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Pod Med III > 4) Entrapment Neuropathies > Flashcards

4) Entrapment Neuropathies Flashcards

1
Q

Entrapment neuropathies secondary to

A
  • Gradual constriction of structures about nerve

- Chronic compression against unyielding structure

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2
Q

Patient history of entrapment neuropathy

A
  • Insidious onset of mild symptoms

- Pain increases and referred along nerve distribution

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3
Q

Entrapment neuropathy diagnosis

A
  • Radiating nerve symptoms and muscle weakness

- EMG and NCV may be helpful

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4
Q

Meralgia Paresthetica

A
  • Entrapment of the Lateral Femoral Cutaneous Nerve
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5
Q

Meralgia Paresthetica is caused by

A
  • Compression of the lateral femoral cutaneous nerve in the leg
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6
Q

LFC nerve provides sensation to

A
  • Skin along the outer thigh starting from the inguinal ligament and extending down toward the knee
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7
Q

Compression of the LFC nerve can result in

A
  • Numbness, tingling, pain or a burning sensation felt in the outer thigh
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8
Q

Common causes of meralgia paresthetica may include

A
  • Repetitive motion of the legs
  • Recent injuries to the hip
  • Wearing tight clothing or heavy belts
  • Weight gain
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9
Q

Lateral Femoral Cutaneous Nerve (L2-L3) course

A
  • Emerges from lateral psoas muscle
  • Runs along brim of pelvis
  • Enters thigh through tunnel in lateral inguinal ligament
  • Bifurcates ~12 cm inferior to exit from pelvis
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10
Q

First sensory branch of plexus (LFC)

A
  • Anterior branch (lateral and anterior thigh)

- Posterior branch )lateral and posterior thigh)

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11
Q

LFC entrapment site

A
  • Lateral aspect of inguinal ligament
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12
Q

LFC entrapment symptoms

A
  • Paresthesias along the nerve
  • Increased while lying down!!!
  • More pressure on inguinal ligament in this position!!!
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13
Q

LFC entrapment treatment options

A
  • Anti-inflammatory modalities
  • Gabapentin
  • Ice and TENS unit
  • Alpha Lipoic Acid 600 mg + Benfotiamine 150 mg BID
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14
Q

Femoral nerve (L2-L4) course

A
  • Emerges from lateral Psoas Muscle
  • Passes under the Inguinal Ligament
  • Lies lateral to the femoral artery
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15
Q

Femoral nerve sensory innervation

A
  • Anterior thigh

- Medial leg

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16
Q

Femoral nerve motor innervation

A
  • Muscles of the anterior thigh
  • Illiacus
  • Pectineus
  • Sartorius
  • Quadriceps Femoris
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17
Q

Femoral nerve controls movement of

A
  • Hip flexion via iliopsoas
  • Thigh flexion via pectineus
  • Knee extension via quadriceps
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18
Q

Femoral nerve entrapment symptoms

A
  • Paresthesias relieved by flexion and external rotation
  • Decreased patellar DTR
  • Sensory alteration in distribution of saphenous nerve
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19
Q

Femoral nerve entrapment site

A
  • Inferior to inguinal ligament
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20
Q

Saphenous nerve (L3-L4)

A
  • Largest and longest PURE SENSORY BRANCH of femoral nerve
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21
Q

Saphenous nerve (L3-L4) course

A
  • Accompanies superficial femoral artery in femoral triangle
  • Descends medially under sartorius
  • Enters Hunter’s canal in distal thigh
  • Becomes superficial 10-15 cm above medial femoral condyle
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22
Q

Saphenous nerve entrapment site

A
  • Usually distal thigh

- Hunter’s Canal/Subsartorial canal/Adductor Canal Secondary to patient positioning

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23
Q

Saphenous nerve innervation

A
  • Medial calf

- Medial aspect of foot to 1st MPJ

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24
Q

Saphenous nerve laceration secondary to

A
  • Trauma
  • Knee Replacement
  • CABG harvest
    (The great Saphenous is harvested for this)
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25
Q

