Literature Review

Peripheral Nerve Injury Associated with a Subdermal Contraceptive Implant: Illustrative

Cases and Systematic Review of Literature
Pierre Laumonerie1,2, Laurent Blasco3, Meagan E. Tibbo4, Olivier Leclair5, Panagiotis Kerezoudis4, Elodie Chantalat2,6,
Pierre Mansat1

Key words - BACKGROUND: Despite demonstrable safety and efficacy of subdermal

- Contraceptive implant contraceptive implants (SCIs), both insertion and removal of SCIs in the arm have
- Implant removal
- Nerve injury
been associated with neurovascular complications. The aim of this study was to
- Peripheral nerve injury investigate type and prognosis of nerve injuries associated with SCIs.
Abbreviations and Acronyms - METHODS: We performed a comprehensive search of 4 electronic databases
IO: Interossei for studies pertaining to patients with nerve injury and concurrent SCI. Studies
MABC: Medial antebrachial cutaneous published between January 1987 and June 2017 were included. Implant location,
MRI: Magnetic resonance imaging
SCI: Subdermal contraceptive implant damaged nerves, clinical presentation, preoperative imaging (x-ray, ultrasound,
US: Ultrasound magnetic resonance imaging), neurologic evaluation (nerve conduction studies,
electromyography), and treatment methods were reviewed. To outline manage-
From the 1Department of Orthopaedic Surgery, Institut
Locomoteur, Hôpital Pierre-Paul Riquet, Toulouse, France;
ment strategies, 2 illustrative cases of major nerve injury caused by SCI removal
2
Anatomy Laboratory, Department of Orthopaedic Surgery, were presented.
Faculty of Medicine, Toulouse, France; 3Department of
Orthopaedic Surgery, Centre Hospitalier Universitaire de - RESULTS: We analyzed 10 studies including 12 patients. Fourteen nerve in-
Reims, Reims, France; 4Department of Orthopaedic Surgery, juries in 12 patients were reported during SCI insertion (n [ 1) and removal
Mayo Clinic, Rochester, Minnesota, USA; 5Department of
Orthopaedic Surgery, Médipôle de Koutio, New Caledonia,
(n [ 11). Medial antebrachial cutaneous (n [ 5) and median (n [ 5) nerves
France; and 6Department of Gynecological Surgery, Hopital were primarily affected. Neuropathic pain was the main symptom. Primary
Paul de Viguier, Toulouse, France reasons for nerve injury were pulling or grasping of the nerve (n [ 9) after
To whom correspondence should be addressed: mistaking it for the implant. Neurapraxia (n [ 7) was the most common lesion
Pierre Laumonerie, M.D.
[E-mail: laumonerie.p@chu.toulouse.fr]
and was treated with implant removal and clinical surveillance (n [ 6). Five
Citation: World Neurosurg. (2018) 111:317-325.
patients completely recovered; the remaining patients continued to have motor
https://doi.org/10.1016/j.wneu.2017.12.160 and/or sensory deficit at mean follow-up of 0.7 year (range, 0e2 years).
Journal homepage: www.WORLDNEUROSURGERY.org
- CONCLUSIONS: Nerve injuries related to SCIs are rare but potentially
Available online: www.sciencedirect.com
serious. For nonpalpable SCIs, a multidisciplinary approach, including practi-
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All
rights reserved.
tioners with experience treating peripheral nerve injuries, is invaluable.

