Diagnostic Nerve Research Articles

A Novel Approach to New Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

A Novel Approach to New Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

End-to-Side Nerve Transfer for the Management of Chronic Leg Compartment Ankle Dorsiflexion Weakness

Abstract Background A proximal deep peroneal nerve (DPN) injury can significantly impact the functional capacity of the leg, to include compromised motor function of the tibialis anterior (TA) muscle. Clinical examination can range from weakness in ankle dorsiflexion, to complete foot drop. Diagnostic nerve conduction velocity (NCV) testing can demonstrate abnormalities at select areas of impingement (or) entrapment (i.e., regions affected by a demyelinating compression mono-neuropathy), along the proximal course of the common peroneal nerve. Methods We retrospectively report on 17 patients with clinical weakness involving ankle dorsiflexion. All patients underwent surgical end-to-side anastomosis, transferring a muscular nerve branch from the superficial peroneal nerve (SPN) to a segment of the DPN responsible for TA muscle innervation. Outcomes were based on comparisons of preoperative and postoperative DPN motor function to the TA muscle, standardized to the British Medical Research Council Scale for Muscle Strength. Preoperative scores were generally M2 or below. Results Postoperative outcome scores of M4 to M5 were considered good (or) successful. 94.1% of patients demonstrated successful outcomes. Conclusion An end-to-side SPN motor branch anastomosis, into the motor branch of the DPN responsible for TA muscle innervation, can be a viable treatment option for weakness in ankle dorsiflexion. All reported cases involved a compromised segment of deep peroneal nerve within the proximal one-third of the leg.

ID:15869 Intercostal Neuralgia With Allodynia Following Colonoscopy Successfully Treated With Temporary Peripheral Nerve Stimulation

52-year old male referred for 10 months of persistent anterior chest wall pain localized in the right T6 & T7 distribution. He developed this pain following routine screening colonoscopy. Pain is described as stabbing and ranges from 1-6/10 in intensity on the numerical pain rating scale (NPRS) and is aggravated by postural shifting, ambulating and activities such as driving. Additionally, the patient describes severe pain allodynia from stimuli such as contact with overlying clothing, bedsheets and sleeping on the affected side. He has taken measures to minimize these exposures. Patient reports treatment initially targeting a myofascial etiology with trigger point injections of local anesthetic. These interventions were given in addition to 10% topical lidocaine ointment and duloxetine. He states the topical lidocaine ointment is the only treatment that offered partial relief to the persistent nature of his symptoms. Examination reveals a cardboard cut-out taped to his skin to keep his shirt from making contact with his skin, allodynia was confirmed to light touch. Imaging modalities including chest/abdominal radiographs and MRI revealed no discernible pathology. Given clinical symptoms of neuropathic pain in a thoracic intercostal nerve distribution, diagnostic right T6 and T7 intercostal nerve blocks followed by therapeutic injections both under ultrasound guidance were performed (1). Lidocaine ointment and duloxetine was continued. At 3 months follow up, he describes having 100% relief initially but symptoms eventually returned to baseline. He proceeded to temporary peripheral nerve stimulation (PNS) of the right T6 and T7 intercostal nerves as a refractory treatment option.

Ultrasound-guided continuous radiofrequency ablation of the suprascapular nerve for chronic shoulder pain secondary to osteoarthritis: a retrospective cohort study.

The objective of this study is to retrospectively evaluate the use of ultrasound-guided continuous radiofrequency (CRF) lesioning of the suprascapular nerve for treating chronic shoulder pain, due to osteoarthritis. We describe a modified distal and selective ablation technique in the spinoglenoid notch, with motor and sensory stimulation, which protects the motor branch of the nerve from ablation. A retrospective analysis was performed of patients, who underwent ultrasound-guided CRF lesioning of the suprascapular nerve from October 2013 to January 2020. During the procedure, the CRF electrode is placed in the spinoglenoid notch, at the distal suprascapular nerve capsular branch. Motor and sensory stimulations are used to confirm the position. CRF lesioning is applied up to three times, at 3 different points, for 1 min each time, at 80° C. In total, 127 first CRF suprascapular nerve lesioning procedures were performed on 101 patients with chronic shoulder pain secondary to osteoarthritis. One hundred nineteen diagnostic ultrasound-guided suprascapular nerve corticosteroid injections were performed prior to ablation. Mean pre-injection Visual Analogue Scale pain score (VAS) was 8.3, with post-injection VAS score of 4.4 at 24 h and 4.5 at 2 weeks. Mean pre-CRF lesioning VAS pain score was 7.7 with post-CRF lesioning VAS score of 4.4 at 24 h and 4.5 at 2 weeks. Ultrasound-guided CRF lesioning of the suprascapular nerve in the spinoglenoid notch is a safe treatment for chronic osteoarthritic shoulder pain, with repeat treatments infrequently required. It is associated with significant improvement in VAS pain scores. • Ultrasound-guided continuous radiofrequency lesioning of the suprascapular nerve in the spinoglenoid notch is a safe treatment for chronic shoulder pain in degenerative disease, with repeat treatments infrequently required. • The procedure is performed under ultrasound guidance, without the use of ionising radiation.

