological examination detected weakness in ankle dorsiflexion/plantarflexion and foot inversion/eversion (motor scale 2-3/5), toe extension/flexion (1/5), foot numbness, and hyperesthesia. Electromyogram confirmed sciatic neuropathy. Magnetic resonance neurogram (MRN) showed a thickened right sciatic nerve abutting a femoral cerclage wire, which appeared contiguous on reconstructed computed tomography imaging. Intraoperatively, the wire was discovered to have clearly transected and remained lodged within the sciatic nerve, requiring orthopedic surgery consultation and wire cutdown at the transection site. The surrounding neuroma was excised and the defect was reconstructed using nerve allograft interposition. Intraoperative neurophysiology monitoring (IONM) signals remained stable. Radiographs confirmed uncomplicated wire disconnection. The patient was discharged home the next day and reported significant symptomatic relief at 1-month follow-up. Delayed presentation of sciatic nerve transection by femoral cerclage wire with ongoing neural compression is rare. The anatomy of injury can be high risk, impelling thoughtful operative planning in THA as well as neuroplasty cases. Strategies include preoperative MRN to evaluate the pathoanatomy of nerve injury, neurosurgery and orthopedic surgery comanagement, and multimodal IONM to reduce risks of intraoperative neural injury and optimize outcomes.
与全髋关节置换术（THA）相关的坐骨神经损伤会导致慢性进行性残疾。损伤机制多种多样，治疗细节往往因具体病例而异。我们讨论一例既往THA术后因股骨环扎钢丝导致的桑德兰4型坐骨神经横断伤，以突出处理复杂病例时的最佳临床策略。一名65岁女性因同侧髋关节置换术后1年出现进行性加重、药物治疗无效的右侧坐骨神经感觉运动性神经病变，就诊于神经外科门诊。神经系统检查发现踝关节背屈/跖屈、足内翻/外翻无力（肌力2 - 3/5级），足趾背伸/屈曲无力（1/5级），足部麻木及感觉过敏。肌电图证实为坐骨神经病变。磁共振神经造影（MRN）显示右侧坐骨神经增粗，紧邻股骨环扎钢丝，在重建的计算机断层扫描图像上二者似乎相连。术中发现钢丝已明显横断并仍留在坐骨神经内，需要请骨科会诊并在横断部位切断钢丝。切除周围神经瘤，使用神经同种异体移植进行缺损重建。术中神经电生理监测（IONM）信号保持稳定。X线片证实钢丝顺利断开，无并发症。患者次日出院，1个月随访时报告症状明显缓解。股骨环扎钢丝导致坐骨神经横断且伴有持续神经压迫的延迟表现较为罕见。损伤部位的解剖结构风险较高，这促使在THA以及神经成形术病例中进行周全的手术规划。策略包括术前MRN评估神经损伤的病理解剖结构、神经外科和骨科联合管理以及多模式IONM，以降低术中神经损伤风险并优化治疗效果。
