Sural Nerve Research Articles

A Novel MYH14 Variant Presenting as a New Phenotype of MYH14-Associated Neuromuscular Disorders—Clinicohistologic Findings and Review of the Literature

Abstract Background: Pathogenic variants in the nonmuscle myosin, MYH14, have been associated with several pathologic conditions including a complex phenotype with peripheral neuropathy, myopathy, hoarseness, and hearing loss. Since its first description in a large Korean kindred, this rare neuromuscular disorder has further been characterized in 1 American and 1 Canadian pedigree. Case presentation: Here, we describe a German patient with atypical MYH14-related neuromuscular disorder. The clinical phenotype included signs of a distal myopathy with early respiratory involvement and a prominent hoarseness and peripheral neuropathy. In contrast to previous reports, no relevant deafness was identified. Muscle biopsy indicated a vacuolated myopathy with excessive autophagy, whereas histology of the sural nerve showed signs of a mixed axonal-demyelinating neuropathy. Next-generation sequencing revealed a loss-of-function variant not identified so far in the MYH14 gene (c.4510del, p.[Arg1504Glyfs*10]). Because of rapid disease progression with respiratory failure, the patient died at the age of 52. Conclusions: We present a novel MYH14 variant resulting in a severe and rapidly progressive MYH14-associated phenotype with predominantly distal myopathy, early respiratory failure, dysphagia, hoarseness, and peripheral neuropathy, without hearing loss. This case expands the clinical spectrum of MYH14-related neuromuscular disorders by providing a new clinical phenotype and disease course and histopathologic features.

Quantifying the Effect of the Cross‐Facial Nerve Graft on the Nonparalyzed Side

AbstractObjectiveThe cross‐facial nerve graft (CFNG) is employed in facial reanimation surgery to restore neural connectivity from the nonparalyzed side of the face to the paralyzed side, facilitating spontaneous smiling. Typically, the sural nerve, due to its length, serves as the donor graft. Implantation involves functional facial branch transection to provide graft input. However, impact of this transection on a patient's smile has not been conclusively quantified.Study Setting & DesignTertiary Care Academic Medical Center; retrospective chart review.MethodsIn a chart review of patients from 2018 to 2022, 15 patients with unilateral flaccid facial paralysis who underwent CFNG were identified. Demographic and clinical data were collated including medical history and operative details. Emotrics software was used to compare preoperative and postoperative photographs by measuring smile parameters. Percent change was analyzed via Student's T‐test.ResultsA zygomatic branch was sacrificed in 8/15 (53%) surgeries and a buccal branch in 4/15 (27%) surgeries. When evaluating smile angle, dental show, upper lip height deviation, and commissure excursion for open and closed smiles, the average relative change for the nonparalyzed side was 3.4%, 2.8 mm, 12.5%, 3.0 mm, and 1.9% respectively. When comparing these metrics preoperatively and postoperatively in the functional side, there was no statistically significant difference (P = .13, P = .65, P = .33, P = .36, P = .64).ConclusionThere was no significant difference in our assessment of smile after facial branch transection in CFNG, suggesting the impact on a patient's smile may be negligible. Additional studies are needed to characterize qualitative impact on patients and result generalizability.

Anatomical research of positional relationship between protective channel and sural nerve during Achilles tendon repair using channel assisted minimally invasive repair technique

To evaluate the positional relationship between protective channel and sural nerve while treating acute Achilles tendon rupture with channel assisted minimally invasive repair (CAMIR) technique based on anatomical observations of cadaver specimens. Twelve adult cadaveric lower limb specimens (6 left, 6 right) were utilized. A CAMIR device was implanted at a distance of 4 cm from the proximal end of the specimen to the Achilles tendon insertion. The skin was incised along the tendon's medial side, the sural nerve was dissected, and the positional relationship with the protective channel was observed. The distance from the sural nerve-Achilles tendon intersection to the calcaneal insertion, the vertical distance between protective channel and the calcaneal insertion, and the horizontal distance between the sural nerve and protective channel were measured by using vernier caliper. Anatomical examination demonstrated a variable positional relationship between the sural nerve and protective channel, with the sural nerve positioned above (8 specimens) or below (4 specimens) the protective channel. The distance from the sural nerve-Achilles tendon intersection to the calcaneal insertion was (105.67±14.94) mm, the vertical distance between protective channel and the calcaneal insertion was (93.20±9.57) mm, and the horizontal distance between the sural nerve and protective channel was (0.31±0.14) mm. The use of CAMIR technique for the treatment of acute Achilles tendon rupture can effectively avoid iatrogenic injury to the sural nerve.