Radiofrequency Ablation for the Knee Joint: A Survey by the American Society of Pain and Neuroscience.

BackgroundGenicular nerve radiofrequency ablation (RFA) is an effective, minimally invasive procedure often used to treat patients with intractable knee pain secondary to knee osteoarthritis and failed knee replacements. The prevalence of knee pain in adults has been estimated to be as high as 40% and is continuously increasing with an aging population. Over the past two decades, proceduralists have adopted variations in patient preparation, procedural steps, and post-operative care for genicular nerve RFA procedures. A survey was dispensed via the American Society of Pain and Neuroscience (ASPN) to gain a popular assessment of common practices for genicular nerve RFA.MethodsA 29 question survey was dispensed via SurveyMonkey to all members of ASPN. Members were able to respond to the survey a single time and were unable to make changes to their responses once the survey was submitted. After responses were compiled, each question was assessed in order to determine common practices for genicular nerve RFA.ResultsA total of 378 proceduralists responded to the survey. There was high consensus with the three most commonly targeted nerves. The inferomedial, superomedial, and superolateral genicular branches were treated by 95–96% of respondents, while other targets were less commonly treated. There remains some debate among proceduralists regarding the need for a second diagnostic nerve block and the type of steroid used for diagnostic nerve blocks.ConclusionPain physicians use a wide variety of methods to perform genicular nerve ablations. The data offered by the survey show that there is no standardized protocol when it comes to treating knee pain via genicular nerve block and ablation and highlights controversies among proceduralists that ought to serve as the targets of future clinical research aimed at establishing a standardized protocol.

CT-Guided Cooled Radiofrequency Denervation for Chronic Arthritis Pain of the Hip and Shoulder.

The paradigm in the treatment of arthritis pain is shifting for previously open surgical denervations of the hip and shoulder, as it already has for the geniculate nerves in knee arthritis. Interventional radiology is poised to contribute to this space with the use of CT guidance to provide safe, fast, and effective targeting of the target nerves for unequivocal diagnostic nerve block and definitive cooled radiofrequency denervation. The authors provide the background of which nerves are targeted for hip and shoulder denervation and the normal CT appearance of these blocks.

Is the Outcome of Diagnostic Nerve Block Related to Spastic Muscle Echo Intensity? A Retrospective Observational Study on Patients with Spastic Equinovarus Foot.

To investigate the relationship between spastic calf muscles echo intensity and the outcome of tibial nerve motor branches selective block in patients with spastic equinovarus foot. Retrospective observational study. Forty-eight patients with spastic equinovarus foot. Each patient was given selective diagnostic nerve block (lidocaine 2% perineural injection) of the tibial nerve motor branches. All patients were evaluated before and after block. Outcomes were: spastic calf muscles echo intensity measured with the Heckmatt scale; affected ankle dorsiflexion passive range of motion; calf muscles spasticity measured with the modified Ashworth scale and the Tardieu scale (grade and angle). Regarding the outcome of tibial nerve selective diagnostic block (difference between pre- and post-block condition), Spearman's correlation showed a significant inverse association of the spastic calf muscles echo intensity with the affected ankle dorsiflexion passive range of motion (p = 0.045; ρ = 00-0.269), modified Ashworth scale score (p = 0.014; ρ = -0.327), Tardieu grade (p = 0.008; ρ = -0.352) and Tardieu angle (p = 0.043; ρ = -0.306). These findings support the hypothesis that patients with spastic equinovarus foot with higher spastic calf muscles echo intensity have a poor response to selective nerve block of the tibial nerve motor branches.

