Margaret-Ellen Clerkin1, Roisin Dolan1, Jake Mc Donnell2,3, Kevin Cronin1, Aubrie Sowa2,4, Farah Bakhsh2,4, Abidur Rahman3, Aoife O’Brien1,4, Joshua Skeens-Birrane4, Lylas Aljohmani4,5, Kirk Levins4,6
1Department of Plastic & Reconstructive Surgery, St. Vincent’s University Hospital, Dublin, Ireland;
2National Spinal Injuries Unit & Trinity Centre for Biomedical Engineering, Mater Misericordiae University Hospital, Dublin, Ireland;
3Trinity Biomedical Sciences Institute, Trinity College Dublin, The University of Dublin, Dublin, Ireland;
4Department of Surgery, School of Medicine, University College Dublin, Dublin, Ireland;
5Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland;
6Department of Pain Medicine, St. Vincent’s University Hospital, Dublin, Ireland
Background: Subdermal progesterone-releasing contraceptive implants (SCIs) are a popular form of contraception due to their long-term mechanism of action and ease of use. Serious adverse events relating to SCIs are rare, however, significant injuries to the neurovascular structures have been reported. The aim of this systematic review is to assess the incidence, treatment, and clinical outcomes of patients suffering from SCI-associated upper limb peripheral nerve injuries (PNIs) with the goal of providing practitioners with an evidence-based treatment algorithm. We also present six cases of ulnar neuropathy following surgical SCI removal included in the systematic review.
Methods: A systematic review was conducted of Ovid MEDLINE and Ovid EMBASE databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies of interest included retrospective case series and case reports detailing the incidence, treatment, and outcomes of patients with SCIs that reported upper limb sensory +/− motor neuropathy at the time of insertion or removal of the device.
Results: A total of 17 studies were included, totalling 21 patients and 24 upper limb PNIs. The majority of nerve injuries were associated with the Nexplanon© implant (n=8). The ulnar nerve was most commonly injured (n=12). The majority of PNIs occurred at the time of SCI removal (n=15, 71.4%), with 18 patients (86%) having an impalpable SCI. The majority of patients (n=18) required surgical exploration and post-operative clinical surveillance. Of these patients, 9 underwent SCI removal alone, 3 underwent SCI removal and neurolysis, 3 underwent excision of neuroma-in-continuity and primary nerve coaptation, 3 underwent excision of neuroma-in-continuity and autologous sural nerve graft reconstruction, and 1 underwent neurolysis alone.
Conclusions: Whilst SCI-associated neuropathy is rare, it causes significant functional morbidity to the affected young female cohort. We propose an evidence-based algorithm to provide practitioners with a systematic approach in the management of impalpable SCI’s to reduce the risk of PNI and expedite timely treatment for patients with suspected injuries.
Keywords: Subdermal contraceptive implants; peripheral nerve injuries (PNIs); ulnar nerve; neurolysis; neuroma