Long-term outcomes of radiofrequency ablation and cyanoacrylate closure for treatment of small saphenous veins

Aim: Superficial venous insufficiency is less prevalent in the lesser saphenous vein compared to the great saphenous vein. Treating the lesser saphenous vein often presents greater challenges due to its proximity to the sural nerve and anatomical variations. This study evaluates the long-term efficacy of radiofrequency ablation (RFA) and cyanoacrylate closure (CAC) for managing small saphenous veins and discusses our treatment approach. Material and Methods: We performed a retrospective analysis involving 137 patients (64 treated with CAC and 73 with RFA) who received treatment for small saphenous vein insufficiency at our clinic between 2014 and 2019. We assessed quality of life and clinical outcomes at 6 months, and at 1, 3, and 5 years post-treatment. Results: Our findings indicated that radiofrequency ablation showed greater improvements compared to cyanoacrylate embolization in terms of VCSS. However, over the 5-year follow-up period, recurrence rates were observed in 11 (17.1%) patients in the CAC group and 5 (6.8%) patients in the RFA group, with this difference being statistically significant (p=0.045). Conclusion: Radiofrequency ablation for treating venous insufficiency offers superior long-term quality of life benefits compared to cyanoacrylate closure, particularly after three years.

Clinical Reasoning: An Unusual Etiology of Lumbosacral Plexopathy in a Patient With HIV.

We present a compelling case of uncontrolled diabetes, who initially presented as diabetic lumbosacral radiculoplexus neuropathy (DLRPN), with radicular pain in the right lower limb (LL) followed by asymmetric weakness of both LLs (right greater than left) with wasting in the medial compartment of the right thigh and significant sensory loss in the bilateral sural and right saphenous nerve distribution. Electrophysiology was suggestive of right lumbosacral radiculoplexus neuropathy. Incidentally, the patient tested positive for HIV-1 at our tertiary care center. CSF analysis revealed markedly elevated protein levels (>400 mg/dL) with lymphocytosis, a red flag for DLRPN. This observation led to further workup. Nerve biopsy showed large collections of perivascular endoneurial and epineurial lymphoid inflammatory cells, which favored an alternative diagnosis. This case highlights the intricate interplay between HIV infection, diabetes, and neurologic manifestations, challenging the initial clinical suspicion of DLRPN. This study emphasizes the importance of considering atypical presentations of neuropathy, especially in the context of coexisting medical conditions, and emphasizes the significance of comprehensive diagnostic workup, including CSF studies and nerve biopsy, for an accurate diagnosis.

Screening for Diabetic Peripheral Neuropathy: Subjective Versus Objective Measures.

This study compared subjective screening modalities recommended in diabetic foot screening guidelines for the detection of diabetic peripheral neuropathy (DPN) with an objective measure, the NC-Stat DPNCheck®. We assessed 63 participants (mean age 54.5 years ± 10.5) utilising subjective screening tools (Semmes-Weinstein 10-g monofilament, 128-Hz traditional tuning fork, neurothesiometer, O'Brien 128-Hz electronic tuning fork) and compared results with the objective automated sural nerve conduction test NC-Stat DPNCheck®. A significant difference was found in the number of limbs classified with DPN between all screening tools (P < .05). Therefore, this suggests that some screening modalities are more sensitive in diagnosing DPN than others, highlighting the importance of using multiple screening tools to a comprehensive understanding of the patient's neurological status. The findings also emphasize the need to incorporate objective measures in diabetic foot screening and encourage future research to establish a gold standard tool for DPN diagnosis.