Subthreshold Peripheral Nerve Stimulation with a High Frequency Electro-Magnetic Couple Powered Implanted Receiver for the Treatment of Chronic Shoulder Pain

BACKGROUND: Shoulder pain has an estimated population prevalence of up to 26%. The most common source of shoulder pain is the rotator cuff, which is a group of muscles and tendons that surround the shoulder joint, accounting for over two-thirds of cases. CASE REPORT: A 65-year-old man presented with sharp, localized pain on abduction of the left shoulder due to a left rotator cuff tear. A diagnostic nerve block provided 100% short-term pain relief. Subsequently a peripheral nerve stimulator trial was offered to the patient, which was successful. The permanent peripheral nerve stimulator was implanted at the supraspinous fossa with the middle electrodes at the suprascapular notch. A receiver was inserted into the inner lumen of electrode array and the neurostimulator was coiled and fixated to the fascia. The following stimulation settings were used: frequency at 1.5 kHz, pulse width at 30 µs, and amplitude of 3.5 mA. CONCLUSION: At one year after implant, the patient had close to 100% pain relief and reported excellent mobility of the shoulder. Wirelessly powered peripheral nerve simulation was a successful option for this patient suffering from debilitating left shoulder pain due to a left rotator cuff tear. KEY WORDS: Chronic shoulder pain, glenohumeral osteoarthritis, peripheral nerve stimulator, suprascapular neuralgia

Phosphorylated TDP-43 aggregates in peripheral motor nerves of patients with amyotrophic lateral sclerosis.

Phosphorylated TDP-43 (pTDP-43) aggregates in the cytoplasm of motor neurons and neuroglia in the brain are one of the pathological hallmarks of amyotrophic lateral sclerosis. Although the axons exceed the total volume of motor neuron soma by several orders of magnitude, systematic studies investigating the presence and distribution of pTDP-43 aggregates within motor nerves are still lacking. The aim of this study is to define the TDP-43/pTDP-43 pathology in diagnostic motor nerve biopsies performed on a large cohort of patients presenting with a lower motor neuron syndrome and to assess whether this might be a discriminating tissue biomarker for amyotrophic lateral sclerosis and non-amyotrophic lateral sclerosis cases.We retrospectively evaluated 102 lower motor neuron syndrome patients referred to our centre for a diagnostic motor nerve biopsy. Histopathological criteria of motor neuron disease and motor neuropathy were applied by two independent evaluators, who were blind to clinical data. TDP-43 and pTDP-43 were evaluated by immunohistochemistry, and results compared to final clinical diagnosis.We detected significant differences between amyotrophic lateral sclerosis and non-amyotrophic lateral sclerosis cases in pTDP-43 expression in myelinated fibres: axonal accumulation was detected in 98.2% of patients with amyotrophic lateral sclerosis versus 30.4% of non-amyotrophic lateral sclerosis samples (P < 0.0001), while concomitant positive staining in Schwan cell cytoplasm was found in 70.2% of patients with amyotrophic lateral sclerosis versus 17.4% of patients who did not have amyotrophic lateral sclerosis (P < 0.001). Importantly, we were also able to detect pTDP-43 aggregates in amyotrophic lateral sclerosis cases displaying normal features at standard histopathological analysis.Our findings demonstrated that a specific pTDP-43 signature is present in the peripheral nervous system of patients with amyotrophic lateral sclerosis, and could be exploited as a specific, accessible tissue biomarker. The detection of pTDP-43 aggregates within motor nerves of living patients with amyotrophic lateral sclerosis, occurring before axonal degeneration, suggests that this is an early event that may contribute to amyotrophic lateral sclerosis pathogenesis.

Isolating the Superficial Peroneal Nerve Motor Branch to the Peroneus Longus Muscle with Concentric Stimulation during Diagnostic Motor Nerve Biopsy

ABSTRACT Motor nerve biopsies are performed in the workup of neuropathies of unknown origin when motor neuron disease is suspected. Biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle has been described as a convenient alternative to other commonly biopsied motor nerves. To date, neuromonitoring techniques have not been described for this procedure. We describe the surgical neurophysiology techniques necessary for preservation of motor function and associated data during muscle biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle. We present a case of a patient who underwent uncomplicated biopsy of the motor branch of the superficial peroneal nerve innervating the peroneus longus muscle during workup for suspected motor neuropathy. The surgical neurophysiology techniques and data are presented in detail. No postsurgical sensory or motor deficit was related to the procedure. Surgical neurophysiology is critical to confirm the appropriate motor branch to the peroneus longus muscle and facilitates safe and accurate motor nerve biopsy.

