the main causes are injury to the nervous system , including the central and peripheral nervous systems , or musculoskeletal abnormalities . in rare cases
in particular , paralysis of the limbs can be caused by a conversion disorder after surgical procedures , including laparoscopic operations .
we found a patient who became paralyzed in her lower extremity after undergoing laparoscopic appendectomy .
our findings indicate that psychological problems can be related to limb paralysis without organ damage in patients who have undergone laparoscopic surgical procedures .
a 13-year - old patient visited the department of general surgery complaining of sudden abdominal pain after experiencing intermittent nausea and vomiting for a few days . tenderness and rebound tenderness in the right lower portion of her abdomen was observed upon physical examination .
the operation was performed with the patient in a supine position while under general anesthesia .
an incision was made 1 cm below the umbilicus , and a trocar 11 cm in length was inserted after pneumoperitoneum was induced using a veress needle .
next , 5 mm trocars were inserted around the suprapubic area and anti - mcburney 's point .
the appendix was extracted with laparoscopic forceps and the mesoappendix was removed by laparoscopic electric cautery .
the base of the appendix was ligated with two endo - loops ( covidien co. ltd . ,
mansfield , ma , usa ) and a 10 mm distal region of the base was also clipped with a laparoscopic clip .
two days after the operation , the patient complained of hypesthesia and weakness in the right lower extremity .
the patient was transferred to the department of rehabilitation medicine , and a neurological examination was performed .
the ability to sense pain and temperature were normal , but the sense of light touch was abnormal between the t11 and l2 dermatome , indicative of hypesthesia .
muscle strength of right hip flexor , knee extensor , and knee flexor was reduced to 2/5 , but the strength of other muscles was unchanged according to a manual muscle test .
pelvic and lumbar magnetic resonance imaging ( mri ) was performed in order to evaluate the cause of lower limb paralysis .
the patient complained of pain around the surgical site , and paralysis of the right lower extremity persisted for 10 days after surgery .
muscle strength of the right hip flexor , knee extensor , and knee flexor was still decreased in the follow - up manual muscle test . an electrodiagnostic study ( emg )
nerve conduction and needle electromyography results appeared normal , except that the interference pattern of motor unit action potential in the muscles was decreased at maximal volition .
rehabilitation training was performed by the patient for 40 minutes twice a day with a physical therapist since being transferred to the department of rehabilitation medicine .
the patient indicated that she liked ' taekwondo ' and desired to become a taekwondo athlete .
therefore , functional training , including balance and posture exercises related to taekwondo , was performed continuously .
. the sense of balance when in specific positions also improved while functional training was performed .
on postoperative day 14 , tenderness around the right lower quadrant of the abdomen was still observed and the degree of the pain was 6 on the visual analogue scale . because the pain around the operation site and right lower abdomen persisted , a general surgery consultation was performed to evaluate the presence or absence of laparoscopic complications .
however , the operation wound was found to be well healed , and no abscesses or mass lesions were found by follow - up abdominal computed tomography . on postoperative day 20 , a follow - up emg was performed in which no significant interval changes were observed , and the results were the same as the previous emg .
therefore , peripheral nerve lesions and myopathy were ruled out as the cause of paralysis .
brain , cervical , and thoracic mri was performed in order to detect disorders of the central nervous system , but definite abnormal findings were not observed .
we subsequently decided to explore the possibility of psychological problems after organ damage , including nerve or muscle injury , was ruled out as the cause of paralysis .
an interview with the patient 's parents was conducted on postoperative day 21 . according to
the results of the interview , the patient was having trouble adjusting to school and her parents had visited the school several times to meet with her teacher .
the patient hoped to move to another school that has a taekwondo club in order to be an athlete , but the patient 's parents were against the idea .
on postoperative day 22 , significant improvement of the leg strength was not observed but the patient could independently walk from the general ward to the rehabilitation clinic .
although right hip flexor strength was still 2/5 the normal level , her lower extremities moved well without claudication from the stance to swing phase during gait training .
on postoperative day 23 , we interviewed with the patient 's parents and explained that a conversion disorder could be a possible cause of paralysis .
the parents were encouraged to resolve the conflict concerning the patient 's career path through continuous psychiatric consultation . the patient was discharged .
paralysis of the patient 's lower extremity improved gradually and the patient returned to normal life .
laparoscopic surgery is widely performed instead of open appendectomy due to many advantages , such as diagnostic help , shorter hospitalization periods , reduced post - operative pain , decreased need for analgesics , fewer cases of wound infection , and improved cosmetic results.1 ) however , direct organ injuries , vascular injury , wound infection , hernia formation , tumor seeding , and endometriosis resulting from laparoscopic surgery have been reported.2 ) although rare , paralysis due to nerve injury may also occur owing to positional injury , trocar injury , peritoneal adhesion , or pneumoperitoneum after laparoscopic surgery.3 ) if organ problems or physical disorders are ruled out as the cause of sensorimotor dysfunction appearing after laparoscopic surgery , a conversion disorder might be the cause of limb paralysis.4,5 ) we came across a case of paralysis of the lower extremity after laparoscopic appendectomy . although a complete workup was performed in order to uncover the cause , no organ problems could be found .
