When giving gluteal injections, it is safest to use the upper outer quadrant. The choice of site for injection must be based on good clinical judgment, using the best evidence available and individualized client assessment. There is wide agreement in the literature that the ventrogluteal site is preferable (Small, 2004). Review of the literature on relevant injection procedure found that injury to the sciatic nerve is associated with use of the dorsogluteal site for injection, because the sciatic nerve commonly courses this site (Fig. 1).
Ndiaye, Sakho, Fall, Dia, and Sow (2004) performed sciatic nerve gluteal dissection on 10 fresh adult African cadavers, on both sides. The nerve pathway was 19 times out of 20 in the subpiriformis canal. In all cases the pathway was identical, with an oblique and vertical portion running down through the ischio-trochanteric channel. The cutaneous projection of the sciatic nerve was distant from the upper lateral quadrant of the buttock.
The site of injection is the crucial factor in determining the degree of nerve fiber injury. The degree of injury varies significantly, depending upon the specific agent injected. The most severe injuries have been associated with widespread axonal and myelin degeneration (Gentili, Hudson, and Hunter, 1980a). Pathological alterations in the nerve were evident as early as 30 minutes following injection injury (Gentili et al., 1980b).
Although postinjection injury can occur in both adults and children, children appear to be at higher risk (Krasnikova, 1986). Fatunde and Familusi (2001) did a retrospective study of all children with a diagnosis of sciatic nerve injury during a 12-year period. They examined 27 children, 5 months-12 years of age, with a diagnosis of postinjection sciatic nerve injury. The drugs administered to 17 patients included chloroquine, novalgin, paraldehyde, procaine penicillin, and sulfadoxine-pyrimethamine. However, the most neurotoxic agents tested in a previous study appear to be penicillin G, diazepam, and chlorpromazine (Yaffe, Pri-Chen, Lin, Engel, & Modan, 1986). The postulated mechanisms of injury include direct needle trauma, secondary constriction by scar, and direct nerve fiber damage, due to both axon and Schwann cell, with a breakdown in the blood-nerve barrier by neurotoxic chemicals in the injected agent (Gentili et al., 1980b; Villarejo & Pascual, 1993)
Neurological sequelae can range from minor transient sensory disturbance to severe sensory disturbance and paralysis, with poor recovery (Villarejo & Pascual, 1993). In one study, seven patients (26%) presenting with foot drop had had recent IM injections in the buttock. An additional 20 patients (74%) presented much later (Fatunde & Familusi, 2001). In fact, gluteal IM injection that led to sciatic nerve injury most often presented as paralytic drop foot (Mayer & Romain, 2001; Sobel, Huang, & Wieting, 1997).
Children who present with drop foot may later develop gluteal fibrosis (diagnosed 5.1 years after the injections). In contrast, sciatic nerve palsy, presenting as equinovarus or equinus deformity, was diagnosed on average 3.8 months after the intragluteal injections (Napiontek & Ruszkowski, 1993). Cavovarus and calcaneocavus foot deformities have also been reported (Bigos & Coleman, 1984).
Medical treatments including administration of vitamins and alphachymotrypsine have been tried with varying results, depending on the extent of the lesion. Early (within 2 months) physiotherapy may provide a better chance of recovery (Bourrel & Souvestre, 1982). Our patient presented 12 months after nerve injury and, thus, his chances of recovery were small.
The recommended treatment ranges from a conservative approach to immediate operative exposure and irrigation and has included early neurolysis or delayed exploration with neurolysis or resection and anastomosis (Villarejo & Pascual, 1993). Of 190 patients with gluteal sciatic nerve injuries in one retrospective study, the injuries were caused by injection in 164 patients (86.32%). Fifteen were treated by conservative means, and the other 175 had surgical intervention. Neurolysis was performed in 160 cases, epineural neurorrhaphy in 12 cases, nerve grafting in 2 cases, and nerve exploration but no repair in 1 case. Late-stage functional reconstruction of the foot and ankle was performed in 23 cases. Follow-up of 151 patients for an average 8.5 years revealed excellent to good nerve recovery (i.e., 57% and 78% in the early and late stage, respectively). We believe that neurolysis should be performed as soon as possible in cases of injection injury (Huang, Yan, & Lei, 2000).
Epineural neurorrhaphy should be performed in cases of nerve rupture. Functional reconstruction of the foot and ankle should be carried out in the late stage for the improvement of the limb function, if a surgical team is available for this purpose (Huang et al., 2000). If performed within 24 hours after injury, neurolysis may prevent the occurrence of paralysis (Mayer & Romain 2001; Yaffe et al., 1986). Our patient was offered physiotherapy rather than surgical treatment because of his late presentation. To date, his improvement has been minimal.
The implications for nurses include the need to learn and practice safe injection technique. Nurses must also assess for complications (both immediate and long term), and educate patients.
J Neurosci Nurs. 2006;38(4):238-240. © 2006 American Association of Neuroscience Nurses
Cite this: Sciatic Nerve Injury Following Intramuscular Injection: A Case Report and Review of the Literature - Medscape - Aug 01, 2006.