Saphenous nerve entrapment symptoms

A
  • Deep ache of the medial knee with radiating paresthesias

- Sensory deficit only (no motor weakness)

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26
Q

Saphenous nerve entrapment treatment

A
  • Local infiltration of anesthesia and corticosteroid
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27
Q

Obturator nerve (L2-L4) course

A
  • Formed within the psoas
  • Enters pelvis anterior to sacroiliac joint
    Bifurcates at obturator canal (anterior and posterior branches)
  • Anastomoses with saphenous nerve
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28
Q

Obturator nerve innervation

A
  • Anterior branch = adductor longus, brevis and gracilis
  • Posterior branch = obturator externus and part of adductor magnus
  • Sensory to upper medial thigh
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29
Q

Obturator nerve entrapment symptoms

A
  • Groin and medial thigh pain
  • Painful ambulation with “unstable” leg
  • Weakness exacerbated by jumping
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30
Q

Obturator nerve entrapment etiology

A
  • Malposition of the limb secondary to hip surgery
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31
Q

Obturator nerve entrapment treatment

A
  • E-stim, stretching and massage

- Often requires surgery

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32
Q

Sacral plexus

A
  • Arises from L5, S1 and S2 nerve roots anterior to the sacroiliac joint
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33
Q

Common sacral plexus variations

A
  • (High) Prefixed pattern – includes a major contribution from L4
  • (Low) Postfixed pattern – contains a contribution of L5
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34
Q

Superior gluteal nerve (L4-S1) innervation

A
  • Supplies the Gluteus Medius, Gluteus Minimus and Tensor Fascia Lata
  • Thigh abduction and internal rotation
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35
Q

Inferior gluteal Nerve (L5-S2)

A
  • Supplies the Gluteus Maximus

- Thigh abduction, external rotation and extension

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36
Q

Sciatic nerve

A
  • Union of anterior rami of L4-S3 nerve roots
  • Peroneal portion – posterior division
  • Tibial portion – anterior division
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37
Q

Sciatic nerve course

A
  • Courses through greater sciatic foramen

- Passes inferiorly to lower thigh and divides

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38
Q

Sciatic nerve divides into

A
  • Common peroneal nerve (deep and superficial peroneal after this)
  • Tibial nerve
  • Medial plantar nerve
  • Lateral plantar nerve
  • Medial calcaneal nerve
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39
Q

Sciatic neuropathy

A
  • One of the most common neuropathies of the lower extremities second only to common fibular (peroneal) neuropathy
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40
Q

One of the most common presentations of sciatic neuropathy

A
  • Foot drop
  • Ankle dorsiflexion weakness, with or without lower extremity sensory impairment, may also be associated with several other clinical syndromes
  • Careful evaluation is necessary before confirming a diagnosis of sciatic neuropathy
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41
Q

Sciatic neuropathy diagnostic testing

A
  • Electrodiagnostic testing
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42
Q

Tibial nerve (L4-S3) course

A
  • Arises from within the medial popliteal fossa
  • Passes between heads of gastrocnemius and soleus muscles
  • Upper calf – rests between the PT and FDL muscles
  • Ankle joint – rests between the FDL and FHL tendons
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43
Q

Tibial nerve innervation

A
  • Motor to superficial and deep posterior leg muscle groups
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44
Q

Posterior tibial nerve course

A
  • Courses behind the medial malleolus

- Bifurcates into medial and lateral plantar nerves

45
Q

Medial plantar nerve course

A
  • Courses along with medial plantar artery
46
Q

Medial plantar nerve innervation

A
  • Motor function to abductor hallucis, FDB, FHB and first lumbrical muscle
  • Sensory function to the medial 3 ½ digits
47
Q

Lateral plantar nerve course

A
  • Courses laterally to heel and lateral aspect of plantar foot
  • First branch – Baxter’s nerve running between deep fascia of abductor hallucis and medial fascia of quadratus plantae continues to FDB belly
48
Q