Human assumed central sensitisation (HACS) in patients with chronic low back pain radiating to the leg (CLaSSICO study)

IntroductionPatients with chronic low back pain radiating to the leg (CLBPr) are sometimes referred to a specialised pain clinic for a precise diagnosis based, for example, on a diagnostic selective...

The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review.

Neck and back pain is increasingly prevalent, and has increased exponentially in recent years. As more resources are dedicated to the diagnosis of pain conditions, it is increasingly important that the diagnostic techniques used are as precise and accurate as possible. Traditional diagnostic methods rely heavily upon patient history and physical examination to determine the most appropriate treatments and/or imaging studies. Though traditional means of diagnosis remain a necessity, in many cases, correlation with positive or negative responses to injections may further enhance diagnostic specificity, and improve outcomes by preventing unnecessary treatments or surgeries. This narrative review aims to present the most recent literature describing the diagnostic validity of precision injections, as well as their impact on surgical planning and outcomes. Diagnostic injections are discussed in terms of facet arthropathy, lumbar radiculopathy, discogenic pain and discography, and sacroiliac joint dysfunction. There is a growing body of evidence supporting the use of diagnostic local anesthetic injections or nerve blocks to aid in diagnosis. Spinal injections add valuable objective information that can potentially improve diagnostic precision, guide treatment strategies, and aid in patient selection for invasive surgical interventions.

Sixty-Day Pudendal Nerve Stimulation: A Potential Therapy for Refractory Pudendal Neuralgia Case Report

BACKGROUND: Pudendal neuralgia (PN) can cause severe, disabling chronic pain. Though common, PN is frequently unrecognized and misdiagnosed. Historically, the last-resort treatment for PN has been permanent implantation of spinal cord stimulation (SCS), but SCS for PN carries high risk of complications and explantation. We report the first case of temporary (60-day) peripheral nerve stimulation (PNS) treatment for refractory PN. CASE REPORT: A 63-year-old woman presented with one year of chronic bilateral suprapubic vaginal pain radiating to the bilateral proximal medial thighs with concomitant dysuria, urinary frequency, and pain with intercourse. PN was confirmed via diagnostic pudendal nerve block. Using fluoroscopic guidance, we implanted PNS leads on the left and, subsequently, the right pudendal nerves, with explantation at 60 days for each lead. The patient reported continuing pain reduction with 80% improvement in the Visual Analog Scale score at 6 months, resumption of normal activity and functionality, discontinued use of opioids, and high satisfaction with treatment. This case is notable for the sustained pain relief provided by this temporary and minimally invasive treatment. CONCLUSIONS: This case suggests that 60-day PNS with fluoroscopic guidance is a viable treatment for refractory PN in correctly selected patients. This treatment is low-risk, minimally invasive, and may be used early in the care continuum, potentially sparing patients multiple failed treatments and the risks associated with permanently implanted devices. KEY WORDS: Pudendal nerve, peripheral nerve stimulation, neuromodulation, chronic pain, pelvic pain, perineal pain, case report

Clinical Effectiveness of Peripheral Nerve Blocks for Diagnosis of Migraine Trigger Points.