Trans-Achilles percutaneous fixation technique for posterior malleolus fracture: a cadaveric study

BackgroundIt has been reported that 43.6% of ankle fractures are accompanied by posterior malleolus fractures. The aim of this study is to define a safe zone for posterior malleolus fractures by determining the locations of the important anatomical structures in this region. Additionally, it aims to identify the trans-Achilles passage line for Kirschner wire insertion through a posteroanterior approach for posterior malleolus fragments.MethodsSix below-knee amputee fresh-frozen leg cadavers were used in this study. A trans-Achilles Kirschner wire was applied to the cadavers in the posteroanterior direction under the guidance of fluoroscopy. The areas where the Kirschner wire passed were dissected, and their proximity to vital anatomical structures was measured.ResultsIn all cadavers, the transverse thickness of the Achilles tendon at the level of the trans-Achilles Kirschner wire was 15.5 mm and the trans-Achilles Kirschner wire application was 18.6 mm from the sural nerve, 16 mm from the posterior tibial tendon, and 12.16 mm from the flexor digitorum longus muscle. It was performed 15.16 and 14.6 mm from the posterior tibial artery and vein, 12.3 mm from the tibial nerve, 13.6 mm from the tibiofibular joint, and 55.5 mm from the insertion site of the Achilles tendon to the calcaneus and at a sufficient distance from vital anatomical structures.ConclusionsThe proposed trans-Achilles percutaneous surgical technique is safe from neurovascular structures for fixing posterior malleolar fractures. However, the long-term clinical outcomes of this technique need to be explored.Level of evidenceLevel III, A cadaveric study.

Clinical Cues for the Early Diagnosis of Transthyretin-Related Polyneuropathy.

The estimated prevalence of hereditary transthyretin-related familial amyloid polyneuropathy (TTR-FAP) and the small number of known patients in Germany indicate that many patients with TTR-FAP remain undiagnosed, and may instead be classified as "idiopathic." The aim of this study was to identify biomarkers for detecting TTR-FAP among a cohort of patients with idiopathic polyneuropathy (PNP). Clinical evaluations (including the Neuropathy Impairment Score and Neuropathy Disability Score), nerve conduction studies (NCSs), quantitative sensory testing, and autonomic function tests were performed on 23 patients with TTR-FAP and 89 with idiopathic PNP. Discriminant analysis was then performed to identify variables useful for predicting TTR-FAP. Patients with TTR-FAP had paresis of the finger and thumb muscles, and reduced vibration perception and increased pressure pain in the upper and lower extremities. The NCSs showed that action potentials were smaller in the median, ulnar (both motor and sensory), and sural nerves in TTR-FAP. The sensory nerve conduction velocity was also reduced in the ulnar nerve. Autonomic neuropathy was confirmed by reduced sympathetic skin responses in the hands and feet in TTR-FAP. Multivariate discriminant analysis revealed that finger abduction strength, sensory ulnar nerve action potential amplitude, and vibration detection and pressure pain thresholds in the upper extremities were sufficient to correctly identify TTR-FAP in 81.3% of cases. Detailed clinical and neurophysiological investigations of standard parameters in the upper limb may help to identify the otherwise-rare TTR-FAP.

Percutaneous repair of achilles tendon ruptures: short-term results of 41 patients

