Focal brachial cutaneous neuropathy associated with Norplant<SUP>®</SUP> use: Suggests careful consideration of the recommended site for inserting contraceptive implants

Abstract

A case of neuropathy in the medial antebrachial cutaneous nerve of the forearm following a Norplant ® removal is described. The incidence of this problem is uncertain. The suggested siting of the contraceptive implants directly over the bicipital groove is questioned. Case reportA 33-year-old woman presented to the family planning clinic for a routine removal of Norplant ® having had it inserted 5 years previously. She reported that at the time of insertion one of the six capsules gave rise to pain in the arm and was removed and replaced. The implant was sited on the anterio-medial aspect at approximately the mid point of the left upper arm, as is standard procedure. 1 The standard -u -technique under local anaesthetic was used for removal. It was noticed at the time that there was quite marked fibrosis, and one capsule was removed in three pieces. Following the removal the patient was treated with antibiotics as there was thought to be infection present with pain and tenderness. She complained of intermittent parasthesiae on the inner anterior aspect of the arm and was referred for a neurological opinion.On examination she was found to have reduced sensation to pin prick in the left arm in the distribution of the medial antebrachial cutaneous nerve of the forearm. Nerve conduction testing demonstrated a consistent and reliable sensory potential in the right medial and lateral antebrachial cutaneous nerves of the forearm, as well as the left lateral antebrachial cutaneous nerve of the forearm. This potential was absent in the left medial antebrachial cutaneous nerve of the forearm, over her site of hypo-esthesia.No other clinical or neurophysiological disturbance was found in the arm apart from a Tinel's phenomenon when percussing the site of the Norplant ® removal, which radiated to the site of the symptoms in the territory of the medial antebrachial cutaneous nerve of the forearm.

Surgical Anatomy of the Medial Antebrachial Cutaneous Nerve: Clinical Application in Ulnar Nerve Decompression Surgery in the Elbow

“…Although its lesion is reported as a complication of medial elbow surgery, there are no parameters described to facilitate its location. [1][2][3][4][5][6] The objective of the present study is to facilitate the identification of this posterior branch during ulnar nerve decompression surgery in the elbow through measurements regarding specific anatomical points; additionally, although it is not the main purpose, the information provided will also be useful for surgeries requiring medial approaches in the elbow and procedures to block sensitive branches, thus extending the application of the results obtained with the present study.…”

Medial Antebrachial Cutaneous Nerve: Anatomical Relationship with the Medial Epicondyle, Basilic Vein and Brachial Artery

“…The branches of MACN in these zones are clinically important as they are vulnerable to injuries induced by several procedures. In the arm, insertion and removal of hormonal contraceptive implant can cause MACN injury (Nash & Staunton, 2001;Wechselberger et al, 2006). Injury of the posterior branch of MACN has been reported in patients undergoing cubital tunnel surgery (Lowe et al, 2004;Mackinnon & Novak, 2007).…”

Peripheral Nerve Injury Associated with a Subdermal Contraceptive Implant: Illustrative Cases and Systematic Review of Literature

“…Scarring induced by a malpositioned implant can also place pressure on the nerve at a distance from the SCI insertion site. 20,21 Clinical assessment should include a detailed history to accurately understand the patient's symptoms as well as attempted implant palpation; this provides an initial impression regarding the location of possible nerve injuries. Neuropathic pain at the level of the upper arm or a history of SCI use should prompt the physician to suspect nerve injury.…”