INTRODUCTION
Use of subdermal contraceptive implants removal time as well as complexity. article, we present a systematic review of
(SCIs) has been steadily increasing for However, as procedural standardization the literature on nerve injuries associated
approximately a decade.1 The first SCI occurred, surgeons and obstetrician- with SCIs. We also describe 2 patients at
(Norplant; Wyeth-Ayerst International gynecologists became less and less our institution who sustained significant
Inc., Wayne, Pennsylvania, USA) was involved in the insertion of SCIs in favor of nerve injuries during removal of SCIs;
approved in 1983 and consisted of 6 rods general practitioners and midwives.2-6 these serve as illustrative cases in an
placed subcutaneously into the medial Adverse events related to insertion, effort to demonstrate our approach to
side of the nondominant arm. Norplant localization, and removal of the SCI are the treatment of these injuries. The
was followed by a succession of innovative rare, affecting 1% of insertions and 1.7% primary aim of this study was to
SCIs, including 2-rod (Jadelle; Bayer of removals, respectively.7 The investigate the types of nerve injuries
Healthcare, Leverkusen, Germany, and manufacturer of Nexplanon implants associated with SCIs.
Sino-implant; Shanghai Dahua Pharma- estimates that intravascular placement
ceuticals Co., Shanghai, China) and has occurred in just over 1 patient per 1
subsequently single-rod (Nexplanon and million Nexplanon implants sold.8 MATERIALS AND METHODS
Implanon; Merck, Darmstadt, Germany) However, given the recommended site of
designs with a length of 40 mm and a implantation, neurovascular injuries Illustrative Cases
diameter of 2 mm. These innovations remain a potential complication for both Between 1983 and 2017, 2 patients with
significantly reduced insertion and SCI insertion and removal.9 In this serious nerve injuries resulting from SCI

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 LITERATURE REVIEW
PIERRE LAUMONERIE ET AL. NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

Figure 1. Case 1. (A) Preoperative photograph depicting prior image of the ulnar nerve (arrow). (C and D) Close-up of the ulnar
incision (arrow) used to insert the subdermal contraceptive nerve neuromas (arrow). UN, ulnar nerve.
implant into the medial aspect of the arm. (B) Intraoperative

insertion were treated at our institution fire the palmar and dorsal interossei (IO), No nerve action potential was recorded
(Médipôle de Koutio, Nouvelle-Calédonie, flexor carpi ulnaris, or flexor digitorum across the lesion. Resection of the neu-
France); their cases were retrospectively profundus (fourth and fifth digits) roma was performed to expose healthy
reviewed. The SCIs were inserted at another muscles; she had a positive Froment sign nerve tissue (1.5 cm); histologic examina-
institution, and the patients were referred and grade S3 sensory loss over the ulnar tion later confirmed the diagnosis of
to a peripheral nerve specialist (O.L.) in our aspect of the palm (according to the British neuroma. A 15-cm external neurolysis in
department to remove the device and treat Medical Research Council). The addition to subcutaneous transposition
resulting nerve injuries. Records pertaining aforementioned findings were initially were performed. The nerve was repaired
to consultations, hospitalizations, and diagnosed by the treating physician and using a 10-0 nonabsorbable monofilament
surgical interventions in addition to labo- subsequently confirmed by a neurologist. epiperineurial suture in an interrupted
ratory examination data (nerve conduction At 1 month, atrophy of IO and flexible fashion. At 12 months postoperatively,
studies and electromyography, ultrasound ulnar claw posturing were also reported. extrinsic and intrinsic muscles had grade
[US], magnetic resonance imaging [MRI]) Electrophysiologic testing confirmed a M3 (British Medical Research Council)
were reviewed for each case by an ortho- severe sensorimotor ulnar neuropathy. The strength, and ulnar clawing was dimin-
paedic surgeon (P.L.) with experience in first dorsal IO and abductor digiti minimi ished. Partial sensory recovery was ob-
peripheral nerve surgery. demonstrated 3þ fibrillations without tained (S3þ according to the British
activation. Sensory recordings were Medical Research Council), but the pa-
Case 1. A 25-year-old woman was referred to significant for persistence of tient’s ulnar paresthesias persisted.
our department after experiencing radiating low-amplitude signals (25 mV). US Sequential postoperative electromyograms
pain in the ulnar nerve distribution during revealed fusiform enlargement of the ulnar documented reinnervation of ulnar nerve.
removal of an expired SCI (Figure 1). The nerve fascicle as it coursed over the distal
Implanon device was palpable on the third of the arm. Case 2. A 31-year-old woman was referred to
medial aspect of the arm and had been Owing to lack of improvement, surgical our department for a sensorimotor deficit
removed under local anesthesia by a exploration under general anesthesia was occurring after failed removal of her SCI
midwife in clinic. Immediately performed 2 months later. The ulnar nerve (Figure 2). The procedure had been
postoperatively, the patient was unable to was in continuity with a 1-cm neuroma. performed in the operating room under

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 LITERATURE REVIEW
PIERRE LAUMONERIE ET AL. NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