Lateral plantar nerve innervation

A
  • Motor – all but 4 intrinsics

- Sensory – lateral sole and lateral 1 ½ digits

49
Q

Tarsal tunnel syndrome (medial plantar nerve)

A
  • 79% have only one branch
  • Branches penetrate flexor retinaculum where it can become entrapped
  • Sensory: medial and proximal heel
50
Q

Medial plantar nerve entrapment (tarsal tunnel syndrome)

A
  • Coincides with heel spur syndrome abnormal pronation
  • Large or accessory abductor hallucis
  • Accessory fascial bands
51
Q

Proximal tarsal tunnel syndrome etiologies (anatomic)

A
  • Neurovascular bundle attachment to septal fibers –> traction injury
  • Enlarged abductor hallucis muscle belly
  • Presence of os tibialis externum or accessory navicular
52
Q

Proximal tarsal tunnel syndrome etiologies (vascular)

A
  • Nerves are well supplied with blood flow –> very susceptible to ischemic injury
  • Presence of varices (apply a tourniquet to facilitate engorgement, symptoms can be reproduce)
53
Q

Tarsal tunnel syndrome divided into

A
  • Intrinsic etiologies
  • Extrinsic etiologies
  • Mechanism of impingement can be identified in approximately 80% of cases
54
Q

Tarsal tunnel syndrome intrinsic etiologies

A
  • Tendinopathy, tenosynovitis, perineural fibrosis
  • Osteophytes
  • Hypertrophic retinaculum
  • Space-occupying or mass effect lesions (enlarged or varicose veins, ganglion cyst, lipoma, neoplasm, and neuroma)
  • Arterial insufficiency can lead to nerve ischemia
55
Q

Tarsal tunnel syndrome extrinsic etiologies

A
  • Poorly fitting shoes, trauma, anatomic-biomechanical abnormalities (tarsal coalition, valgus or varus hindfoot)
  • Post-surgical scarring
  • Systemic diseases, generalized lower extremity edema, systemic inflammatory arthropathies, diabetes, and post-surgical scarring
56
Q

Proximal tarsal tunnel syndrome etiologies (occupational)

A
  • Increased applied pressure to medial foot
57
Q

Proximal tarsal tunnel syndrome etiologies (biomechanical)

A
  • Excessive pronation
  • Maximally everted heel in midstance
  • Ligamentous laxity
58
Q

Proximal tarsal tunnel syndrome symptoms

A
  • Tingling, burning, numbness, weakness of foot
  • Valleix phenomenon (proximal radiation of symptoms)
  • Positive Tinel Sign elicited at the laciniate ligament
59
Q

Proximal tarsal tunnel syndrome diagnostic tests

A
  • Electromyography (EMG)

- Nerve conduction tests

60
Q

Distal tarsal tunnel syndrome

A
  • Medial plantar nerve = Jogger’s foot

- Lateral plantar nerve (first branch) = Baxter’s neuritis

61
Q

“Jogger’s” foot

A
  • Distal tarsal tunnel syndrome of medial plantar nerve

- Compression between the navicular tuberosity and abductor hallucis belly

62
Q

Baxter’s neuritis

A
  • Distal tarsal tunnel syndrome of lateral plantar nerve (first branch)
  • Chronic heel pain with “afterburn” (20-30 mins after getting off weight-bearing)
  • Post static dyskinesia
  • Most common form
63
Q

Baxter’s neuritis characteristics

A
  • AKAdistal tarsal tunnel syndrome
  • Entrapment of the first branch of the lateral plantar nerve
  • Rare
  • WHEN IT OCCURS IT IS OFTEN MISTAKEN FOR PLANTAR FASCIITIS
64
Q

Common peroneal nerve (L4-S1)

A
  • Arises from the sciatic nerve within the popliteal fossa
65
Q

Common peroneal nerve course

A
  • Becomes superficial at the popliteal fossa proximal to knee
  • At head of fibula – passes through fibro-osseous channel in superficial head of peroneus longus
  • Gives off recurrent branch to patella
  • Bifurcates distal to fibular head
66
Q