With a 13 percent global prevalence, migraine headaches are the most commonly diagnosed neurologic disorder, and are a top five cause of visits to the emergency room. Surgical techniques, such as decompression and/or ablation of neurovasculature, have shown to provide relief. Popular diagnostic modalities to identify trigger loci include handheld Doppler examinations and botulinum toxin injection. This article aims to establish the positive predictive value of peripheral nerve blocks for identifying therapeutic surgical targets for migraine headache surgery. Electronic medical records of 36 patients were analyzed retrospectively. Patients underwent peripheral nerve blocks using 1% lidocaine with epinephrine and subsequent surgery on identified migraine headache trigger sites. Patients were grouped into successful and unsuccessful blocks and further categorized into successful and unsuccessful surgery subgroups. Group analysis was performed using paired t tests, and positive-predictive value calculations were performed on subgroups. The preoperative Migraine Headache Index of patients with positive blocks was 152.71, versus 34.26 postoperatively (p < 0.001). Each index component also decreased significantly: frequency (22.11 versus 15.06 migraine headaches per month; p < 0.001), intensity (7.43 versus 4.12; p < 0.001), and duration (0.93 versus 0.55 days; p < 0.001). The positive-predictive value of diagnostic peripheral nerve blocks in identifying a migraine headache trigger site responsive to surgical intervention was calculated to be 0.89 (95 percent CI, 1 to 0.74). To the authors' knowledge, this is the first study to investigate the positive-predictive value of peripheral nerve blocks as used in the diagnostic workup of patients with chronic migraine headaches. Peripheral nerve blocks serve as a reliable clinical tool in mapping migraine trigger sites for surgical intervention while offering more flexibility in their administration and recording as compared to established diagnostic methods. . Diagnostic, IV.

Myelination, axonal loss and Schwann cell characteristics in axonal polyneuropathy compared to controls.

IntroductionPolyneuropathy is a debilitating condition characterized by distal sensory and motor deficits. Schwann cell dysfunction and axonal loss are integral factors in pathophysiology and disease progression of polyneuropathy.AimsThe aim of this study was the assessment of Schwann cell characteristics, nerve fibers and myelination parameters in polyneuropathy patients compared to controls.MethodsNerve tissue was obtained from polyneuropathy patients (n = 10) undergoing diagnostic sural nerve biopsies. Biopsies of healthy peripheral nerves (n = 5) were harvested during elective sural nerve grafting for chronic peripheral nerve lesions. Exclusion criteria for the healthy control group were recent neurological trauma, diabetes, neurological and cardiovascular disease, as well as active malignancies and cytotoxic medication within the last 12 months. The over-all architecture of nerve sections and myelination parameters were histomorphometrically analyzed. Immunofluorescent imaging was used to evaluate Schwann cell phenotypes, senescence markers and myelination parameters.ResultsHistomorphometric analysis of nerve biopsies showed significant axonal loss in polyneuropathy patients compared to controls, which was in accordance with the neuropathological findings. Immunofluorescent staining of Schwann cells and myelin basic protein indicated a significant impairment of myelination and lower Schwann cell counts compared to controls. Phenotypic alterations and increased numbers of non-myelinating p75-positive Schwann cells were found in polyneuropathy patients.DiscussionThis study provided quantitative data of axonal loss, reduced myelination and Schwann cell dysfunction of polyneuropathy patients compared to neurologically healthy controls. Phenotypic alterations of Schwann cells were similar to those seen after peripheral nerve injury, highlighting the clinical relevance of Schwann cell dysfunction.

Hereditary neuropathies: A pathological perspective.

Hereditary neuropathies may result from mutations in genes expressed by Schwann cells or neurons that affect selectively the peripheral nervous system (PNS) or may represent a minor or major component of complex inherited diseases that involve also the central nervous system and/or other organs and tissues. The chapter is constantly expanding and reworking, thanks to advances of molecular genetics; next-generation sequencing is identifying a plethora of new genes and is revolutionizing the diagnostic approach. In the past, diagnostic sural nerve biopsies paved the way to the discovery and elucidation of major genes and molecular pathways associated to most frequent hereditary motor-sensory neuropathies. Nowadays, a sural nerve biopsy may prove useful in selected cases for the differential diagnosis of an acquired neuropathy when clinical examination, nerve conduction studies, and molecular tests are not sufficiently informative. Skin biopsy has emerged as a minimally invasive window on the PNS, which may provide biomarkers of progression and clues to the physiopathology and molecular pathology of inherited neuropathies. The aim of our review is to illustrate the pathological features of more frequent and paradigmatic hereditary neuropathies and to highlight their correlations with the roles of the involved genes and functional consequences of related molecular defects.

The Role of Diagnostic Nerve Blocks in Headache Surgery

The Role of Diagnostic Nerve Blocks in Headache Surgery

Anococcygeal Nerve and Sitting Pain: Differential Diagnosis and Treatment Results.