Figure 2. Case 2. (A) Preoperative photograph depicting (asterisk) in contact with the median nerve. (C and D) The ulnar
previous incision (arrow) over the subdermal contraceptive nerve after neuroma resection (arrow in C) at the time of implant
implant on the medial aspect of the arm. (B) Intraoperative removal was treated with a sural nerve graft (arrow in D).
photograph showing the subdermal contraceptive implant MN, median nerve; BA, brachial artery; UN, ulnar nerve.

regional anesthesia by a gynecologist; migration of the implant toward the and S3 in fifth digit) and resolution of
preoperative US did not allow for distal third of the medial arm. neuropathic pain. Sequential postoperative
identification of the nonpalpable implant. Surgical exploration was performed 7 electromyograms demonstrated reinnerva-
The gynecologist noted resistance after months later owing to lack of improvement tion changes in the ulnar nerve.
pulling on a nerve rather than the and necessity of implant removal. Preop-
implant; the patient described at that erative US-guided hook-wire marking of Literature Review
moment radiating pain in the ulnar nerve the implant was performed; this facilitated Literature Search Strategy. A literature
distribution. At 1 month postoperatively, removal of the nonpalpable implant. The search was performed using Medical
weakness involving the IO, flexor carpi ulnar nerve had a 1.5-cm neuroma in Subject Headings and keywords in the
ulnaris, and flexor digitorum profundus continuity at the site of putative injury. No following databases: Ovid Medline, Ovid
(fourth and fifth digits) was graded 2 nerve action potential was recorded across Embase, Scopus, Web of Science, and
(IO), 0 (flexor carpi ulnaris), and 3 (flexor the lesion. The neuroma was resected to Cochrane. The search was limited to
digitorum profundus). Flexible ulnar expose healthy nerve tissue; subsequently, English language literature; the terms
clawing and Froment sign were noted. interposition sural nerve grafting was “peripheral nerve injury,” “contraception”
The patient reported neuropathic pain performed. Follow-up demonstrated were combined with AND and OR. The
and grade S4 and S0 sensory loss continued clinical improvement. By 11 references in each study were reviewed to
involving the fourth and fifth digits, months postoperatively, there was resolu- identify additional articles corresponding
respectively. At 6 months, atrophy of the tion of ulnar clawing and there were to the research criteria.
hypothenar eminence and all IO was improvements in both intrinsic and
noted. Electrophysiologic testing extrinsic muscle strength (IO, grade 4; Selection Criteria. Articles included in the
confirmed a severe ulnar neuropathy flexor carpi ulnaris, grade 5; flexor dig- present study were limited to articles that
without signs of reinnervation. MRI itorum profundus fourth and fifth digits, discussed nerve injuries caused by SCIs
demonstrated fusiform enlargement of grades 3 and 0). The patient also experi- published between January 1988 and 2017.
the ulnar nerve fascicle in addition to enced sensory recovery (S3þ in fourth digit Studies in a language other than English or

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 LITERATURE REVIEW
PIERRE LAUMONERIE ET AL. NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

63 Clinical studies were identified from the following medical

databases
Identification 0 Cochrane
15 Embase
18 Medline
23 Scopus
7 Web of Science

42 Records selected after duplicates removed

0 Cochrane
9 Embase
Screening

18 Medline
14 Scopus
1 Web of science

42 Records screened 27 Records excluded

Did not meet first step inclusion criteria
Eligibility

15 Full-text articles assessed for eligibility Secondary screening by 2 independent reviewers with
full-text articles

5 Number of studies and reasons for drop out :

10 Studies included in qualitative synthesis

2 Abstract of congress
Included

2 Comment, letter to the editor

1 Radiological case report

10 Studies included in quantitative synthesis

Figure 3. Preferred Reporting Items for Systematic Reviews and relevant studies on peripheral nerve injuries caused by
Meta-Analyses flow chart summarizing search strategy for subdermal contraceptive implants.

