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Bilateral foot drop: looking for the needle in the wrong haystack?

Padhar Hospital, Padhar, Betul, Madhya Pradesh, India, E-mail: neipe{at}yahoo.com

To the Editor:

We read with interest the description of a case of bilateral foot drop following spinal anesthesia.¹ We have described the etiology of such postoperative deficits (preoperative injury, co-existing neuropathy, surgical trauma, tourniquets, positioning and anesthetic techniques).² The case mentioned requires further clarification.

1. Documentation of neurovascular deficits in any limb with fractures is considered part of basic trauma (orthopedic) examination. Further, trauma to the lumbosacral spine may also result in bilateral foot drop.
   
2. Did the patient have other co-existing disease with subclinical neuropathy (e.g., diabetes)? Pre-existing neuropathies have been identified as risk factors in nerve palsies.³
   
3. Does the plural "tibial pins" suggest that these were inserted on both sides?
   
4. Was the femur alone operated? How were the leg fractures managed? If they were also operated upon, the foot drop could be related to the surgery.⁴
   
5. What was the position of the patient during surgery? Femoral traction on a hip table (supine) may stretch the sciatic nerve. In the lateral position the sciatic nerve of the dependent side may be compressed.⁵
   

The authors erroneously identify paralysis of foot flexors as the cause of foot drop. Neurological examination is more important to rule out neurological deficits following the trauma rather than preceding the anesthetic (as they recommend). Prior to searching for iatrogenic causes, if they had documented the presence or absence of bilateral foot drop (at admission or after the traction pin application), they may not be faulted for looking for the metaphoric needle in the wrong anesthetic haystack!

References

1 Ghai A, Hooda S, Kumar P, Kumar R, Bansal P. Bilateral foot drop following lower limb orthopedic surgery under spinal anesthesia (Letter). Can J Anesth 2005; 52: 550.[Free Full Text]

2 Eipe N, Padhi NR. Tourniquet palsy or residual block (Letter). Anesth Analg 2005; 100: 903–4.[Free Full Text]

3 Horlocker TT, Cabanela ME, Wedel DJ. Does postoperative epidural analgesia increase the risk of peroneal nerve palsy after total knee arthroplasty? Anesth Analg 1994; 79: 495–500.[Abstract/Free Full Text]

4 Bauer T, Hardy P, Lemoine J, Finlayson DF, Tranier S, Lortat-Jacob A. Drop foot after high tibial osteotomy: a prospective study of aetiological factors. Knee Surg Sports Traumatol Arthrosc 2005; 13: 23–33.[Medline]

5 Roy S, Levine AB, Herbison GJ, Jacobs SR. Intraoperative positioning during cesarean as a cause of sciatic neuropathy. Obstet Gynecol 2002; 99: 652–3.[Abstract/Free Full Text]

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