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Equine Veterinary Journal Sep 2021Neurovascular variation may be relevant when performing surgical techniques to the proximal plantar metatarsal region.
BACKGROUND
Neurovascular variation may be relevant when performing surgical techniques to the proximal plantar metatarsal region.
OBJECTIVES
To document variations in the neurovascular anatomy of the proximal plantar metatarsal region and study the relationship of the neurovascular components to each other and other structures located in this area.
STUDY DESIGN
Descriptive anatomical study.
METHODS
Paired cadaver hind limbs from 15 horses were dissected from the distal tibia to the metatarsophalangeal joint. Deep branch of the lateral plantar nerve (DBLPN) length, location of its origin from the lateral plantar nerve (LPN), individual DBLPN ramifications into the suspensory ligament (SL) and relationship of the DBLPN to the plantar arch and accessory ligament of the deep digital flexor tendon (ALDDFT) were recorded.
RESULTS
Mean DBLPN length was 5.8 ± 1.7 cm with the nerve arising 3.7 ± 1.5 cm proximal to the head of the fourth metatarsal bone (MTIV). There was a median of three individual DBLPN ramifications (range 2-6) entering the SL. There were no significant left/right differences. In 57% (CI 39%-74%; n = 17) limbs, the deep plantar arch was superficial to the DBLPN, whereas in 33% (CI 16%-50%; n = 10) limbs, the DBLPN passed between the venous and arterial components of the arch. In 10% (CI 1%-20%; n = 3) limbs, the deep plantar arch was deep to the DBLPN. In 67% (CI 50%-84%; n = 20) limbs, the DBLPN was superficial to the ALDDFT, whereas in 33% (CI 16%-50%; n = 10) limbs, the nerve ran deep to the ALDDFT. An additional branch from the LPN was noted in one limb.
MAIN LIMITATIONS
Limbs were used from horses with unknown clinical history.
CONCLUSIONS
Anatomical variation, in particular the relationship of the DBLPN and deep metatarsal fascia to the deep plantar arch and the ALDDFT is an important consideration when undertaking surgical approaches to the proximal plantar metatarsal region.
PubMed: 34569652
DOI: 10.1111/evj.13507 -
Modern Pathology : An Official Journal... Mar 2020Lipomatosis of nerve is a rare malformation characterized by a fibrolipomatous proliferation within peripheral nerve. Lipomatosis of nerve most frequently involves the...
Lipomatosis of nerve is a rare malformation characterized by a fibrolipomatous proliferation within peripheral nerve. Lipomatosis of nerve most frequently involves the median nerve, and manifests clinically as a compressive neuropathy. However, 30-60% of cases are associated with tissue overgrowth within the affected nerve's territory (e.g., macrodactyly for lipomatosis of nerve in the distal median nerve). Somatic activating PIK3CA mutations have been identified in peripheral nerve from patients with lipomatosis of nerve with type I macrodactyly, which is now classified as a PIK3CA-related overgrowth spectrum disorder. However, the PIK3CA mutation status of histologically confirmed lipomatosis of nerve, including cases involving proximal nerves, and cases without territory overgrowth, has not been determined. Fourteen histologically confirmed cases of lipomatosis of nerve involving the median (N = 6), brachial plexus (N = 1), ulnar (N = 3), plantar (N = 2), sciatic and superficial peroneal nerves (N = 1 each) were included. Ten cases had nerve territory overgrowth, ranging from macrodactyly to hemihypertrophy; and four cases had no territory overgrowth. Exome sequencing revealed "hotspot" activating PIK3CA missense mutations in 6/7 cases. Droplet digital polymerase chain reaction for the five most common PIK3CA mutations (p.H1047R, p.H1047L, p.E545K, p.E542K, and p.C420R) confirmed the exome results and identified an additional six cases with mutations (12/14 total). PIK3CA mutations were found in 8/10 cases with territory overgrowth (N = 7 p.H1047R and N = 1 p.E545K), including two proximal nerve cases with extremity overgrowth, and 4/4 cases without territory overgrowth (p.H1047R and p.H1047L, N = 2 each). The variant allele frequency of PIK3CA mutations (6-32%) did not correlate with the overgrowth phenotype. Three intraneural lipomas had no detected PIK3CA mutations. As PIK3CA mutations are frequent events in lipomatosis of nerve, irrespective of anatomic site or territory overgrowth, we propose that all phenotypic variants of this entity be classified within the PIK3CA-related overgrowth spectrum and termed "PIK3CA-related lipomatosis of nerve".