with inadequate design (meta-analysis, re- description of the nerve injuries, contra- criteria, 15 articles underwent full-text
view of the literature, abstract for meetings) ceptive implants (model and location), evaluation. After detailed evaluation, 8
and studies centered exclusively on the preoperative clinical and radiographic case reports (level of evidence V) and 2
radiographic method of localization and/or presentation, surgical management, and case series (level of evidence IV) were
on removal techniques of nonpalpable midterm to long-term clinical outcomes included in the analysis. A summary of the
contraceptive implants were excluded. following surgery. Level of evidence in the search strategy is presented in Figure 3.
included studies was assessed using the
Data Extraction and Critical Appraisal. Data criteria established by Oxford Centre for Population Characteristics
were extracted from article text, tables and Evidence-based Medicine Levels of The cohort consisted of 12 patients with a
figures. Two investigators (P.L. and L.B.) Evidence.10 mean age of 29.8 years (range, 19e44
independently reviewed the full text of all years) who were evaluated at a mean
eligible articles. Disagreements between follow-up of 0.7 year (range, 0e2 years); 1
the 2 reviewers were resolved via discus- RESULTS patient was lost to follow-up.8 Norplanon
sion and consensus. When information (n ¼ 4), Implanon (n ¼ 4), and
was incomplete, the corresponding au- Quality of Studies Nexplanon (n ¼ 4) SCIs were implanted
thors of the articles were contacted. Data Our electronic search yielded 63 studies. in the nondominant arm (8 left and 2
extracted from the articles included a After applying inclusion and exclusion right; not available for 2 cases) either

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 LITERATURE REVIEW
PIERRE LAUMONERIE ET AL. NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

Table 1. Patient Characteristics in 10 Articles Describing Peripheral Nerve Injuries Secondary to Subdermal Contraceptive Implants
Published Between January 1988 and June 2017
Characteristics

Patients Subdermal Contraceptive Implant

Age Upper Prior Removal Implant

Study Country (years) Limb Attempts Model Inserted by Site Depth Palpable

Smith et al., 199818 USA 23 Right 0 Norplant Gynecologist Medial aspect of arm Subcutaneous Yes
Sarma et al., 199819 USA 36 Left 1 Norplant Gynecologist Medial aspect of arm Subfascial No
20
Marin and McMillian, 1998 USA 17 Left 1 Norplant Gynecologist Medial aspect of arm Subfascial No
21
Nash and Staunton, 2001 United Kingdom 33 Left 1 Norplant NA Medial aspect of arm Subcutaneous NA
Wechselberger et al., 200616 Austria 24 Left 1 Implanon Gynecologist Medial aspect of arm Subfascial No
13
Gillies et al., 2011 Australia 44 NA 1 Implanon General practitioner Medial aspect of arm Subcutaneous No
26 NA 1 Implanon General practitioner Medial aspect of arm Subcutaneous No
12
Brown and Britton, 2012 United Kingdom 26 Right 1 Implanon NA Medial aspect of arm Subcutaneous No
17
Restrepo and Spinner, 2016 USA 19 Left 0 Nexplanon Gynecologist Medial aspect of arm Subcutaneous No
Belyea et al., 201711 USA 39 Left 2 Nexplanon Gynecologist Medial aspect of arm Subfascial No
14
Odom et al., 2017 USA 36 Left 4 Nexplanon Gynecologist Medial aspect of arm Subfascial No
25 Left 1 Nexplanon Gynecologist Medial aspect of arm Subfascial Yes

NA, not available.

subcutaneously (n ¼ 6) or beneath the were reported. The 2 most commonly DISCUSSION

