Skip to main content

Neural lesions in obstetrics: a diagnostic tree

To the Editor:

We read with great interest the case report by S. Shimizu, describing a unilateral radiculopathy due to adhesive arachnoiditis after spinal anesthesia for emergency cesarean section. His analysis concludes that there was a localized arachnoiditis of the left L5-S1 nerve roots, based on clinical findings and MRI imaging [1].

We were puzzled by the clinical presentation and evolution of symptoms. It began with hypoesthesia of the lateral aspect of the left thigh, resembling meralgia paresthetica, involving the femoral lateral cutaneous nerve (L2-3-4 nerve roots). They also noted motor weakness on dorsiflexion and plantar flexion of the left foot, suggesting lumbosacral plexus involvement (L4-S4). There is no other clinical description to allow a definite diagnosis. Also, MRI findings are equivocal and may not support the diagnosis of arachnoiditis since nerve roots are not adherent and the dural thickening is most likely due to a chemical shift artifact (type 1).

We believe this is a case report of foot drop syndrome in a patient that may have hereditary neuropathy with liability to pressure palsy that can be better described by ruling out positive and negative findings. This clinical dilemma is not unusual, especially in obstetrical patients where neural palsies are due to pregnancy or from obstetrical causes, and seldom from anesthesia origin [2]. We present a scheme that can help discriminate clinically different diagnoses.

Clinical assessment for post cesarean section foot drop syndrome.

  1. 1.


    1. a.

      Previous spine disease (disk herniation, hereditary neuropathy with liability to pressure palsy, diabetes, etc.)

    2. b.


      1. i.

        Leg support malposition: common fibular nerve palsy

      2. ii.

        Prolonged labor stages and forced leg positions: femoral nerve or lateral cutaneous femoral nerve palsy (meralgia paresthetica)

      3. iii.

        Instrumental delivery: sacral plexus palsy

    3. c.

      Cesarean section:

      1. i.

        Surgical retractors: nerves or sacral plexus palsies

      2. ii.

        Leg malposition: femoral nerve or lateral cutaneous femoral nerve palsy (meralgia paresthetica)

    4. d.

      Neuraxial anesthesia: Cauda equina syndrome, conus medullaris syndrome, or spinal lesion due to direct puncture, pharmacological damage, or infection

  2. 2.

    Neurological assessment

    1. a.

      Motor function

      1. i.

        No flexion or eversion of the leg + hypoesthesia of leg and foot: common fibular nerve

      2. ii.

        No flexion or eversion of the leg + no abduction of the thigh (gluteus medius muscle): L5 nerve root palsy

      3. iii.

        No flexion or eversion of the leg + sphincter incontinence: cauda equina syndrome or lumbosacral palsy

    2. b.

      Sensory function

      1. i.

        Leg and foot hypoesthesia only: superficial fibular nerve

      2. ii.

        Leg and foot hypoesthesia + abolished calcaneal (Achiles’) tendon reflex: sciatic nerve palsy or lumbosacral plexus palsy

      3. iii.

        Bilateral leg hypoesthesia: Cauda equina syndrome or conus medullaris syndrome

Availability of data and materials

Not applicable.


  1. Shimizu S. Unilateral radiculopathy away from the puncture site due to adhesive arachnoiditis after spinal anesthesia for an emergent cesarean delivery: a case report. JA Clin Rep. 2022;8(1):28.

    Article  Google Scholar 

  2. Reynolds F. Neurological infections after neuraxial anesthesia. Anesthesiol Clin. 2008;26(1):23–52.

    Article  Google Scholar 

Download references


Not applicable.


The current letter had only departmental funding for the writing process.

Author information

Authors and Affiliations



HL conceived, analyzed, and interpreted the data; PM analyzed and interpreted the data; JPC analyzed the neuroimages and interpreted the data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hector J. Lacassie.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lacassie, H.J., Mellado, P. & Cruz, J.P. Neural lesions in obstetrics: a diagnostic tree. JA Clin Rep 8, 39 (2022).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: