Deep Peroneal Research Articles

Dexmedetomidine Added to Local Anesthetic Mixture of Lidocaine and Ropivacaine Enhances Onset and Prolongs Duration of a Popliteal Approach to Sciatic Nerve Blockade

PurposeA literature review of multiple clinical studies on mixing additives to improve pharmacologic limitation of local anesthetics during peripheral nerve blockade revealed inconsistency in success rates and various adverse effects. Animal research on dexmedetomidine as an adjuvant on the other hand has promising results, with evidence of minimum unwanted results. This randomized, double-blinded, contrastable observational study examined the efficacy of adding dexmedetomidine to a mixture of lidocaine plus ropivacaine during popliteal sciatic nerve blockade (PSNB). MethodsSixty patients undergoing varicose saphenous vein resection using ultrasonography-guided PSNB along with femoral and obturator nerve blocks as surgical anesthesia were enrolled. All received standardized femoral and obturator nerve blocks, and the PSNB group was randomized to receive either 0.5 mL (50 µg) of dexmedetomidine (DL group) or 0.5 mL of saline (SL group) together with 2% lidocaine (9.5 mL) plus 0.75% ropovacaine (10 mL). Sensory onset and duration of lateral sural cutaneous nerve, sural nerve, superficial peroneal nerve, deep peroneal nerve, lateral plantar nerve, and medial plantar nerve were recorded. Motor onset and duration of tibial nerve and common peroneal nerve were also examined. FindingsSensory onset of sural nerve, superficial peroneal nerve, lateral plantar nerve, and medial plantar nerve was significantly quicker in the DL group than in the SL group (P < 0.05). Sensory onset of lateral sural cutaneous nerve and deep peroneal nerve was not statistically different between the groups (P > 0.05). Motor onset of tibial nerve and common peroneal nerve was faster in the DL group than in in the SL group (P < 0.05). Duration of both sensory and motor blockade was significantly longer in the DL group than in the SL group (P < 0.05). ImplicationsPerineural dexmedetomidine added to lidocaine and ropivacaine enhanced efficacy of popliteal approach to sciatic nerve blockade with faster onset and longer duration.

Continuous Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison With Novel, Alternative Analgesic Modalities.

A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted catheter with its tip adjacent to a target nerve/plexus through which local anesthetic may be administered, providing a prolonged block that may be titrated to the desired effect. In the decades after its first report in 1946, a plethora of data relating to CPNB was published, much of which was examined in a 2011 Anesthesia & Analgesia article. The current update is an evidence-based review of the CPNB literature published in the interim. Novel insertion sites include the adductor canal, interpectoral, quadratus lumborum, lesser palatine, ulnar, superficial, and deep peroneal nerves. Noteworthy new indications include providing analgesia after traumatic rib/femur fracture, manipulation for adhesive capsulitis, and treating abdominal wall pain during pregnancy. The preponderance of recently published evidence suggests benefits nearly exclusively in favor of catheter insertion using ultrasound guidance compared with electrical stimulation, although little new data are available to help guide practitioners regarding the specifics of ultrasound-guided catheter insertion (eg, optimal needle-nerve orientation). After some previous suggestions that automated, repeated bolus doses could provide benefits over a basal infusion, there is a dearth of supporting data published in the past few years. An increasing number of disposable infusion pumps does now allow a similar ability to adjust basal rates, bolus volume, and lockout times compared with their electronic, programmable counterparts, and a promising area of research is communicating with and controlling pumps remotely via the Internet. Large, prospective studies now document the relatively few major complications during ambulatory CPNB, although randomized, controlled studies demonstrating an actual shortening of hospitalization duration are few. Recent evidence suggests that, compared with femoral infusion, adductor canal catheters both induce less quadriceps femoris weakness and improve mobilization/ambulation, although the relative analgesia afforded by each remains in dispute. Newly published data demonstrate that the incidence and/or severity of chronic, persistent postsurgical pain may, at times, be decreased with a short-term postoperative CPNB. Few new CPNB-related complications have been identified, although large, prospective trials provide additional data regarding the incidence of adverse events. Lastly, a number of novel, alternative analgesic modalities are under development/investigation. Four such techniques are described and contrasted with CPNB, including single-injection peripheral nerve blocks with newer adjuvants, liposome bupivacaine used in wound infiltration and peripheral nerve blocks, cryoanalgesia with cryoneurolysis, and percutaneous peripheral nerve stimulation.

Ganglion Cyst at the Proximal Tibiofibular Joint in a Patient with Painless Foot Drop

Entrapment neuropathies of the fibular nerve and its branches are often underdiagnosed due to the lack of reliable diagnosis using clinical examination and electrophysiologic evaluation. Most fibular nerve compressions may be classified into 2 broad categories: (a) mechanical causes, which occur at fibrous or fibro-osseous tunnels, and (b) dynamic causes related to nerve injury during specific limb positioning. Foot drop resulting from weakness of the dorsiflexor muscles of the foot is a relatively uncommon presentation and closely related to L5 neuropathy caused by a disc herniation. However, we herein describe a rare case of usually painless foot drop triggered by a cyst at the proximal tibiofibular joint compressing the deep fibular nerve. The presence of multilevel disc diseases made the diagnosis more difficult. Foot drop is highly troubling, and health care providers need to broaden their search for the imperative and overlapping causes especially in patients with painless drop foot, and the treatment is variable and should be directed at the specific cause. The magnetic resonance imaging (MRI), including high-resolution and 3D MR neurography, allows detailed assessment of the course and anatomy of peripheral nerves, as well as accurate delineation of surrounding soft-tissue and osseous structures that may contribute to nerve entrapment. Knowledge of normal MRI anatomy of the nerves in the knee and leg is essential for the precise assessment of the presence of peripheral entrapment conditions that may produce painless or painful drop foot. In conclusion, we stress the importance of preoperative anatomic mapping of entrapment neuropathies to minimize neurological complications. Key words: Foot drop, fibular nerve, ganglion cyst, proximal tibiofibular joint

Surface Projection of Interosseous Foramen of the Leg: Cadaver Study.

Purpose. This study was conducted to identify the surface projection of the interosseous foramen and associated structures of the proximal leg using the average clinician's thumb width as a quick measurement to assist in differential diagnosis and treatment. Methods. Twelve cadavers (5 males and 7 females, age range = 51–91 years, and mean age = 76.9) were dissected for analysis. Location and size of interosseous foramen, location of anterior tibial artery, location of deep fibular nerve, and corresponding arterial branches were measured and converted into thumb widths. Results. Mean thumb width measured among the cadavers was 17.94 ± 3.9 mm. The interosseous foramen measured was approximately 1 thumb width vertically (18.47 ± 3.0 mm) and 1/2 thumb width horizontally (7.32 ± 2.1 mm) and was located approximately 1 thumb width distally to the tibial tuberosity (20.81 ± 6.8 mm) and 2 thumb widths (37.47 ± 4.7 mm) lateral to the tibial ridge. The anterior tibial artery and deep fibular nerve converged approximately 4 thumb widths (74.31 ± 14.8 mm) inferior to the tibial tuberosity and 2 thumb widths (33.46 ± 4.9 mm) lateral to the tibial ridge. Conclusion. Clinicians may identify anatomical structures of the proximal leg with palpation using the thumb width for measurement.

Repetitive Electroacupuncture Attenuates Cold-Induced Hypertension through Enkephalin in the Rostral Ventral Lateral Medulla.

Acupuncture lowers blood pressure (BP) in hypertension, but mechanisms underlying its action are unclear. To simulate clinical studies, we performed electroacupuncture (EA) in unanesthetized rats with cold-induced hypertension (CIH) induced by six weeks of cold exposure (6 °C). EA (0.1 – 0.4 mA, 2 Hz) was applied at ST36-37 acupoints overlying the deep peroneal nerve for 30 min twice weekly for five weeks while sham-EA was conducted with the same procedures as EA except for no electrical stimulation. Elevated BP was reduced after six sessions of EA treatment and remained low 72 hrs after EA in 18 CIH rats, but not in sham-EA (n = 12) and untreated (n = 6) CIH ones. The mRNA level of preproenkephalin in the rostral ventrolateral medulla (rVLM) 72 hr after EA was increased (n = 9), compared to the sham-EA (n = 6), untreated CIH rats (n = 6) and normotensive control animals (n = 6). Microinjection of ICI 174,864, a δ-opioid receptor antagonist, into the rVLM of EA-treated CIH rats partially reversed EA’s effect on elevated BP (n = 4). Stimulation of rVLM of CIH rats treated with sham-EA using a δ-opioid agonist, DADLE, decreased BP (n = 6). These data suggest that increased enkephalin in the rVLM induced by repetitive EA contributes to BP lowering action of EA.

Correction of Hammertoe Deformity With Novel Intramedullary PIP Fusion Device Versus K-Wire Fixation

K-wire fixation has been the most common method of fixation for hammertoe deformity. However intramedullary devices are gaining ground in both number of available choices and in procedures performed. This study aimed to compare the outcomes of hammertoe correction performed with K-wire fixation versus a novel intramedullary fusion device (CannuLink). A retrospective review of hammertoe correction by a single surgeon was performed from June 2011 to December 2013. Sixty patients (95 toes) underwent K-wire fixation and 39 patients (54 toes) underwent fusion with the CannuLink implant. Average age was 61.7 years and 61.4 years, respectively. Average length of follow-up was 12.9 and 12.3 months, respectively. Patients were evaluated for medical comorbidities, smoking status, inflammatory arthritis, peripheral vascular disease, peripheral neuropathy, pre- and postoperative visual analog pain scale, bony union percentage, revision rate, complications (hardware and surgery-related), and persistent symptoms at last follow-up. There was no significant difference in demographics or comorbidities between the 2 groups ( P > .05). In the K-wire group, 16 patients (18 toes) remained symptomatic at last follow-up (27%). Nine toes (9.5%) had recurrent deformity, 3 toes (3%) developed a late infection because of the recurrent deformity, and 1 toe (1%) developed partial numbness. One patient suffered a calf deep vein thrombosis (DVT) and peroneal nerve neuritis, 1 patient developed foot drop, and 3 patients continued to complain of pain. Five toes required revision surgery (5.3%). In the intramedullary group, 3 (7.7%) patients remained symptomatic and all were associated with a complication. One patient developed chronic regional pain syndrome in the foot, a calf DVT, and a nonfatal pulmonary embolus. A second patient developed a painless recurrent deformity. A third patient had wound dehiscence. Nobody had hardware failure or required a second operation. The CannuLink intramedullary device for hammertoe correction resulted in fewer complications, only 1 recurrent deformity, and no reoperations compared with K-wire fixation. Level III, retrospective comparative study.

Uncommon Development of Acute Isolated Lateral Leg Compartment Syndrome with Peroneus Longus Muscle Tear and Deep Peroneal Nerve Palsy: A Case Report.

An acute isolated lateral leg compartment syndrome with peroneus longus muscle tearand deep peroneal nerve palsy due to avulsion in sport injury is uncommon and rare aswell as difficult to diagnose as not all characteristics of the compartment syndrome arepresented. This case reports on the pre-surgical finding, surgical finding and postoperativeoutcome to raise awareness of the injury itself and how to process towards full recoveryof deep peroneal nerve palsy.

A cadaveric study showing the anatomical variations in the branches of the dorsalis pedis artery at the level of the ankle joint and its clinical implication in ankle arthroscopy.

Introduction Pseudoaneurysm formation following ankle arthroscopy is a rare but potentially catastrophic complication. The placement of anterior ankle portals carries inherent risk to the superficial and deep peroneal nerves, as well as to the dorsalis pedis artery. Anatomical variations in the dorsalis pedis and the presence of branches at the joint line may increase the risk of vascular injury and pseudoaneurysm formation during arthroscopy. There is limited anatomical evidence available regarding the branches of the dorsalis pedis artery, which occur at the point at which they cross the ankle joint. Objectives The objective of the study was to describe the frequency and direction of branches of the dorsalis pedis crossing the ankle joint. Materials and Methods Nineteen cadaveric feet were carefully dissected to explore the course of the dorsalis pedis artery, noting in particular the branching pattern at the joint line. Results Eleven of the nineteen feet had a branch of the dorsalis pedis artery that crossed the level of the ankle joint. Out of these, six were lateral, four medial and one bilateral. Eight of the eleven specimens had one branch at, or just before, the level of the joint. Two specimens had two branches and one had three branches crossing the ankle, which were all in the same direction, crossing laterally to the main trunk of the dorsalis pedis. Conclusions Our study demonstrated high rates of branching of the dorsalis pedis artery at the level of the ankle joint. The role of these branches in pseudoaneurysm formation during anterior hindfoot surgery remains unclear.

Pain Relief and Health-Related Quality-of-Life Improvement After Microsurgical Decompression of Entrapped Peripheral Nerves in Patients With Painful Diabetic Peripheral Neuropathy

Surgery had been shown to be effective for superimposed peripheral nerve entrapment syndrome in patients with diabetic peripheral neuropathy (DPN), with pain relief and sensation restored. Few studies, however, have reported the quality-of-life outcomes of surgery for the treatment of painful DPN (PDPN). The objective of the present study was to evaluate the effects of microsurgical decompression of multiple entrapped peripheral nerves on pain and health-related quality of life in patients with refractory PDPN of the lower limbs. Eleven patients with intractable PDPN of the lower limbs were recruited for the present study. All the patients underwent microsurgical decompression of the common peroneal nerve, deep peroneal nerve, and posterior tibial nerve. The pain intensity was assessed using the visual analog scale and health-related quality of life was measured using the short-form 36-item quality-of-life survey. Six (54.6%) patients experienced >50% pain relief (both daytime pain and nocturnal pain) at 2weeks after the decompression procedure and 8 (72.7%) patients at 24months postoperatively. Two (18.2%) patients experienced a >50% decrease in peak pain at the 2weeks after the procedure and 8 (72.7%) patients at 24months. Additionally, the scores from the short-form 36-item quality-of-life survey were significantly improved in the following 2 domains: bodily pain and general health at 2weeks after the decompression procedure. Also, at 24months postoperatively, 6 domains had significantly improved, including physical function, bodily pain, general health, social function, role emotional, and mental health. No significant side effects were recorded during the study. Microsurgical decompression of peripheral nerves is an effective and safe therapy for intractable PDPN with superimposed nerve compression.

Distribution of branches of deep and common fibular nerves to extensor hallucis longus and extensor digitorum longus muscles. Application to the treatment of their hypertonia

The spastic hemiplegic patient often presents dystonia of extensor hallucis longus (EHL) and, more rarely, extensor digitorum longus (EDL). This dystonia is difficult to treat by tendon lengthening, because its primum movens is purely neurological without retraction musculo-tendinous. A hyponeurotisation by partial section of the branches of the common and deep fibular nerve(s) could be a therapeutic alternative to botulinum toxin injections. Its technique has never been described. Ten legs from formalin-preserved corpses were dissected. The number of branches to EHL and EDL, their level of emergence from the common and deep fibular nerves, and their entry point into the muscle have been measured from the lateral femoral-tibial articular space (LTF). There was always a common trunk to the EDL and the EHL, arisen on average at 10.3 cm (8.2–13.6) from the LTF line. Six times out of 10 in addition to this common one (3), two (2) or three (1) additional branches to the EDL, arisen between 4.6 and 12 cm downstream the LTF line. Six times out of 10 in addition to this common trunk existed one (4) or two (2) additional branches to the EHL, arisen between 13 and 26 cm downstream the LTF line. This first study allow establishing the surgical technique of the hyponeurotisation of muscles LEH and LEO. The first results are presented.

Distribution of the branches of common and superficial fibular nerves to peronei longus et brevis muscles. Use in the treatment of spasticity of fibular muscles

Beside the posterior leg compartment, spasticity of the hemiplegic patient can involve other muscle groups in the leg. Spasticity of the lateral compartment is responsible of a vertical clonus that may be confused with the clonus of the triceps surae (long fibular) or a transverse clonus (short fibular), and by the liveliness of the tendon reflex when striking their tendon. Beside recurrent botulinum toxin injections, this spasticity may be treated by a hyponeurotisation by partial section of the branches of the superficial fibular nerve to the muscle(s) concerned. Its technique has never been described. Twelve legs of formalin corpses have been dissected. The number of branches to PL and PB, their level of emergence from the common and deep fibular nerves, and their entry point into the muscle have been measured from the lateral femoral-tibial articular space (LTF). There was always a common trunk to the EDL and the EHL, arisen on average at 10.3 cm (8.2–13.6) from the LTF line. Six times out of 10 in addition to this common one (3), two (2) or three (1) additional branches to the EDL, arisen between 4.6 and 12 cm downstream the LTF line. Six times out of 10 in addition to this common trunk existed one (4) or two (2) additional branches to the EHL, arisen between 13 and 26 cm downstream the LTF line. This first study allow establishing the surgical technique of the hyponeurotisation of PL and PB muscles. The first results are presented.

Association between clinical condition and F-waves changes in the acute phase of stroke.

To relate F-waves with clinical and laboratory exams in the acute phase of stroke. Inclusion criteria for this cross-sectional study were: hemiplegia, absence of previous cranial trauma, myopathy, diabetes, alcoholism or other known causes of peripheral neuropathy, and normal sensory and motor conduction. The National Institutes of Health Stroke Scale (NIHSS) score, glycemia, glucosilate hemoglobin, and CPK were obtained at admission by routine blood exams. After hospital admission, the F-wave latencies and persistence were obtained from the deep peroneal nerve using symmetrical techniques. Evaluation of 20 individuals - mean age 66 years, 50% male and 85% Caucasian - showed association of F-wave persistence with glycemia (r = 0.71; p < 0.001) and NIHSS categorized (NIHSS 1-7 = 65.0 x NIHSS 9-23 = 100; p = 0.004). Multivariate analysis found only association of F-wave persistence with glycemia β = 0.59 (0.44-0.74); p < 0.001. The increase in the persistence of F-waves are associated with hyperglycemia in the acute phase of stroke.

Peripheral nerve crushing to relieve chronic pain in diabetic and ischaemic foot ulcers.

We retrospectively assessed the effectiveness of peripheral nerve crushing (Smithwick operation) in relieving intractable chronic pain associated with foot ulcers caused by diabetes mellitus (DM) or atherosclerosis. From April 2009 to April 2012, patients underwent peripheral nerve crushing in the leg affected by foot ulceration. The cause of ulceration was either DM alone, atherosclerosis alone, or both DM and atherosclerosis. Because sensation in the foot is associated with five nerves: the tibial, deep peroneal, superficial peroneal, sural, and saphenous, one or more of these nerves were crushed over a length of 1.5cm by using a 'pean' in the distal third of leg the where there are no major motor nerves. There were 36 patients recruited with ulcers grade 3-5 according to the Wagner ulcer classification system that affected the toes, dorsum pedis, or any part of the plantar surface or the heel. The mean duration of foot ulcerations before the nerve crushing was 22.3±9.7 weeks. In all 36 patients, the nerve crushing was performed successfully without any perioperative surgical complication. Of the 36 patients, 34 (94.4%) had substantial pain relief immediately after nerve crushing. While the mean pain level before the procedure was 86.6±0.51mm on visual analogue scale (VAS), pain level dropped significantly after the operation to 18.6 ± 5.4mm at one week, 14.8±4.8mm at one month, 13.7±4.1mm at two months, 9.8±4.1mm at three months, 11.8±5.7mm at four months, 10.1±4.7mm at five months and 8.8±3.3mm at six months. The time to regeneration of the sensory nerves was 121±6.5 days (range: 80-181 days). The surgical complications were wound infection (6 patients) and temporary toe paralysis (three patients). The foot ulcers in 20 of the 36 patients (55.6%) were resolved by debridement or minor amputation. In seven patients (19.4%), a major amputation (five below and two above the knee) was required because of ischemia or infection. No patient died within 30 days of the operation, while nine patients died during the observation period because of comorbid conditions. Peripheral nerve crushing could be the alternative procedure for achieving analgesia in patients with intractable chronic pain from foot ulcers caused by DM or atherosclerosis.

Evaluating the Safety of Percutaneous Dorsolateral Talonavicular Joint Fixation in Modified Double Arthrodesis

Category: Hindfoot Introduction/Purpose: Hindfoot arthrodesis has demonstrated reliable long-term outcomes for treatment of symptomatic hindfoot arthritis, but the incidence of nonunion of the talonavicular joint has been reported as high as 29%. Retrograde percutaneous insertion of a dorsolateral screw in addition to the standard medial distal to proximal screw has been shown to add significant construct stiffness across the talonavicular joint in biomechanical testing. However, placement of this dorsolateral screw may result in increased neurovascular injury. The purpose of this cadaveric study was to investigate the proximity of important anatomic structures to dorsal, percutaneous, screw fixation across the talonavicular joint for hindfoot arthrodesis. Methods: 17 fresh frozen cadaveric limbs without deformity were transected across the supracondylar femur. A single fellowship-trained orthopedic surgeon performed all procedures. Percutaneous dorsolateral fixation across the talonavicular joint was performed with a cannulated screw. A 1.5-cm incision was created over the lateral third of the navicular after localization under fluoroscopy, and a 4.5 mm cannulated screw was inserted using standard AO technique. The guide wire was left within the screw. The incision was extended 2 cm proximal and distal and a separate orthopaedic surgeon used a caliper to measure the distance from the guide wire to the superficial peroneal nerve, extensor hallucis longus, extensor digitorum longus, deep peroneal nerve, and deep peroneal artery. Injuries to neurovascular structures were noted. Finally, solder wire was laid atop the deep neurovascular bundle to allow radiographic imaging of the screw and the bundle. Results: Injury to the deep neurovascular bundle occurred in 6 of 17 specimens (35.3%). There were 5 injuries (29.4%) to the deep peroneal nerve, 3 to the deep peroneal artery, and 2 to branches of the superficial peroneal nerve. The average distances from the guide wire to anatomic structures were superficial peroneal nerve: 1.8 mm (0.5-4.10 mm), extensor hallucis longus: 6.10 mm (0.6-15.0), extensor digitorum longus: 6.8 mm (0.5-14.0 mm), deep peroneal artery: 2.27 mm (0.0-5.1), and deep peroneal nerve: 2.4 mm (0.0-7.10 mm). Conclusion: A high rate of neurovascular injury was observed after percutaneous dorsolateral fixation across the talonavicular joint. These data suggest that this approach should be avoided in favor of an open approach, which allows identification and protection of the superficial peroneal nerve, extensor tendons, and the neurovascular bundle.

Medical Student and Primary Care Physician Perception of the Surgical Management of Upper- and Lower-Extremity Peripheral Nerve Entrapment.

Upper- and lower-extremity peripheral neuropathies are commonly encountered in the primary care setting and account for 14.3 million specialist referrals in the United States annually. Despite the integral role of plastic surgeons in the development of the field of peripheral nerve surgery, plastic surgeons are not commonly recognized as peripheral nerve specialists. The purpose of this study was to investigate the pattern of diagnosis, treatment, and referral of upper- and lower-extremity peripheral nerve entrapment syndromes by both medical students and primary care providers. An online survey including 5 peripheral nerve entrapment clinical scenarios (2 upper extremity and 3 lower extremity) was administered to medical students and primary care providers at a large academic medical center. Respondents were surveyed for level of training, prior clinical exposure, initial diagnostic studies of choice, initial therapeutic modalities of choice, need for subspecialty referral, and appropriate surgical subspecialists for management of the peripheral nerve entrapment. Overall, 248 medical students (38.3% response rate) and 54 primary care providers (13.5% response rate) completed the study. The majority of medical students and primary care providers indicated prior clinical experience with upper-extremity peripheral nerve entrapment in contrast to lower-extremity peripheral nerve entrapment with 26.2% and 39.9% of medical students and primary care physicians reporting prior clinical exposure, respectively. Medical students and primary care providers identified orthopedic surgery as the preferred choice for subspecialty referral for both upper- and lower-extremity peripheral nerve entrapment. Primary care physicians are more inclined to initially manage upper-extremity nerve entrapment without referral to other specialties than for the management of lower-extremity nerve entrapment; 38.0% and 61.1% of the primary care physicians surveyed would refer to another specialty for the initial management of carpal tunnel and cubital tunnel syndromes, in contrast to 83.0%, 90.0%, and 88.2% for the management of common peroneal nerve compression, sural nerve compression, and deep peroneal nerve compression, respectively. We contend that early education of medical students and primary care providers regarding the role of plastic surgeons as peripheral nerve specialists may improve future referral patterns.

Prevalence of leprous neuropathy determined by neurosensory testing in an endemic zone in Ecuador: Development of an algorithm to identify patients benefiting from early neurolysis

The success of a microneurosurgical intervention in leprous neuropathy (LN) depends on the diagnosis of chronic compression before irreversible paralysis and digital loss occurs. In order to determine the effectiveness of a different approach for early identification of LN, neurosensory testing with the Pressure-Specified Sensory Device™ (PSSD), a validated and sensitive test, was performed in an endemic zone for leprosy. A cross-sectional study was conducted to analyze a patient sample meeting the World Health Organization (WHO) criteria for Hansen's disease. The prevalence of LN was based on the presence of ≥1 abnormal PSSD pressure threshold for a two-point static touch. A total of 312 upper and lower extremity nerves were evaluated in 39 patients. The PSSD found a 97.4% prevalence of LN. Tinel's sign was identified in 60% of these patients. An algorithm for early identification of patients with LN was proposed using PSSD testing based on the unilateral screening of the ulnar and deep peroneal nerves.

Repeated bouts of resistance training with short interval activate Akt‐mTOR signaling, but not protein synthesis in mouse skeletal muscle

Resistance training activates Akt‐mTOR signaling pathway, thereby stimulates the protein synthesis within skeletal muscle. However, insufficient recovery period between training bouts may lead to the accumulation of fatigue, known as “overtraining”.PurposeTo obtain an insight into the mechanism of overtraining, changes in muscle protein synthesis and Akt‐mTOR signaling activity were investigated with changing the interval between training bouts.MethodsMale C57BL/6J mice were randomly assigned into four groups: Control (Cont), resistance‐trained with 3 bouts at interval of 72h (72H), 24h (24H) and 8h (8H). The resistance exercise consisted of 50 repetitions of maximal isometric contraction of the tibialis anterior muscle. The muscle contraction was induced by transcutaneous electrical stimulation of deep fibular nerve under anesthesia. Muscle samples were collected 6h after the final exercise session, and kept frozen until analysis. Fifteen minutes prior to the muscle sampling, mice were injected with 0.04 μmol/g puromycin.ResultsPhosphorylation of Akt and p70S6K was observed in 24H and 8H, and that in 8H was significantly higher than in 24H. The phosphorylation of rpS6 was observed in all exercised groups, and was higher in 24H and 8H than in other groups. Puromycin‐incorporated proteins, i.e., newly synthesized proteins in ribosomes, increased in 72H, but not in 24H and 8H.ConclusionThe present results suggest that bouts of resistance training with interval shorter than 24h do not cause an increase in protein synthesis, even though activate Akt‐mTOR signaling pathway.

High-Resolution Ultrasonography of the Superficial Peroneal Motor and Sural Sensory Nerves May Be a Non-invasive Approach to the Diagnosis of Vasculitic Neuropathy.

High-resolution ultrasonography (HRUS) is an emerging new tool in the investigation of peripheral nerves. We set out to assess the utility of HRUS performed at lower extremity nerves in peripheral neuropathies. Nerves of 26 patients with polyneuropathies of different etiologies and 26 controls were investigated using HRUS. Patients underwent clinical, laboratory, electrophysiological assessment, and a diagnostic sural nerve biopsy as part of the routine work-up. HRUS was performed at the sural, tibial, and the common, superficial, and deep peroneal nerves. The superficial peroneal nerve longitudinal diameter (LD) distinguished best between the groups: patients with immune-mediated neuropathies (n = 13, including six with histology-proven vasculitic neuropathy) had larger LD compared to patients with non-immune-mediated neuropathies (p < 0.05) and to controls (p < 0.001). Among all subgroups, patients with vasculitic neuropathy showed the largest superficial peroneal nerve LD (p < 0.001) and had a larger sural nerve cross-sectional area when compared with disease controls (p < 0.001). Enlargement of the superficial peroneal and sural nerves as detected by HRUS may be a useful additional finding in the differential diagnosis of vasculitic and other immune-mediated neuropathies.