Topics: Adult; Cell Proliferation; Child; Child, Preschool; Class I Phosphatidylinositol 3-Kinases; DNA Mutational Analysis; Female; Genetic Predisposition to Disease; Humans; Infant, Newborn; Lipomatosis; Male; Mutation; Peripheral Nerves; Peripheral Nervous System Diseases; Phenotype; Polymerase Chain Reaction; Terminology as Topic; Exome Sequencing
PubMed: 31481664
DOI: 10.1038/s41379-019-0354-1 -
Clinical Neurophysiology : Official... Apr 2008Clinical utility of nerve conduction studies (NCS) of the medial plantar and dorsal sural nerves in the early detection of polyneuropathy have already been shown...
OBJECTIVE
Clinical utility of nerve conduction studies (NCS) of the medial plantar and dorsal sural nerves in the early detection of polyneuropathy have already been shown separately. However, at present, there is no data about the combined assessment of these two nerves in distal sensory neuropathy. In the present study, we aimed to evaluate the medial plantar and dorsal sural NCS in a group of diabetic patients with distal sensory neuropathy (DSN) and in healthy controls.
METHODS
Thirty healthy and 30 diabetic adult patients were included. In all subjects, peripheral motor and sensory NCS were performed bilaterally with surface electrodes on the lower limbs including medial plantar and dorsal sural nerves. In addition, motor and sensory nerves were studied unilaterally on the upper limb.
RESULTS
In all patients, nerve action potential (NAP) amplitudes of sural and superficial peroneal nerves were within normal ranges, but in the patient group mean value was significantly lower than in the controls. Among clinically defined 30 DSN patients, medial plantar NAP amplitude was abnormal in 18 (60%) and dorsal sural nerve amplitude was abnormal in 13 (40%) of the patients bilaterally. Additionally, the onset NCV of the dorsal sural nerve was significantly slower in patients than controls (P=0.038). Evaluation of both of these nerves increased the sensitivity up to 70% in the detection of neuropathy.
CONCLUSIONS
Bilateral NCS assessment of both of the medial plantar and dorsal sural nerves together increases the rate of diagnosis of diabetic distal sensory neuropathy compared to assessment of either of these nerves.
SIGNIFICANCE
Assessment of medial plantar in addition to dorsal sural NCS together increases the sensitivity in the detection of neuropathy and allows earlier diagnosis, especially when routine NCS are normal.
Topics: Action Potentials; Diabetic Neuropathies; Electromyography; Humans; Middle Aged; Neural Conduction; Sural Nerve; Tibial Nerve
PubMed: 18291716
DOI: 10.1016/j.clinph.2008.01.001 -
Foot & Ankle International Jul 2004A retrospective review was conducted of 23 patients (26 feet) to assess operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor...