The plastic surgeon is often asked to reconstruct the sacral area related to pilonidal cysts or a tumor, or after other surgery, such as coccygectomy. When sitting pain is not due to the pudendal or posterior femoral cutaneous nerve injury, the anococcygeal nerve (ACN) must be considered. Clinically, its anatomy is not well known. Rather than consider coccygectomy when the traditional nonoperative treatment of coccydynia fails, resection of the ACN might be considered. A review of traditional anatomy textbooks was used to establish classical thoughts about the ACN. A retrospective cohort of patients with sitting pain related to the coccyx was examined, and those operated on, by resecting the ACN, were examined for clinicopathologic correlations. When the ACN is described in anatomy textbooks, it is with varying distributions of innervated skin territory and nerve root composition. Most include an origin from sacral 5 and coccygeal 1 ventral roots. Most agree that the ACN forms on the ventral side of the sacrum/coccyx, alongside the coccygeus muscle, to emerge laterally and travel dorsally to innervate skin over the coccyx and lower sacrum. A review of 13 patients with sitting pain due to the ACN, from 2015 to 2019, demonstrated a mean age of 54.6 years. Eleven were female. The etiologies of ACN injury were falls (9), exercise (3), and complication from surgery (1). Six of the 9 patients who had surgery were able to be followed up with a mean length of 36.3 months (range, 11-63 months). Overall, 3 had an excellent result, 2 had a good result, and 1 was not improved. The one with a failed result showed improvement with coccygectomy. The ACN must be included in the differential diagnosis of sitting pain. It is most often injured by a fall. The ACN can be evaluated with a diagnostic nerve block, can be identified at surgery, and can be resected, and its proximal end can be implanted into the coccygeus muscle. This surgery may prove an alternative to coccygectomy.

Pulsed Radiofrequency of the Occipital Nerves: Results of a Standardized Protocol on Chronic Headache Management.

BackgroundPulsed radiofrequency (PRF) of the occipital nerves has neuromodulative properties and is used for chronic pain management. However, its role in various types of chronic headaches has not been adequately investigated so far.ObjectivesΤhis was an observational, open-label, prospective study aiming to assess the efficacy of PRF of occipital nerves on various types of chronic headache management.MethodsPatients with chronic headaches followed up at the pain management unit were scheduled for PRF of both occipital nerves after a positive diagnostic nerve block. PRF was applied following a standardized protocol at 42°C, and the number of headaches per month was assessed as a primary outcome at baseline (before treatment), as well as after 1, 3, and 6 months. Pain intensity during headache crises was recorded using the Numeric Rating Scale (NRS, 0 - 10),ResultsFifty-seven patients suffering from chronic migraines, cluster headaches, tension-type headaches, and occipital neuralgia were studied. PRF significantly improved the number of headache episodes per month, as well as the pain intensity of the crises. The median number of headache episodes per month was significantly reduced in patients with migraine, from 14.5 to 4 after 1 month, and to 6.5 after 6 months. The same was seen for patients with clusters, who were also improved. A statistically significant reduction in NRS values over time was seen for all types of headaches.ConclusionsPRF of the occipital nerves can lead to a reduction of the number of headache episodes per month, improving the intensity of pain during each episode.

FOOT DROP FOLLOWING COVID-19 INFECTION. A CASE REPORT AND ITS OUTCOME

INTRODUCTION: Corona virus disease-19 (COVID-19) is one among the worst pandemics faced by mankind and there are various neurological manifestations either direct or indirect effect of Corona virus. Here we report a case of foot drop secondary to entrapment peroneal injury in COVID-19 patient as a sequelae of prone positioning. CASE REPORT: A 55-year-old gentleman was diagnosed with RT PCR positive COVID19 and was hospitalized for severe respiratory syndrome. HRCT thorax done showed CORADS score of 6 with severity index of 14/25. During this period, patient was on treatment according to ICMR guidelines and prone position for about 20 hours/day for 20 days for severe pneumonia. During follow up after 15 days of discharge, he had developed features of foot drop secondary to common peroneal nerve palsy which was later conrmed by electro diagnostic studies and nerve ultrasound. Patient was started on oral steroids and along with supportive measures. He is followed up for a period of 3 months and has noted 50% improvement in his symptoms. CONCLUSION: While prone positioning should continue to be utilized in COVID-19 pneumonia as dictated by the current literature, precaution has to be taken with it. Changing patient positioning at shorter intervals and timely mobilization are necessary.