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Case Report | DOI: https://doi.org/10.31579/2641-5194/027
Necmettin Erbakan University, GETAT CENTER, Konya, Turkey.
*Corresponding Author: Hayriye Alp, Necmettin Erbakan University, GETAT CENTER, Konya, Turkey.
Citation: Hayriye Alp (2021) Neuropathy Case Seen After Bariatric Surgery. J. Gastroenterology Pancreatology and Hepatobilary Disorders. 5(2) DOI: 10.31579/2641-5194/027
Copyright: © provided the original work is properly cited.
Received: 14 April 2021 | Accepted: 20 April 2021 | Published: 30 April 2021
Keywords: peroneal neuropathy; prolotherapy; neural therapy
Peroneal neuropathy is a rare complication after bariatric surgery, but it occurs in 15% of mononeuropathy. The etiology of peroneal neuropathy is multifactorial and is often blamed for these factors due to rapid weight loss and nutritional imbalance. Emine Karaca, 25 years old, female Patient 1 year ago, she had a stomach reduction (obesity surgery) surgery due to her weight of 130 kg. Six months after the operation, it decreased to 60 kg. Meanwhile, numbness in his right foot began to be pain and loss of strength after the operation. In the EMG performed on May 10, 2016, he was diagnosed with Fibulahead entrapment neuropathy-low foot. He was tied to lie in the same position for a long time during the operation.
After this diagnosis, 15% prolotherapy was applied around the peroneal nerve of the fibular head on 11.05.2016. Prolotherapy was applied 2 times with 10 days intervals. L4-5 and L5-S1 segmental neural therapy in the lumbar region and neural therapy around the fibular head of the peroneal nerve and along its trace were applied twice a week. After a total of 2 prolotherapy and 6 neuraltherapy applied in 3 weeks, complete clinical recovery was achieved. This complete recovery was confirmed by EMG. Since electrophysiological findings of denervation occur after 2-3 weeks, it is recommended that EMG examination be performed 3 weeks later. Treatment includes relief of complaints (analgesics and gabapentin), physical therapy applications and support immobilizers. In cases that do not respond to treatment, nerve exploration and relaxation is provided with a surgical approach. Prolotherapy and neural therapy, among complementary medicine modalities, can also be used in peroneal nerve neuropathy.
Peroneal neuropathy is a rare complication after bariatric surgery, but it occurs in 15% of mononeuropathy. The etiology of peroneal neuropathy is multifactorial and is often blamed for these factors due to rapid weight loss and nutritional imbalance. Although the peroneal nerve is covered with only skin and subcutaneous tissue throughout the fibular head and due to rapid weight loss, subcutaneous tissue loss makes it susceptible to trauma to the fibular head (1). Prolotherapy literally means proliferating treatment. With prolotherapy treatment, hypertonic solutions called proliferators are injected. The most used solution is dextrose. Generally, 15% of dextrose injection is made around the joint and 25% in a sterile manner. The solution draws the fluid in the vascular area into the tissue with its hypertonic effect where it is injected. At the same time, the tissue is traumatized iatrogenically with the injection technique. It is aimed to initiate wound healing phases with the contact of the needle with the bone and the bleeding of the area. The physiological repair mechanisms of the organism are activated by using physiological serum. With the wound healing phases, blood circulation will increase and a sterile inflammation will be initiated. By allowing a controlled inflammation, the tissue is enabled to activate the fibroblasts. Fibroblasts stimulate collagen production. At the same time, osteoblasts and chondroblasts are activated. Cartilage and bone proliferation is provided by the stimulation of osteoblasts and chondroblasts. Inflammatory markers, CRP and increased sedimentation are observed during treatment.
25 y, Female Patien
She had a stomach reduction (obesity surgery) surgery 1 year ago, due to her weight of 130 kg. 6 months after the operation, it decreased to 60 kg. Meanwhile, numbness in his right foot began to be pain and loss of strength after the operation. In the EMG performed on May 10, 2016, he was diagnosed with Fibulahead entrapment neuropathy-low foot. He was tied to lie in the same position for a long time during the operation.
After this diagnosis, 15% prolotherapy was applied around the peroneal nerve of the fibular head on 11.05.2016. Prolotherapy was applied 2 times with 10 days intervals. L4-5 and L5-S1 segmental neural therapy in the lumbar region and neural therapy around the fibular head of the peroneal nerve and along its course were applied twice a week. After a total of 2 prolotherapy and 6 neuraltherapy applied in 3 weeks, complete clinical recovery was achieved. This complete recovery was confirmed by EMG.
Method
Prolotherapy (23 Gauge, 80mm; 1cc 1% lidocaine, 15-20
In peripheral nerve injuries, diabetes [2,3, 4,5], obesity [3,5,6,4] or weakness [3,6,7], pre-existing peripheral neuropathy [3], hypotension [3,8], deep hypothermia [3] has been reported as predisposing factors. Among the involved nerves, the brachial plexus and ulnar in the upper extremities [2,9] are the common perineal nerve in the lower extremities [3]. While brachial plexus injuries are mostly caused by traction [2,3], compression is more common in ulnar and peroneal injuries [2]. Injuries due to tourniquet and elastic bandage application occur more frequently in the lower extremities [3,10].
Among the positions given to the patient during surgery, the most common injury in the lithotomy position is reported in the literature [3,11,12]. Sciatica [11], common peroneal [3,11,12], tibial, femoral, lateral femoral cutaneous, saphenous and obturator nerve [3] injuries in this position have been reported, and it has been reported that the risk of injury increases with the prolongation of the patient's stay in this position [3,13]. Other positions include axillary [3], ulnar [3.9] common peroneal [3.10], pudendal [7] in the prone and lateral decubitus, common peroneal in sitting position [3], sciatica [3.14], pudendal in supine position [7] nerve injuries can be seen. The most common ulnar, radial and common peroneal injuries due to tourniquet and elastic bandage have been reported [3].
Since electrophysiological findings of denervation occur after 2-3 weeks, it is recommended that EMG examination be performed 3 weeks later [2,3].
Conservative treatment is often sufficient in peroperative peripheral nerve injuries [3]. Treatment consists of symptom relief (analgesics and gabapentin), physical therapy applications and support immobilizers. In cases that do not respond to treatment, nerve exploration and relaxation are provided with a surgical approach [3,15,5]. Prolotherapy and neural therapy, among complementary medicine modalities, can also be used in peroneal nerve neuropathy.
Prolotherapy is especially used for the treatment of ligament instabilities. Ligament instability can be diagnosed by orthopedics, physiotherapists and physicians trained in prolotherapy. Ligament instability is seen in many degenerative joint diseases as well as athletes. Ligament instabilities, which can also develop in patients who have been operated for different reasons, may cause reflected pain in the patient. With complementary medicine applications such as prolotherapy, advanced age who do not want to be operated in such cases offers new options to patients with degenerative bone disease. In appropriate patients, instabilities can be detected with an accurate history and physical examination, and ligaments can be strengthened by injections around the joint with an appropriate technique. Thus, larger surgical interventions can be postponed. Prolotherapy has an important place in chronic painful conditions caused by degenerative joint diseases. Injections containing 15
As a result, procaine added to neural therapy and prolotherapy has an increasing effect on tissue blood flow. It can be used effectively especially in peroneal nerve neuropathy seen after bariatric surgery.
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