Aims: Despite the current popularity of surgical treatment of Achilles tendon ruptures, there is no clear consensus about which technique should be applied. The aim of this study is to evaluate the short- to mid-term results of acute Achilles tendon ruptures treated with the percutaneous method and to discuss these results in light of the literature. Methods: In this study, 41 patients who were operated on percutaneously with the diagnosis of acute Achilles tendon rupture between 2016 and 2019, whose treatment was completed, and who had a follow-up period of at least 1 year were included. At the patients’ final follow-up visits, the range of motion of the ankle joint, time to return to work and sports, and complications were evaluated. For functional evaluations, the scoring system of the American Orthopaedic Foot &amp; Ankle Society (AOFAS) for the ankle joint was used. Results: The mean age of the patients was 29.3 (18-50) years and the mean follow-up duration was 23 (12-38) months. The mean dorsiflexion angle was 32.27° (20-45°) and the mean plantar flexion angle was 34.58° (20-45°). The time to return to work was 14.2 (8-21) weeks, while time to return to sports was 30.4 (17-49) weeks. The mean AOFAS score of the patients was 91.63 (74-100). The complications included infection in 2 (4.8%) patients, wound necrosis in 1 (2.4%) patient, re-rupture in 1 (2.4%) patient, and sural nerve neuropraxia in 1 (2.4%) patient. Conclusion: The findings of this study suggest that percutaneous repair is an effective method in the treatment of acute Achilles tendon ruptures, like other surgical methods that offer good functional results with low complication rates.

Knowledge gaps in diagnosing chronic polyneuropathy: Review of national guidelines.

The prevalence of chronic polyneuropathy will increase due to the aging population, and therefore, it becomes ever so important to optimize the diagnostic process. However, it is uncertain which blood tests are required and when nerve conduction studies (NCS) should be done in the workup of chronic polyneuropathy. We aimed to investigate the methodology used to develop national polyneuropathy guidelines and to provide an overview and strength of evidence of the recommendations. We searched PubMed and websites of national neurological associations as listed on the website of the World Federation of Neurology to identify national guidelines pertaining to the workup of chronic polyneuropathy by neurologists in an outpatient clinic setting. We identified three national guidelines in the United States and seven national guidelines in Denmark, France, Germany, the Netherlands, Norway, Spain, and Turkey. The methodology used to develop the guidelines differed greatly. All guidelines recommend a series of blood tests. Some guidelines advise to conduct NCS in all patients, while other guidelines advise to conduct NCS when certain symptoms are present. There is variation in recommendations about the extensiveness of NCS, but all mention measuring the sural nerve and the motor peroneal nerve. The evidence for the recommendations is graded as low. Despite some overlap, there are disparities between guidelines regarding the workup that is advised to do in patients with chronic polyneuropathy. It remains unclear which combination of blood tests are to be strongly recommended. Furthermore, it is undetermined whether NCS are always necessary.

Mini-open versus percutaneous surgical repair for acute Achilles tendon rupture: a systematic review and meta-analysis.

To compare the clinical outcomes and complications of mini-open (MOT) and percutaneous techniques (PT) in the surgical repair of acute Achilles tendon rupture (AATR). We systematically searched PubMed, Scopus, Web of Science, Clinical Trials, and the Cochrane Library for studies comparing MOT with PT for AATR. We assessed functional outcomes, complication rates, and operation time. Statistical analyses were performed using RevMan Web. Odds ratios (ORs) and mean difference (MD) with 95% confidence intervals (CIs) were pooled with a fixed-effects model for dichotomous and continuous endpoints, respectively. Heterogeneity was evaluated with I2 statistics. Eight studies, comprising 484 patients, were included, of whom 226 (46%) underwent MOT. MOT was associated with a significantly lower re-rupture rate (1.48% vs. 6.11%; OR 0.28; 95% CI 0.09-0.86; p = 0.03; I2 = 6%) and sural nerve injury rate (0.57% vs. 5.64%; OR 0.24; 95% CI 0.07-0.81; p = 0.02; I2 = 0%). No significant differences were observed in venous thrombosis (OR 0.81; 95% CI 0.17-3.94; p = 0.33; I2 = 0%), wound infection (OR 0.56; 95% CI 0.12-2.62; p = 0.46; I2 = 0%), or operation time (MD 1.83min; 95% CI -1.13-4.79; p = 0.23; I2 = 88%). Functional outcomes showed higher American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores in the MOT group (MD 1.52 points; 95% CI 0.62-2.42; p = 0.001; I2 = 3%), while (Achilles Tendon Total Rupture Score) ATRS, time to return to activities, and ankle plantar and dorsiflexion were comparable. MOT for AATR repair seems to reduce re-ruptures and sural nerve injuries while improving AOFAS scores, with no significant differences in other complications compared to PT. These findings suggest that the MOT may offer a safer and equally effective alternative to PT for AATR.