A retrospective review was conducted of 23 patients (26 feet) to assess operative outcome of partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle for recalcitrant plantar fasciitis. Nonsurgical treatment was implemented in all patients with no relief of symptoms (average 20.8 months) prior to surgery. Using a visual analog pain scale (0-10), the average preoperative pain was 9.2 (range, 8-10). Prior to surgery, 65.2% of patients had severe limitations of activity, and 34.8% of patients had moderate limitations of activity. An average 25.3-month follow-up (range, 8-51) was performed by telephone interview. Average postoperative pain decreased to 1.7 using the same visual analog scale. Thirteen patients (57%) had no functional limitations postoperatively and nine patients (39%) had minimal functional limitations postoperatively. One patient (4%) had moderate functional limitations postoperatively. Twenty patients (87%) were completely satisfied with the surgery, two patients (9%) were satisfied with reservations, and one patient (4%) was unsatisfied with the surgery. The average period before return to work or daily activities was 1.5 months. Two patients had minor complications of partial wound dehiscence that healed uneventfully and mild dorsal midfoot pain which required temporary use of a boot walker. While the majority of patients with plantar fasciitis can be managed with nonoperative treatment, those patients with recalcitrant plantar fasciitis can be effectively treated with partial plantar fasciectomy and neurolysis to the nerve of the abductor digiti minimi muscle.
Topics: Adult; Combined Modality Therapy; Fasciitis, Plantar; Fasciotomy; Female; Humans; Male; Middle Aged; Muscle, Skeletal; Peripheral Nerves; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 15319106
DOI: 10.1177/107110070402500707 -
Plastic and Reconstructive Surgery Oct 2009The anatomical basis for the surgical techniques used to treat tarsal tunnel syndrome is not well studied. The authors sought to evaluate their hypotheses that (1)...
BACKGROUND
The anatomical basis for the surgical techniques used to treat tarsal tunnel syndrome is not well studied. The authors sought to evaluate their hypotheses that (1) pronation and pronation with plantar flexion of the intact foot would have higher pressures than the intact foot in other positions; (2) decompression surgery would significantly lower the pressure in all three tunnels in all foot positions, and roof incision plus septum excision would lower the pressure further in some positions; and (3) the pressures in symptomatic patients would be significantly higher than those in an analogous cadaver study.
METHODS
In 10 patients with tarsal tunnel syndrome, the authors intraoperatively measured pressures in the tarsal, medial plantar, and lateral plantar tunnels in multiple foot positions before and after excision of the tunnel roofs and intertunnel septum.
RESULTS
The authors found that (1) pronation and plantar flexion significantly increased pressures in the medial and lateral plantar tunnels, to levels sufficient to cause chronic nerve compression; (2) tunnel release and septum excision significantly decreased those pressures; and (3) compared with cadaver pressures, patients had similar tarsal tunnel pressures but higher lateral plantar tunnel pressures in some positions.
CONCLUSIONS
Many surgeons operating on patients with tarsal tunnel syndrome do not decompress the respective medial plantar and lateral plantar nerves and excise the septum. The authors' study validates the hypotheses that patients who are clinically suspected of having chronic compression of the tibial nerve and its branches at the ankle have higher tunnel pressures and that releasing these structures decreases the pressures.
Topics: Adult; Aged; Cadaver; Decompression, Surgical; Female; Humans; Intraoperative Period; Male; Middle Aged; Posture; Pressure; Prospective Studies; Tarsal Tunnel Syndrome; Tibial Nerve
PubMed: 19935304
DOI: 10.1097/PRS.0b013e3181b5a3c3 -
Electromyography and Clinical... 2010The purpose of this study was to determine the most sensitive diagnostic test for nerve conduction study (NCS) of the foot for early detection of diabetic... (Comparative Study)
Comparative Study
The purpose of this study was to determine the most sensitive diagnostic test for nerve conduction study (NCS) of the foot for early detection of diabetic polyneuropathy. We compared the sensitivities for diagnosis of sensory polyneuropathy of four different nerve conduction techniques in the same nerves: nerve conduction studies of the medial plantar nerve with surface electrodes using three different techniques and a nerve conduction study of the digital and interdigital nerves of the foot using a near-nerve needle technique. In 25 patients with diabetic polyneuropathy with normal routine NCS, diagnosis of sensory neuropathy was confirmed by medial plantar NCS in 5 patients (20.0%) using Guiloff's method, in 5 patients (20.0%) using Ponsford's method and in 9 patients (36.0%) using Hemmi's method. In digital and interdigital NCS of the foot, a definite neuropathy pattern was observed in 15 patients (60.0%). The most common abnormality was low amplitude of sensory nerve action potential, indicating axonal degeneration. This study demonstrated that digital and interdigital NCS using the near-nerve needle technique is a more sensitive method for detection of early-stage diabetic polyneuropathy.