fascia (n ¼ 6). The implants were not injured nerves were the medial ante- Difficulties encountered during the
palpable in 7 patients; this information brachial cutaneous (MABC) nerve (n ¼ 5) removal of SCIs have stimulated intensive
was not available for 1 case. All patients and median nerve (n ¼ 5). Nerve injury research into the development of easy-to-
had an abnormal clinical examination or was primarily due to pulling or grasping of use systems.9,23 The development of
additional study findings. Neuropathic the nerve (n ¼ 9) after mistaking it for the these new devices will likely reduce the
pain (n ¼ 12) was identified in all implant. Neurapraxia (n ¼ 7) was the most incidence of insertion site complica-
patients. Clinical examination revealed common lesion and was treated primarily tions.9,24,25 Although rare, SCIs have the
paresthesias in 11 patients, weakness in 6 with implant removal and clinical surveil- potential to cause serious peripheral nerve
patients, and sensory loss in 8 patients. lance (n ¼ 6). Nerve coaptation (n ¼ 2) injuries during insertion and
Electrodiagnostic studies were performed was performed for partial nerve transec- removal.11,14,17 The broader, more com-
in symptomatic patients (n ¼ 4) either tion. Neurolysis (external neurolysis mon spectrum of adverse implant site re-
before or after device removal. [n ¼ 1] or epineurolysis [n ¼ 1]) was actions include pain, hematoma, swelling,
Ultrasound images (n ¼ 8) and/or performed to treat neuroma or nerve redness, and scarring.4,26 These compli-
radiographs (n ¼ 2) were sufficient to compression by scar tissues and/or SCIs. cations were described in 5.9% of women
localize the implant in 7 patients8,11-16 Of patients, 5 completely recovered, and 6 within the first few years after SCI inser-
and, later, to better describe the nerve continued to have a motor and/or sensory tion and/or removal.27 The insertion
injury in 1 patient.17 No patient deficit at short-term to long-term follow- procedure is straightforward and can
underwent preoperative MRI. Population up; 1 patient was lost to follow-up.19 No typically be performed in the office.
characteristics are reported in Tables 1 additional interventions were performed Implants must be inserted into the
and 2. for the treatment of sequelae. subcutaneous space on the medial aspect
Management by a pain specialist was of the nondominant arm 8e10 cm
Peripheral Nerve Injuries requested in 1 case owing to persistent proximal to the medial epicondyle under
There were 14 peripheral nerve injuries dysesthesia and paresthesia in the hand local anesthesia via a disposable sterile
associated with SCIs reported during or 4 months after coaptation of the median applicator. The SCI must be palpable
after insertion (n ¼ 2) and removal nerve.22 The results are summarized in throughout the duration of its use.15,23
(n ¼ 12) procedures; no associated lesions Table 2.

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 LITERATURE REVIEW
PIERRE LAUMONERIE ET AL. NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