Hypertension is associated with the reduction in epidermal small fibres independently of sural nerve inflammation in type 2 diabetic subjects.

Diabetic polyneuropathy (DPN) is a multifactorial disease associated not only with hyperglycaemia but also with circulatory disturbances such as hypertension. A close interaction between the immune system and hypertension is known. It remains unclear whether the inflammatory response is associated with hypertension in the pathology of human DPN. Autopsied patients were evaluated: 7 non-diabetic patients (nDM), 11 non-diabetic patients with hypertension (nDMHT), 6 patients with diabetes (DM) and 9 patients with hypertension and diabetes (DMHT). Intraepidermal nerve fibre density (IENFD) was examined by immunofluorescent staining. Dissected sural nerve (SNs) were morphometrically quantified. Dermal and endoneurial macrophage infiltration was evaluated by double immunostaining using anti-CD68 and anti-CD206 antibodies. IENFD was significantly decreased in DM compared to nDM (p < 0.05) and was further decreased in DMHT (p < 0.05). Myelinated nerve fibre density (MNFD) in the SN was significantly decreased in DM compared with nDM (p < 0.05) and further decreased in DMHT (p < 0.01 vs. DM). The infiltration of CD206-/CD68+ proinflammatory macrophages in the SN was significantly increased in DM compared to nDM (p < 0.05), whilst the number of CD206+/CD68+ anti-inflammatory macrophages was decreased in DM (p < 0.05). Hypertension had no impact on macrophage infiltration. The ratio of CD206- and CD206+ macrophage was negatively correlated with MNFD (r = 0.42, p < 0.05) but not IENFD (r = 0.30, p = 0.09). Dermal CD206+ macrophage infiltration was similar amongst all groups. Diabetes complicated by hypertension significantly increased the total diffusion barrier thickness (p < 0.01 vs. DM). Total diffusion barrier thickness was inversely correlated with both IENFD (r = -0.59, p < 0.01) and MNFD (r =-0.62, p < 0.01). Our results suggest that vascular factors and inflammation might be synergistically involved in pathological changes in human diabetic patients through different mechanisms.

Short term efficacy of subtalar arthroscopy combined with medial calcaneal-talar joint distraction in minimally invasive treatment of diabetic patients with calcaneal fractures: a retrospective study

BackgroundThe surgical treatment and management of postoperative soft tissue complications in diabetic patients with displaced calcaneal fractures are still controversial. We aimed to evaluate the short-term efficacy of percutaneous minimally invasive screw fixation in treatment of diabetic patients with Sanders II and III calcaneal fractures under subtalar arthroscopy assisted by preoperative musculoskeletal ultrasonic locating lateral calcaneal branch (LCB) of the sural nerve and calcaneal-talar joint distraction device.MethodsThe clinical data of 52 diabetic patients diagnosed with Sanders II or III calcaneal fractures from March 2016 to August 2020 were followed up and analyzed. There were 23 patients of type II and 29 patients of type III, 34 males and 18 females, with a mean age of 61.7 ± 14.5 years (range: 45–72 years). Preoperative musculoskeletal ultrasonography was routinely examined to locate LCB of the sural nerve. During surgery, we performed arthroscopic percutaneous prying reduction screw fixation assisted by medial calcaneal-talar joint distraction. Incision healing, local skin paraesthesia and other conditions were observed regularly at 3 days, 6, 12 months, and the last follow-up after surgery. Also, we measured the length, width, height, Böhler angle, and Gissane angle of the calcaneus on lateral and axial x-rays. Visual analogue pain scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score and Maryland score were used to evaluate the efficacy.Results52 patients were followed up for 23.7 ± 3.2 months (range: 20–28 months) without incision-related complications. Calcaneal radiographic parameters (length, width, height, Böhler/Gissane angle) were improved after surgery, and the differences were all statistically significant (P<0.05). There was no difference between calcaneal radiographic parameters at 6,12 months and the last follow-up compared with 3 days after surgery without significant loss in overall morphology (P>0.05). Postoperative VAS, AOFAS scores, and Maryland scores were significantly improved compared with those before surgery (P<0.05).ConclusionsPreoperative ultrasonic locating LCB of the sural nerve and arthroscopic percutaneous minimally invasive screw fixation of Sanders II and III calcaneal fractures with the assistance of calcaneal-talar joint distraction have good short-term efficacy and clinical feasibility in diabetic patients.