therefore , we investigated the possibility that the paralysis may be due to psychological problems .
we were aware that the patient was coming into conflict with her parents over the patient 's career path and was having trouble adjusting to school .
according to the diagnostic criteria of conversion disorder in the dsm - iv,6 ) we diagnosed the patient as having conversion disorder due to the motor weakness of the right lower extremity and decision of her career .
in addition , there were no organ injuries causing limb paralysis in spite of multilateral evaluations , absences from school due to gait disturbance , and points that were not explained by other symptoms of mental illness .
conversion disorder is a type of somatoform disorder that causes dyssynergia , tremor , dystonia , or paralysis of one or more extremities .
this condition is also known as chronic neurosis , psychosomatic disorder , functional disorder , or functional overlay.7 ) conversion disorder is characterized by motor or sensory symptoms accompanied by psychological factors .
functional loss is not intentional or related to general medical problems.8 ) conversion disorder must be distinguished from malingering , in which symptoms occur intentionally and are related to secondary gain .
one characteristic of conversion disorder is that somatic symptoms are not provoked by intent.9 ) ten percent to 23% of patients with conversion disorder have paralysis of limbs as a major symptom.10 ) patients with conversion disorder are more likely amicable , cooperative , and reliant than malingerers and accept evaluation and treatment gladly .
patients with conversion disorder are more likely to report historical gaps , incorrect , and unpredictable changes , whereas malingerers are more likely to provide extremely thorough and definite explanations of their experiences precipitating their illness.11 ) the patient cooperated well with medical examination and there were vagaries about her symptoms and signs .
these factors were helpful in differentiating the diagnosis from malingering . for patients with paralytic symptoms due to conversion disorder ,
hospitalization is required for a few day or months , and functional recovery is good.4 ) not much research has been conducted on the outcomes or long - term prognosis of conversion disorder in children and adolescents .
it has been reported that many conversion disorder symptoms spontaneously improve after a few days or weeks or require minimal intervention .
it was also found that the rates of clinical improvement are good , ranging from 56% to 100% .
in particular , a good prognosis is associated with young age , fast diagnosis , rapid identification of stressors , and a good relationship with family members.12 ) however , it must be noted that the clinical symptoms may be perpetuated if diagnostic tests were performed aggressively in order to identify the causes , but the cause is not detected at an early stage .
symptoms are also more likely to be chronic by excessive concern from family or medical staff.13 ) in the current study , we only considered the possibility of organic problems soon after the onset of symptoms and thus conducted several diagnostic tests .
however , the cause was not identified with these methods and the patient 's family became increasingly concerned .
fortunately , we determined that the cause was a stressor related to a conflict regarding the patient 's career path .
furthermore , a close relationship was formed between the family members and the parents with respect to the patient 's desire to become a ' taekwondo ' athlete .
this is thought to be an important step as the patient 's symptoms were not chronic and completely resolved within 2 months .
treatments for conversion disorder include group or individual psychotherapy , medications , and rehabilitation therapies.4 ) rehabilitation therapy for patients with paralysis generally includes strengthening exercises for the paralytic muscles , stretching exercises to maintain range of motion for each joint , and functional training to improve gait or transfer .
it is important to provide this treatment while not showing excessive concern or reinforcing abnormal gait patterns caused by paralysis that is associated with conversion disorder . in particular , kanarek et al.4 ) reported that it is important to plan task - oriented goals based on functional training while considering the patient 's interests in order to improve the patient 's function .
rehabilitation training that included muscle - strengthening exercises and functional gait training was conducted for 40 minutes twice a day with a physical therapist .
functional training , with balance and posture exercises relating to taekwondo , was also performed continuously considering the patient 's interest .
we believe that a good rapport with the patient through these therapies prevented the development of sequelae associated with conversion disorder and promoted functional improvement .
 limb paralysis can develop for various reasons . 
 we found a 13-year - old patient who became paralyzed in her lower extremities after laparoscopic appendectomy . some tests , including electrodiagnostic studies and magnetic resonance imaging , 
 were performed to evaluate the cause of lower limb paralysis . 
 none of the tests yielded definite abnormal findings . 
 we subsequently decided to explore the possibility of psychological problems . 
 the patient was treated with simultaneous rehabilitation and psychological counseling . 
 paralysis of the patient 's lower extremity improved gradually and the patient returned to normal life . 
 our findings indicate that psychological problems can be related to limb paralysis without organ damage in patients who have undergone laparoscopic surgical procedures . 
INTRODUCTION
CASE REPORT
DISCUSSION