Common peroneal nerve entrapment symptoms

A
  • Weakness of anterior muscle group

- EDB is profoundly affected

67
Q

Common peroneal nerve entrapment diagnosis

A
  • EMG changes – can overlap with L5 radiculopathy
  • Steppage gait
  • Anterior Muscle Group
  • Lift leg up higher because of they can’t dorsiflex the foot (drop foot)
  • Midswing tripping
68
Q

Superficial peroneal nerve (musculocutaneous) course

A
  • Descends inferiorly between the peroneal muscles
  • Becomes superficial ~ 10 cm above tip of lateral malleoli
  • Bifurcates 4-6 cm above tip of lateral malleoli
  • Passes anterior to extensor retinaculum
69
Q

Most commonly injured nerve in the foot

A
  • Superficial peroneal nerve
70
Q

Superficial peroneal nerve sites of entrapment

A
  • Peroneal tunnel before exit
  • Site of exit through deep fascia
  • Herniation of muscle or fat
71
Q

Intermediate dorsal cutaneous nerve

A
  • Branch of superficial peroneal
  • aka “Lemont’s” nerve
  • Courses ~ 1 cm anterior to medial aspect of lateral malleoli
  • Sensory to majority of dorsum of foot
72
Q

Medial dorsal cutaneous nerve

A
  • Branch of superficial peroneal
  • Courses medially to first ray
    Directly over first cuneiform-first metatarsal joint
73
Q

Superficial peroneal nerve entrapment etiologies

A
  • Exercise mediated

- Contusion

74
Q

Intermediate dorsal cutaneous nerve etiologies

A
  • Inversion ankle injury
  • Ankle arthroscopy – anterior lateral portal
  • Ill-fitting shoes
75
Q

Medial dorsal cutaneous nerve entrapment etiologies

A
  • Surgeon’s error
  • Ill-fitting shoes
  • Alternate lacing technique to reduce pressure
  • Prolonged squatting
76
Q

Superficial peroneal nerve entrapment diagnosis

A
  • Apply pressure over area where nerve exits superficial fascia
  • Ask patient to dorsiflex and evert foot against resistance
  • Places superficial peroneal on stretch → symptoms
  • Passively plantarflex and invert foot
  • Places intermediate dorsal cutaneous nerve on stretch
  • Percuss the nerve directly
77
Q

Deep peroneal nerve (aka anterior tibial nerve) course

A
  • Lies between tibialis anterior and EHL in the lower 1/3 of the leg
  • Approximately 3-5 cm above the ankle joint the EHL crosses it → lies between EHL and EDL
78
Q

Arthroscopy considerations for deep peroneal nerve

A
  • Anterior central portal for surgery

- Want to place it between EHL and TA so you avoid the nerve

79
Q

Deep peroneal nerve innervation

A
  • Anterior muscle group and EDB
  • Sensory – first intermetatarsal space
  • Ankle joint dorsifelxion
  • Supination of longitudinal midtarsal joint (via TIBIALIS ANTERIOR)
80
Q

Anterior tarsal tunnel syndrome (deep peroneal nerve) secondary to injuries

A
  • Broadens under the extensor retinaculum
  • Sensitive to blunt trauma at this level
  • Presence of tarsal spurs
81
Q

Anterior tarsal tunnel syndrome (deep peroneal nerve) secondary to compression

A
  • Ill-fitting shoe gear – ski boots

- High topped sneakers

82
Q

Deep peroneal nerve compression

A
  • No Tinel’s sign distal to cuneiform joints

- Sits directly under the extensor hallucis brevis tendon

83
Q

Deep peroneal nerve compression etiologies

A
  • Diabetic neuropathy

- Metatarsal-cuneiform exostoses

84
Q

Deep peroneal nerve entrapment symptoms

A
  • Paresthesias over the dorsum of foot
  • First intermetatarsal space numbness
  • Nocturnal pain relieved by foot movement
  • Wasting of EDB muscle belly
85
Q