Early aggressive constriction resection for hourglass-like constriction of peripheral nerve in the upper extremity: a retrospective study

ObjectivesThe hourglass like constriction (HGC) of peripheral nerves is a characteristic pathological manifestation of Neuralgic Amyotrophy. Once identified, early surgical intervention is essential. However, the method of surgery is controversial, particularly regarding whether HGC needs to be excised. This study aims to explore the efficacy of early aggressive resection of HGC in the upper limb nerves. Materials and methodsThis retrospective study focuses on 13 nerves of spontaneous upper limb paralysis treated at our hospital from June 2019 to July 2023, in which HGC was identified during surgery. During surgery, epineurectomy and interfascicular neurolysis were performed on the constricted areas. Post-neurolysis, constriction excision was carried out if any of the following conditions were met: (1) A single constriction with constriction ≥75%. (2) Constriction combined with torsion. (3) The presence of ≥2 constrictions. Regular face-to-face follow-ups were conducted postoperatively. ResultsFour cases with a single constriction of less than 75% underwent epineurotomy and interfascicular neurolysis; eight underwent constriction excision, of which four cases with a single constriction and associated torsion had direct end-to-end suturing after excision, and four had more than two constrictions treated with autologous sural nerve grafts. Postoperative follow-ups showed good recovery in all but one case, which had unique pathological features and had underwent only epineurectomy, showing moderate recovery. ConclusionsFor early surgical treatment of HGCs in peripheral nerves of the upper limbs, if severe constriction, constriction combined with torsion, or the presence of more than two constrictions are identified during surgery, aggressive constriction resection may be a better option.

Nerve conduction studies of sensory nerves with proven vasculitic neuropathy often show an absent electrical response.

In vasculitic neuropathy (VN), it is not known whether nerve conduction studies (NCSs) showing low amplitude sensory nerve action potentials (SNAPs) or those with absent responses have a higher yield in detecting appropriate nerves for pathological confirmation. Our goal was to describe NCS findings of nerves prior to biopsy in patients with VN. We performed a retrospective study between January 2000 and April 2021 in patients with VN who either met pathological definite criteria for VN or criteria for clinically probable VN and had NCS of the sural or superficial radial sensory nerves prior to biopsy of the same nerve. We included 61 patients with VN. The pathological findings showed 37 (60.7%) definite, 14 (23%) probable, and 2 (3.3%) possible VN; eight (13%) samples did not meet Peripheral Nerve Society pathological criteria. Most patients who met definite (20 out of 37, 54%) and probable (9 out of 14, 64%) VN pathological criteria had absent SNAPs. Only three out of eight (37.5%) patients without VN pathological findings had absent SNAPs. There was no statistically significant correlation between pathological diagnosis and SNAP amplitude (χ2 = 1.98, p = .58). Additionally, no association was found between VN pathological criteria and use of immunomodulatory treatment (p = .67) or corticosteroids (p = .52). Most nerves with pathological VN findings showed no response on NCS. In patients with suspected VN, sural or superficial radial sensory nerves with absent responses on NCS are adequate biopsy targets as compared to nerves in which SNAPs can be recorded.

