Complications nerveuses iatrogènes en chirurgie du membre supérieur (main exclue)
Revue de Chirurgie Orthopédique et Traumatologique, ISSN: 1877-0517, Vol: 110, Issue: 6, Page: 951-961
2024
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Review Description
Les lésions neurologiques sont les complications les plus redoutées en chirurgie du membre supérieur. Environ 17 % des lésions nerveuses sont ainsi d’origine iatrogène et disposent souvent d’un faible potentiel de récupération. Ces lésions sont dans près d’un quart des cas associées à une plainte ou à une procédure et sont rarement liées à une mauvaise installation ou à la réalisation de l’anesthésie locorégionale. Lors d’une intervention, les lésions peuvent être créées lors de la réalisation de la voie d’abord, lors de la mise en place du matériel ou lors d’une réduction en traumatologie. Elles sont le plus souvent liées à la manipulation du nerf : libération, protection par les écarteurs, ou allongement inadapté du segment de membre. Un phénomène d’allongement/compression du tronc nerveux ou de l’une de ses branches est donc souvent constaté. Pour objectiver une lésion neurologique, l’imagerie (échographie, scanner ou IRM) permet d’analyser la morphologie du nerf, mais ne donne aucune information sur le potentiel de récupération. C’est l’électromyographie, qui en complément du bilan clinique, confirme le diagnostic et aide à la prise en charge, à la surveillance des atteintes nerveuses, et permet de poser les indications opératoires de chirurgie nerveuse ou palliative. L’électromyographie a également une valeur pronostique (diagnostic initial et suivi) car il confirme ou non la régénération nerveuse. La connaissance anatomique des zones de sécurité et des zones de passages des nerfs lors des voies d’abord est un préalable incontournable à tout geste chirurgical, permettant de maîtriser les zones à risque de lésions nerveuses. IV. Nerve injury is the most dreaded complications of upper limb surgery. In about 17% of cases, the injury is iatrogenic and the potential for recovery poor. Patients apply for compensation in about a quarter of cases. Faulty patient installation or locoregional anaesthesia are rarely the cause of nerve injury. Nerve injury may occur during creation of the surgical approach, implantation of the material, or reduction of a traumatic injury. The injury is usually related to nerve release, nerve protection by retractors, or inappropriate limb-segment lengthening. Stretching and/or compression of a nerve trunk or branch is thus often noted. Among diagnostic tools, imaging studies (ultrasonography, computed tomography, and magnetic resonance imaging) provide information on nerve structure but not on the potential for recovery. Electromyography combined with the neurological examination provides the diagnosis, guides the management strategy, allows nerve-function monitoring, and indicates when nerve repair or palliative surgery is in order. Electromyography also has prognostic value, both at diagnosis and during follow-up, by showing whether nerve regeneration is under way. When creating the surgical approaches, thorough familiarity with anatomic safe zones and nerve trajectories is crucial to ensure full control of the zones at highest risk for nerve injury. IV.
Bibliographic Details
Elsevier BV
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