After a maximum of 3 years, the palpable cases,2 with most implants migrating <2 cm recommend intraoperative US-guided
implant is removed under local from the initial insertion site. Too-deep hook-wire marking of the implant by an
anesthesia through a small incision at initial positioning and/or migration of experienced musculoskeletal radiologist to
the distal end of the rod. Manual the implant may lead to difficulty with facilitate safe dissection.38 For
pressure is applied to the proximal end localization via palpation at the time of symptomatic patients, nerve conduction
of the device to push it through the implant removal. In our study, 83% of studies and electromyography can assist
2-mm incision and grasp it with forceps nerve injuries involved patients with non- further by determining the severity of the
as it appears; no dissection is palpable implants. A standardized clinical injury and confirming its location; these
required.4,5,15,28,29 and radiographic evaluation should be studies also allow for improved clinical
In the medial aspect of the midarm, undertaken to locate the nonpalpable SCI, follow-up of patients in whom lesions
neurovascular structures are separated the neurovascular structures, and possible are treated with or without surgery.
from one another by the brachialis fascia associated lesions to facilitate safe implant All nerve injuries that occurred during
that divides the arm into superficial and removal.14,24 Neurovascular sequelae the removal of nonpalpable SCIs were
deep compartments. The MABC nerve lies resulting from insertion or removal of a caused by providers without formal micro-
within the subcutaneous space along with SCI must be identified at the time of initial surgical training (Table 2). Given the risks
the basilic vein.16 The MABC nerve courses evaluation for patients requesting a new of neurovascular injury with nonpalpable
within the anterior proximal arm, medial device. Scarring induced by a malposi- SCIs, we recommend asking a peripheral
to the brachial artery; it becomes a tioned implant can also place pressure on nerve specialist for assistance with
subcutaneous structure when it pierces the nerve at a distance from the SCI removal.14,24 In the event that an
the brachial fascia (basilica hiatus) 14 cm insertion site.20,21 Clinical assessment inadvertent nerve injury is suspected,
proximal to the medial epicondyle. SCIs should include a detailed history to accu- immediate action should be undertaken.
are typically inserted in this vicinity; rately understand the patient’s symptoms We avoid local anesthetics and paralytics,
therefore, it follows that incorrect as well as attempted implant palpation; as they preclude intraoperative nerve
subcutaneous positioning of the implant this provides an initial impression stimulation. In the present study, 75% of
may induce damage to the branches of regarding the location of possible nerve nerve injuries were associated with
the MABC nerve (anterior, or ulnar).16,30 injuries. Neuropathic pain at the level of accidental traction (pulling or grasping)
The subaponeurotic course of the MABC the upper arm or a history of SCI use on the nerve when it was mistaken for
nerve also places it at risk for injury should prompt the physician to suspect the SCI. For this reason, we advocate for
owing to accidental traction at the time nerve injury. Any loss of distal sensory and wide operative exposure, avoiding
of implant removal. The spectrum of motor function associated with insertion grasping the nonpalpable implant with
injuries to the MABC nerve described in or removal of an SCI should be treated as a surgical instruments until it has been
the literature is broad, ranging from suspected serious nerve injury and identified in its entirety and separated
neurapraxia to complete nerve addressed within days (Table 2); any delay from adjoining tissues (Figure 1, Tables 1
transection (Table 2). Clinical symptoms in treatment exposes patients to the risk of and 2).17 For patients with clinical or
are also variable and may include neuroma formation (Figure 1C).17 Recent electromyographic evidence of nerve
impaired sensation. An area of localized, literature describes the use of various injury, the nerves in close proximity to the
severe pain in the distribution of the methods to localize nonpalpable SCIs, implant must be exposed and inspected.
MABC nerve may occur in the case of a including x-rays, US, computed A nerve stimulator (Vari-Stim III Nerve
transected nerve trapped in scar tissue.16 tomography, and MRI.1,14,20,24,26,32-36 US Locator; Medtronic Xomed, Inc.,
Neurovascular structures beneath the examination should be considered the Jacksonville, Florida, USA) is needed to
fascia are also at risk; these structures first-line imaging because of its low cost, identify abnormally functioning nerves in
include the brachial artery and terminal lack of ionizing radiation, and wide avail- cases where no striking visual abnormality
branches of brachial plexus (Figures 1 ability.24,37 MRI is the best method for is present intraoperatively. When
and 2, Table 2). Accidental traction on unequivocal localization of implants not complete nerve transection is
the nerve rather than the implant at the detectable on US.24,35,37 High-resolution encountered, timely surgical repair should
time of removal and nerve compression 3T MRI with T1-weighted, T2-weighted, be performed using 9-0 or 10-0 epineural
are the 2 primary reasons for incomplete or gradient echo sequences (spoiled nonabsorbable monofilament suture
injuries. Nerve transection (n ¼ 6) is the gradient recalled echo) with robust fat placed in an interrupted fashion under
second most common injury pattern and suppression, with and without gadolinium direct visualization with surgical loupes or
affecting the median and/or ulnar nerves enhancement is the recommended a microscope.32 When direct repair is not
overall; emergent surgical treatment second-line imaging for implant localiza- feasible, a graft must be used (Figure 1).
should be the rule in this setting because tion and peripheral nerve imaging.24,37 Neurotization and/or tendon transfer
of the risk of neuroma formation Despite the fact that US was used in 75% should be considered for proximal nerve
(Figures 1 and 2, Table 2). of patients in this study, no diagnostic transections with motor deficits lasting
Although previous reports quote MRI studies have been reported in the >6 months.22,32,39 In the case of
migration rates reaching 39%,31 a recently literature. In cases where intraoperative superficial lesions, if primary nerve
published study of 4294 practitioners implant localization is challenging, coaptation of the MABC nerve is not
demonstrated migration in only 0.26% of extensive dissection must be avoided. We possible, its proximal end should be

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WORLD NEUROSURGERY 111: 317-325, MARCH 2018

PIERRE LAUMONERIE ET AL.

Table 2. Summary of Various Treatment Approaches in 10 Articles Describing Neurovascular Complications After Subdermal Contraceptive Implant Insertion and/or
Removal Published Between January 1988 and June 2017
Nerve Injury Treatment

Times to
Nerves Mechanism Treating Treatment Treating Functional
Study Involved Lesion Timing of Injury Provider Treatment (months) Provider Outcomes