Promising predictors of diabetic peripheral neuropathy in children and adolescents with type 1 diabetes mellitus

BackgroundDiabetic peripheral neuropathy (DPN) in children and adolescents with type 1 diabetes mellitus (T1DM) is a growing issue, with controversial data in the terms of prevalence and evaluation timelines. Currently, there are no clear standards for its early detection. Therefore, our aim was to assess the contribution of the Michigan neuropathy screening instrument (MNSI), lipid profile, serum neuron specific enolase (NSE), and serum heat shock protein 27 (HSP 27) to the prediction of DPN in children and adolescents with T1DM.MethodsIn this case-control study, fifty children diagnosed with T1DM for at least five years were enrolled and evaluated through complete neurological examination, MNSI, and nerve conduction study (NCS). Additionally, HbA1c, lipid profile, serum NSE, and serum HSP 27 levels were measured for patients and controls.ResultsThe prevalence of DPN in our study was 24% by NCS, and electrophysiological changes showed a statistically significant lower conduction velocity for the posterior tibial and sural nerves, as well as a prolonged latency period for the common peroneal and sural nerves in neuropathic patients. In these patients, older age, earlier age of diabetes onset, longer disease duration, higher total cholesterol, triglycerides, low density lipoprotein cholesterol, HbA1c, serum NSE, and HSP27 levels were observed. The MNSI examination score ≥ 1.5 cutoff point had an area under the curve (AUC) of 0.955, with 75% sensitivity and 94.74% specificity, according to receiver operating characteristic curve analysis. However, the questionnaire’s cutoff point of ≥ 5 had an AUC of 0.720, 75% sensitivity, and 63% specificity, with improved overall instrument performance when combining both scores. Regarding blood biomarkers, serum NSE had greater sensitivity and specificity in discriminating neuropathic patients than HSP27 (92% and 74% versus 75% and 71%, respectively). Regression analysis revealed a substantial dependency for MNSI and serum NSE in predicting DPN in patients.ConclusionsDespite limited research in pediatrics, MNSI and serum NSE are promising predictive tools for DPN in children and adolescents with T1DM, even when they are asymptomatic. Poor glycemic control and lipid profile changes may play a critical role in the development of DPN in these patients, despite conflicting results in various studies.

Update/Refinement of Targeted Muscle Reinnervation Indication: A Scoping Review of Applications for Non-Amputees

Background: Targeted muscle reinnervation (TMR) was originally developed to enhance prosthetic control in amputees. However, it has also serendipitously demonstrated benefits in reducing phantom pain and neuromas. As a result, it has emerged as a secondary treatment for chronic neuromas in amputees and holds promise for managing neuropathic pain in non-amputee patients, particularly those with neuromas. This review synthesizes the current literature on TMR indications for non-amputee patients, highlighting its potential to address chronic peripheral nerve pain and neuromas beyond its original application in amputation. Methods: A thorough search of the PubMed and Cochrane databases up to January 2024 was conducted following the PRISMA guidelines. Inclusion criteria comprised case series, cohort studies, and randomized controlled trials reporting TMR outcomes in non-amputees. Results: Of 263 articles initially identified, 8 met the inclusion criteria after screening and full-text assessment. The articles were all case series with varied sample sizes and mainly focused on neuroma treatment (n = 6) and neuropathic pain management (n = 2) for both upper and lower extremities. Clinical studies included TMR efficacy for sural nerve neuromas in the lower extremities and hand neuromas, showing pain relief and improved function. Key findings were encouraging, showing successful pain relief, patient satisfaction, and psychosocial improvement, with only rare occurrences of complications such as motor deficits. Conclusions: In non-amputee patients, TMR appears to be a promising option for the surgical management of neuropathic pain, demonstrating favorable patient satisfaction and psychosocial outcomes along with low morbidity rates. Although functional improvements in gait recovery and range of motion are encouraging, further research will be important to confirm and expand upon these findings.

Morphological Variability of the Sural Nerve and Its Clinical Significance.