Prevalence of the accessory deep peroneal nerve: A cadaveric study and meta-analysis

ObjectivesThe accessory deep peroneal nerve (ADPN) is a common anatomical variant arising from the superficial peroneal nerve (SPN) and, when present, is often responsible for partial or complete innervation of the extensor digitorum brevis muscle (EDBM). The nerve lies posterior to the peroneus brevis muscle, traveling posterior to the lateral malleolus to terminate in the ankle by giving off sensory branches to the ankle and joints. Although the EDBM is usually supplied by the deep peroneal nerve (DPN), in the presence of an ADPN, electrodiagnostic procedures may be complicated. Due to the lack of detailed anatomical knowledge on the topography of the ADPN, its presence posterior to the lateral malleolus can be iatrogenically injured during surgical procedures on the ankle using a lateral approach. Therefore, this meta-analysis aimed to provide a comprehensive, evidence-based assessment of the anatomical characteristics of the ADPN, supplemented with data from our own cadaveric dissection. Patients and methodsA comprehensive search of all major electronic databases, including Pubmed, Embase, Scopus, Web of Science, ScienceDirect, SciELO, and BIOSIS was performed. All articles with data on prevalence, symmetry and innervation of the EDBM by the ADPN were included. The anatomical data was then extracted and pooled into a meta-analysis using MetaXL 2.0. In addition, we dissected 21 cadavers (n=42 lower limbs) bilaterally to find the ADPN. ResultsA total of 19 studies (n=6070 lower limbs) were included in the meta-analysis. The pooled prevalence of the ADPN was 18.8% (95%CI:14.2–24.0) with a 39.3% prevalence rate for cadaveric studies. The ADPN was present more commonly unilaterally (67.0%) and when it was present, provided branches to the EDBM in 79.5% of cases. In our cadaveric study, the ADPN was identified in 5 of the 42 lower limbs dissected (11.9%); on the right side in 3 lower limbs and on the left side in 2 lower limbs. ConclusionsThe ADPN is a clinically important nerve and has been inculpated in unexplained cases of chronic ankle pain and EDBM atrophy. The variability in detection of the ADPN using electrophysiological techniques can lead to misdiagnoses of peroneal nerve lesions and increase the risk for iatrogenic injury to the ADPN, especially in laterally approaching ankle procedures and sural nerve biopsies.

Differences in F-Wave Characteristics between Spinobulbar Muscular Atrophy and Amyotrophic Lateral Sclerosis.

There is limited data on the differences in F-wave characteristics between spinobulbar muscular atrophy (SBMA) and lower motor neuron dominant (LMND) amyotrophic lateral sclerosis (ALS). We compared the parameters of F-waves recorded bilaterally from the median, ulnar, tibial, and deep peroneal nerves in 32 SBMA patients, 37 patients with LMND ALS, and 30 normal controls. The maximum F-wave amplitudes, frequencies of giant F-waves, and frequencies of patients with giant F-waves in all nerves examined were significantly higher in the SBMA patients than in the ALS patients and the normal controls. The mean F-wave amplitude, maximum F-wave amplitude, frequency of giant F-waves, and frequency of patients with giant F-waves in the median and deep peroneal nerves were comparable between the ALS patients and normal controls. Giant F-waves were detected in multiple nerves and were often symmetrical in the SBMA patients compared with the ALS patients. The number of nerves with giant F-waves seems to be the most robust variable for differentiation of SBMA from ALS, with an area under the curve of 0.908 (95% CI: 0.835–0.982). A cut-off value of the number of nerves with giant F-waves (≥3) for diagnosing SBMA showed high sensitivity and specificity: 85% sensitivity and 81% specificity vs. ALS patients. No significant correlations were found between the pooled frequency of giant F-waves and disease duration in the SBMA (r = 0.162, P = 0.418) or ALS groups (r = 0.107, P = 0.529). Our findings suggested that F-waves might be used to discriminate SBMA from ALS, even at early stages of disease.