Topics: Adult; Aged; Chi-Square Distribution; Diabetic Foot; Diabetic Neuropathies; Female; Humans; Male; Middle Aged; Needles; Neural Conduction; Physical Stimulation; Sensitivity and Specificity
PubMed: 21061773
DOI: No ID Found -
Muscle & Nerve Feb 2022Nerve conduction studies (NCS) are widely used in diagnosing diabetic polyneuropathy. Combining the Z scores of several measures (Z-compounds) may improve diagnostics by...
INTRODUCTION/AIMS
Nerve conduction studies (NCS) are widely used in diagnosing diabetic polyneuropathy. Combining the Z scores of several measures (Z-compounds) may improve diagnostics by grading abnormality. We aimed to determine which combination of nerves and measures is best suited for studies of diabetic polyneuropathy.
METHODS
Sixty-eight patients with type 1 diabetes and 35 controls were included in this study. NCS measurements were taken from commonly investigated nerves in one arm and both legs. Different Z-compounds were calculated and compared with reference material to assess abnormality. A sensitivity proxy, the accuracy index (AI), and Cohen's d were calculated.
RESULTS
Z-compounds with the highest AI consisted of the tibial and peroneal motor, and the sural, superficial peroneal, and tibial medial plantar sensory nerves in one or two legs. All Z-compounds were able to discriminate between diabetic subjects and nondiabetic controls (mean Cohen's d = 1.42 [range, 1.03-1.63]). The association between AI and number of measures was best explained logarithmically (R = 0.401), with diminishing returns above approximately 14 or 15 measures. F-wave inclusion may increase the AI of the Z compounds. Although often clinically useful among the non-elderly, the additional inclusion of medial plantar NCS into Z-compounds in general did not improve AI.
DISCUSSION
Performing unilateral NCS in several motor and sensory lower extremity nerves is suited for the evaluation of polyneuropathy in diabetic patients. The use of Z-compounds may improve diagnostic accuracy in diabetic polyneuropathy and may be particularly useful for follow-up research studies as single summary measures of NCS abnormality development over time.
Topics: Diabetes Mellitus; Diabetic Neuropathies; Humans; Middle Aged; Neural Conduction; Neurologic Examination; Peroneal Nerve; Polyneuropathies; Sural Nerve; Tibial Nerve
PubMed: 34687224
DOI: 10.1002/mus.27445 -
Folia Morphologica 2023Considerable variations have been reported regarding the branching pattern of tibial nerve (TN) close to its termination in foot. In order to comprehend the clinical... (Review)
Review
Considerable variations have been reported regarding the branching pattern of tibial nerve (TN) close to its termination in foot. In order to comprehend the clinical anatomy of heel pain awareness of all the possible variations in relation to terminal branching pattern of TN (close to the tarsal tunnel) is essential. The present study was conducted to undertake a comprehensive review of the variations in TN branches in foot with particular emphasis on the implications for sensory distribution of these branches. Articles were searched in major online indexed databases using relevant key words. The pattern of termination of TN was noted as either trifurcation or bifurcation. Bifurcation pattern was more commonly observed and is associated with the medial calcaneal nerve (MCN) either arising high or low relative to the tarsal tunnel. The most commonly noted type of bifurcation was proximal to malleolar-calcaneal axis but within the tarsal tunnel. Across all five types of bifurcation reported in literature, the termination points of TN ranged from 3 cm proximal to 3 cm distal to malleolar-calcaneal axis and, therefore, the area beyond this region can be considered as safe zone for performing invasive procedures. MCN showed considerable variations in its origin both in trifurcation and bifurcation pattern pertaining to number of branches (one/two/three) at the point of origin. The origin of inferior calcaneal nerve was observed to be relativelyless variable as it mostly arose as a branch of lateral plantar nerve and sometimes as a direct branch from TN before termination. The frequent variation of MCN in the tarsal tunnel should be kept in mind while undertaking decompression measures in medial ankle region.