The sural nerve provides sensory innervation to the skin on the distal posterolateral third of the lower extremity. The morphological variants are characterized by high variability. However, it most commonly arises from a union of the medial sural cutaneous nerve and the peroneal communicating branch of the common fibular nerve. This article overviews the anatomical and clinical significance of the sural nerve. Despite the remarkable development of genetic diagnostics, sural nerve biopsy is still a very important tool to diagnose peripheral neuropathies such as diabetic, vascular and inflammatory neuropathies. Furthermore, the sural nerve is also commonly transplanted due to its characteristics. Such a procedure is applicable in cases of segmental nerve loss, but it is also used to restore potency in patients after radical prostatectomy. The knowledge of anatomical variants of the sural nerve is also crucial as it allows to minimize its damage during surgical procedures. Furthermore, during an ankle surgery, a nerve block can be used to complement anesthesia. The major aim of this work is to review contributions of the sural nerve to physiological and pathophysiological processes.

Nerve conduction velocity studies in diabetic peripheral neuropathy involving sural nerve—A meta-analysis

ABSTRACT Introduction: Diabetes mellitus (DM) poses a significant health burden globally, impacting millions due to its metabolic disruptions. Among its complications, diabetic peripheral neuropathy (DPN) is a prevalent concern, affecting sensory and motor nerves. While various diagnostic methods exist, discrepancies persist in prevalence estimates of DPN among diabetic populations. Objective: This meta-analysis aimed to assess the prevalence of DPN in individuals with DM, focusing on sural nerve conduction velocity (NCV) measurements. Additionally, the study explored how different evaluation techniques influenced prevalence estimates. Methods: A systematic literature search was conducted following PRISMA guidelines across multiple databases. Studies reporting sural nerve NCV measurements in diabetic patients were included. Data extraction, quality assessment, and statistical analyses were performed to synthesize findings. Results: Twenty-six studies met the inclusion criteria, providing insights into sural nerve NCV among diabetic individuals. Pooled analysis revealed a mean sural nerve NCV of 42.12 m/s (95% CI: 39.87-44.36), indicative of reduced conduction velocity in diabetic populations. Furthermore, sural nerve amplitude was significantly lower in diabetic individuals, with a pooled mean of 4.68 μV (95% CI: 3.11-6.25). Conclusion: Individuals with type 2 DM exhibit impaired sural nerve function, as evidenced by reduced NCV and amplitude measurements. Timely NCV assessment, alongside glycemic monitoring, is crucial for identifying and managing DPN to prevent further complications. Interventions addressing glycemic control, dietary regulation, and lifestyle modifications are recommended to mitigate the progression of neuropathy in diabetic populations.

Anatomy of the Achilles tendon-Apictorial review.

The Achilles tendon (AT) is the strongest tendon of the human body. The knowledge of AT anatomy is abasic prerequisite for the successful treatment of acute and chronic lesions. The structure of the AT results from acomplicated fusion of three parts: the tendons of the medial and lateral gastrocnemius and the soleus muscles. From proximal to distal, the tendon fibers twist in along spiral into aroughly 90° internal rotation. The tendon is narrowest approximately 5-7 cm above its calcaneal insertion and from there it expands again. The topography of the footprints of the individual AT components reflects the tendon origins. The anterior (deep) AT fibers insert into the middle third of the posterior aspect of the calcaneal tuberosity, the posterior (superficial) fibers pass over the calcaneal tuberosity and fuse with the plantar aponeurosis. Adeep calcaneal bursa is interposed between the calcaneal tuberosity and the AT anterior surface. The AT has no synovial sheath but is covered along its entire length with asliding connective tissue, the paratenon which is, however, absent on its anterior surface. The AT is supplied by the posterior tibial artery (PTA) and the peroneal artery (PA). Motor innervation of the triceps surae muscle is provided by fibers of the tibial nerve which also gives off sensitive fibers for the AT. Sensitive innervation is also provided via the sural nerve. The sural nerve crosses the AT approximately 11 cm proximal to the calcaneal tuberosity. The forces acting on the AT during exercise may be up to 12 times the body weight. Physiological stretching of AT collagen fibers ranges between 2% and 4% of its length. Stretching of the tendon over 4% results in microscopic failure and stretching beyond 8% in macroscopic failure.