Smith et al., 199818 Ulnar Contusion by needle Removal Nerve contusion Gynecologist Clinical and — Neurologist Residual deficit
(“U” technique)9 physiologic
surveillance
Sarma et al., 199819 Median Neurapraxia Second removal Pulling/grasping on Gynecologist Implant removal and 1 Interventional Lost to follow-up
attempt nerve clinical surveillance radiologist
Marin and Ulnar Neurapraxia After removal Compression by scar Gynecologist Epineurolysis 1 NA Residual deficit
McMillian, 199820 tissues
Nash and Staunton, MABC Neurapraxia After insertion Compression by NA Implant removal and — NA Residual deficit
200121 implant clinical and
and/or scar tissues physiologic
surveillance

NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

Wechselberger MABC Partial section Attempted removal Pulling/grasping on Gynecologist Implant removal and NA Plastic surgeon Full recovery
et al., 200616 nerve nerve coaptation
Gillies et al., 201113 Median Partial section Attempted removal Pulling/grasping on Gynecologist Implant removal and 0.4 (12 days) Hand surgeon Residual deficit
nerve nerve coaptation
Median Partial section Attempted removal Pulling/grasping on Gynecologist Implant removal and 0.03 (1 day) Hand surgeon Residual deficit
nerve nerve coaptation
Brown and Britton, MABC Neurapraxia Insertion Compression by NA Implant removal and 24 Orthopaedic Full recovery
201212 implant clinical surveillance surgeon (immediate
postprocedure)
Restrepo and MABC, median, Sections (n ¼ 3) Removal Pulling/grasping on Gynecologist External neurolysis 5 Neurosurgeon Full recovery (ulnar
www.WORLDNEUROSURGERY.org

Spinner, 201617 and ulnar complicated nerve (median, ulnar, and nerve); residual
by neuromas (n ¼ 3) MABC) deficit (MABC,
median nerves)
Belyea et al., 201711 Median nerve Neurapraxia Second removal Pulling/grasping on Gynecologist Implant removal and NA Orthopaedic Full recovery
attempt nerve clinical surveillance surgeon
Odom et al., 201714 NA Neurapraxia Fourth removal Pulling/grasping on Gynecologist Implant removal and NA Plastic surgeon Full recovery
attempt nerve clinical surveillance
MABC Neurapraxia Removal attempt Pulling/grasping on Gynecologist Implant removal and 0.1 (3 days) Plastic surgeon Full recovery
nerve and/or clinical surveillance

LITERATURE REVIEW
compression by
implant

NA, not available; MABC, medial antebrachial cutaneous.

323
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PIERRE LAUMONERIE ET AL. NERVE INJURY ASSOCIATED WITH SUBDERMAL CONTRACEPTIVE IMPLANT

transposed proximally and buried deep into Administration to avoid confusion at the 13. Gillies R, Scougall P, Nicklin S. Etonogestrel
implants—case studies of median nerve injury
the muscle of the arm to avoid formation of time of implant removal.14
following removal. Aust Fam Physician. 2011;40:
a painful neuroma.16,40 799-800.
CONCLUSIONS 14. Odom EB, Eisenberg DL, Fox IK. Difficult removal
Limitations
Nerve injuries related to SCIs are rare but of subdermal contraceptive implants: a multidis-
The limitations of this study relate to its ciplinary approach involving a peripheral nerve
retrospective, single-center nature and serious. In cases of nonpalpable implants, a expert. Contraception. 2017;96:89-95.
sample size. The retrospective design multidisciplinary approach including prac-
titioners with expertise in the treatment of 15. Rowlands S. Legal aspects of contraceptive im-
inherently leads to more loss of data and plants. J Fam Plann Reprod Health Care. 2010;36:
bias. Owing to the small number of cases peripheral nerve lesions is invaluable. 243-248.
and the nature of this study, specific rec-
ACKNOWLEDGMENTS 16. Wechselberger G, Wolfram D, Pülzl P, Soelder E,
ommendations for surgical treatment Schoeller T. Nerve injury caused by removal of an
cannot be established. Follow-up was of We thank Ms. Ann Farrell (Mayo Clinic implantable hormonal contraceptive. Am J Obstet
short duration for most patients (mean 0.7 Library, Rochester, Minnesota, USA) for Gynecol. 2006;195:323-326.
year; range, 0e2 years), and neurologic her help with the electronic search and 17. Restrepo CE, Spinner RJ. Major nerve injury after
data were sparse; this did not allow for a abstract compilation. contraceptive implant removal: case illustration.
reliable analysis of postoperative outcomes J Neurosurg. 2016;124:188-189.
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