Topics: Humans; Foot; Tibial Nerve; Calcaneus; Pain
PubMed: 35481703
DOI: 10.5603/FM.a2022.0042 -
Foot & Ankle International Sep 2003The tibial nerve trunk and its branches were dissected in 20 embalmed cadaver legs and the relative topographic anatomy was defined at 3-cm intervals up to 15 cm...
The tibial nerve trunk and its branches were dissected in 20 embalmed cadaver legs and the relative topographic anatomy was defined at 3-cm intervals up to 15 cm proximal to the medial malleolar-calcaneal (MMC) axis. Each nerve branch was found in various locations. The calcaneal nerve was found to descend from medial to posteromedial. It was never found anterolaterally and only rarely laterally. The lateral plantar nerve was found to rotate externally from lateral and posterolateral to lateral and posteromedial as it descends. This nerve was not found medially or anteromedially. The first branch of the lateral plantar nerve was indistinguishable from the trunk of the tibial nerve descending medially to between the lateral plantar and calcaneal nerves. The overall pattern of the medial plantar nerve was an internal rotation from anteromedial (proximal) to anterior (distally). It was not found posteriorly. The flexor hallucis longus motor branch was located an average of 17.9 cm (range, 10-24 cm) proximal to the MMC axis. Preliminary application of these data has facilitated surgical dissection and afforded an understanding of how tibial nerve trunk pathology correlates with clinical manifestations.
Topics: Cadaver; Foot; Humans; Tibial Nerve
PubMed: 14524520
DOI: 10.1177/107110070302400908 -
Journal of Clinical Neurophysiology :... Oct 2009The reliability of medial plantar, sural, and superficial peroneal nerve conduction studies (NCS) has not been widely studied. These nerves are usually involved in...
UNLABELLED
The reliability of medial plantar, sural, and superficial peroneal nerve conduction studies (NCS) has not been widely studied. These nerves are usually involved in distal sensory neuropathies and their serial study is relevant in the clinical setting.
PURPOSE
To determine the inter- and intrarater reliability of superficial peroneal, sural, and medial plantar NCS in healthy participants.
METHODS
Two raters performed the bilateral NCS twice in 20 healthy participants (23.5 +/- 3.5 years). Reliability was analyzed by the Bland-Altman method and intraclass correlation coefficient (ICC). Variability was established by the coefficient of variation.
RESULTS
The Bland-Altman method showed a good level of intra- and interrater agreement for all nerves. The amplitude (rater 1) and latency of the medial plantar nerve and the amplitude of the sural nerve (rater 2) had an intrarater ICC of >or=0.75. Interrater analysis showed concordance levels between moderate and very low. The highest coefficients of variations were found for amplitude and the lowest for nerve conduction velocity.
CONCLUSIONS
Although the Bland-Altman method confirmed a good intra- and interrater reliability of the studied nerves, ICC analyses showed mixed results. These statistical approaches are complementary, and each one has advantages and disadvantages that must be considered in their application and interpretation.
Topics: Action Potentials; Adolescent; Adult; Electric Stimulation; Electrodes; Female; Health Status; Humans; Male; Neural Conduction; Observer Variation; Peroneal Nerve; Reproducibility of Results; Skin Temperature; Sural Nerve; Tibial Nerve; Time Factors; Young Adult
PubMed: 19752742
DOI: 10.1097/WNP.0b013e3181baaaea