Deep peroneal nerve entrapment provocative test

A
  • Plantarflex ankle and dorsiflex toes

- Reproduce symptoms with direct palpation just medial to dorsalis pedis artery

86
Q

Sural nerve arises from the union of

A
  • Medial sural cutaneous (branch of the tibial nerve)

- Sural communicating branch of the common peroneal nerve

87
Q

Sural nerve course

A
  • Originates inferior to popliteal fossa
  • Runs between gastrocnemius muscle bellies
  • Runs behind lateral malleolus and onto lateral aspect of foot
88
Q

Sural nerve terminal pranches

A
  • Medial branch (larger)

- Lateral branch

89
Q

Medial branch of sural nerve

A
  • Cutaneous innervation to dorsal skin on the fourth metatarsal base
  • Communicates with IDCN (intermediate dorsal cutaneous nerve)
90
Q

Lateral branch of sural nerve

A
  • Purely Sensory to lateral aspect of fifth toe

- Nerve of choice for biopsy

91
Q

Sural nerve injury etiologies

A
  • “Slip of the hand”

- Inversion ankle injury

92
Q

Evaluation of nerve conduction velocity

A
  • Segmental demyelination
  • conduction block lesion
  • Axonal degeneration
  • Sensory nerve evaluation
93
Q

Segmental demyelination (NCV evaluation)

A
  • NCV minimum of 30% slower than normal
  • Prolonged distal latency
  • Conduction block (correlates with clinical severity)
94
Q

Conduction block lesion (NCV evaluation)

A
  • Distal stimulation is normal

- Proximal stimulation shows smaller than normal muscle response

95
Q

Axonal degeneration (NCV evaluation)

A
  • Near normal NCV
  • Low amplitude evoked responses in muscle
  • Normal distal latencies
  • Slowing of F-responses
96
Q

Sensory nerve evaluation (NCV evaluation)

A
  • Decreased amplitude potentials may exist with clinical sensory loss
97
Q

Normal motor involvement (NCV evaluation)

A
  • Silent at rest

- Motor units under voluntary control is roughly proportional to effort

98
Q

Abnormal motor involvement (NCV evaluation)

A
  • Fasciculations in resting mucles
  • Motor units under voluntary control decrease
  • Collateral nerve cause an increase in duration and amplitude
  • Greater than normal number of fibers
99
Q

Incisional neuromas

A
  • Frequently encountered
  • Surgeon’s error
  • Nerve tissue included in the incision enclosure
  • Must be mindful of location of nerves under superficial fascia
  • Medial and intermediate dorsal cutaneous nerves most often involved
100
Q

Joplin’s Neuroma

A
  • Compression injury of medial plantar digital proper nerve
101
Q

Joplin’s Neuroma symptoms

A
  • Numbness, paresthesias

- Neuralgia radiating along planter medial hallux

102
Q

Joplin’s Neuroma etiology

A
  • Excessive pronation
  • Hallux valgus
  • Apropulsive gait
103
Q

Joplin’s Neuroma treatment

A
  • Local and glucocorticoid
  • 4% sclerosing agent
  • Surgical excision
104
Q

Intermetatarsal neuromas (names)

A
  • 1st IM space = Heuter’s
  • 2nd IM space = Houser’s
  • 3rd IM space = Morton’s
  • 4th IM space = Islen’s
105
Q

IM space neuromas pathophysiology

A
  • Endoneurial edema

- Renaut bodies (chronic finding)

106
Q

Endoneurial edema

A
  • Fibrosis beneath the perineurium
  • Axonal degeneration
  • Cylindrical, hyaline-appearing, loosely-textured, whorled, cell-sparse structures found in the subperineurial space in peripheral nerves
107
Q

Renaut bodies (chronic finding)

A
  • Mainly fibroblasts

- Derived from endoneurium

108
Q

IM space neuromas etiologies

A
  • Abnormal foot mechanics (movement between medial/lateral columns)
  • Vestigial branch between medial/lateral plantar nerves
  • Narrow IM angles
  • Adventitious bursa

Pod Med III (8 decks)

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