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Journal of Ultrasound in Medicine :... May 2018Ultrasonography (US) of peripheral nerves has gained wide popularity because of the increased definition of modern high-frequency electronic transducers, as well as the... (Review)
Review
Ultrasonography (US) of peripheral nerves has gained wide popularity because of the increased definition of modern high-frequency electronic transducers, as well as the well-known advantages of US, which include easy availability, low cost, and the possibility of realizing a dynamic examination. Traditionally, US has been deployed to assess the major nerves of the limbs. More recently, US has also been used to assess the normal appearance and pathologic changes of smaller subcutaneous nerves. The sural nerve is a small sensory nerve in the subcutaneous tissues of the calf that can be affected by a variety of disorders. This pictorial essay illustrates the normal anatomy of the sural nerve, the technique for its examination by US, as well as the US appearance of its main pathologic changes.
Topics: Humans; Peripheral Nervous System Diseases; Sural Nerve; Ultrasonography
PubMed: 29027686
DOI: 10.1002/jum.14444 -
Turkish Journal of Medical Sciences Apr 2021The aim of the present study was to determine the course and possible variations of the sural nerve with all anatomical details in human fetal cadavers.
BACKGROUND/AIM
The aim of the present study was to determine the course and possible variations of the sural nerve with all anatomical details in human fetal cadavers.
MATERIALS AND METHODS
This study was performed on 60 fetal cadavers. Formation type and level of the sural nerve was detected.
RESULTS
According to trimesters, it was determined that the mean transverse and vertical distance between the lowest point of the LM and the SN varied between 1.1 and 2.9 mm and 1.54 and 3.58 mm, respectively. Type 2 was the most common seen type of sural nerve (35.83%). It was determined that the sural nerve was mostly formed at the middle third of the leg (42.5%).
CONCLUSION
Sural nerve graft with the knowledge of the anatomical details may be used for peripheral nerve reconstruction is required in congenital lesions, such as facial paralysis, obstetric brachial paralysis, and posttraumatic lesions in infants and children.
Topics: Cadaver; Child; Dissection; Female; Fetus; Gestational Age; Humans; Infant; Leg; Male; Peripheral Nerve Injuries; Pregnancy; Pregnancy Trimesters; Plastic Surgery Procedures; Sural Nerve
PubMed: 32718120
DOI: 10.3906/sag-2005-225 -
Atlas of the Oral and Maxillofacial... Mar 2023Cross-face nerve grafting (CFNG) allows for spontaneous, involuntary facial movement for patients with irreversible hemifacial paralysis. This technique uses an intact... (Review)
Review
Cross-face nerve grafting (CFNG) allows for spontaneous, involuntary facial movement for patients with irreversible hemifacial paralysis. This technique uses an intact contralateral facial nucleus and nerve as an input and axon source, allowing donor neural input to be routed through a nerve graft across the face. The sural nerve is well equipped for use as a nerve graft due to its length and minimal donor site morbidity. Endoscopic nerve harvest techniques allow for efficient, minimally invasive dissection that improves the integrity of the harvested nerve.
Topics: Humans; Endoscopy; Facial Paralysis; Facial Transplantation; Neurosurgical Procedures; Sural Nerve
PubMed: 36754504
DOI: 10.1016/j.cxom.2022.09.003 -
Plastic and Reconstructive Surgery Apr 2013The sural nerve is commonly used as donor for nerve grafting. Contrary to its constant retromalleolar position, formation and course of the proximal sural nerve show... (Review)
Review
BACKGROUND
The sural nerve is commonly used as donor for nerve grafting. Contrary to its constant retromalleolar position, formation and course of the proximal sural nerve show great variability. The coexistence of different and deceptive terminologies contributes to the complexity, and reviewing the international literature is confusing. Because detailed anatomical knowledge is essential for efficient and safe sural nerve harvesting, this study aims to bring clarity.
METHODS
Previous sural nerve reports listed in the PubMed database and established anatomical textbooks were reviewed. Different terminologies were compared and adjusted. Anatomical details and variations were noted. Subtle prospective anatomical dissections and comparison with actual data followed.
RESULTS
Two hundred twenty-one relevant reports were identified and worked up going back to the nineteenth century. Fourteen established German and English language anatomical textbooks were reviewed. Thirty lower limbs were dissected. In total, this study pools the information of more than 2500 sural nerves.
CONCLUSIONS
This study covers all information about the sural nerve anatomy published internationally. The coexistence of different and confusing terminologies is pinpointed and adjusted to allow comparison of previous reports and to gain a coordinated data pool of more than 2500 investigated sural nerves. Detailed features are clearly described and summarized, findings from the authors' own prospective dissections complete these data, and the prior existing anatomical confusion is resolved. Finally, clinical implications are described.
Topics: Cadaver; Female; Humans; Male; Sural Nerve
PubMed: 23542252
DOI: 10.1097/PRS.0b013e3182818cd4 -
Muscle & Nerve Jun 2019Ultrasound can potentially identify nerves and guide recording and stimulating electrode placement for nerve conduction studies (NCS). This prospective study was...
INTRODUCTION
Ultrasound can potentially identify nerves and guide recording and stimulating electrode placement for nerve conduction studies (NCS). This prospective study was performed to determine whether ultrasound guidance of sural NCS results in higher action potential amplitude, fewer stimuli required, lower stimulus strength required, and less pain experienced.
METHODS
Fourteen healthy individuals underwent bilateral sural NCS, both with and without ultrasound guidance. Studies were separated by at least 48 h, and the order of testing was randomly assigned.
RESULTS
Ultrasound guidance resulted in significantly fewer stimuli and lower stimuli strength required to obtain supramaximal responses (P < 0.01-0.03). Ultrasound guidance required significantly more time to perform than standard sural NCS (P < 0.01). There was no difference in sural nerve amplitude or pain rating between the 2 groups.
DISCUSSION
Neuromuscular ultrasound can be used effectively to guide electrode placement during sural NCS. Muscle Nerve 59:705-707, 2019.
Topics: Adult; Diagnostic Techniques, Neurological; Female; Healthy Volunteers; Humans; Male; Middle Aged; Neural Conduction; Pain, Procedural; Sural Nerve; Time Factors; Ultrasonography
PubMed: 30868637
DOI: 10.1002/mus.26465 -
Journal of Neurological Surgery. Part... Mar 2014Sural nerve has the favorite length and size for nerve graft interposition. Here two techniques, that is, "stocking seam" and "stair-step" or "stepladder," have been...
BACKGROUND
Sural nerve has the favorite length and size for nerve graft interposition. Here two techniques, that is, "stocking seam" and "stair-step" or "stepladder," have been used for harvesting sural nerve. The first technique results in an unsightly scar at the posterior calf, and the latter one takes a long time to perform and exert undue traction to the graft during harvesting. The purpose of this article is to describe our experience in harvesting the sural nerve by a nerve stripper.
PATIENTS AND METHODS
A nerve stripper was used for harvesting sural nerve in 35 adult patients (in 6 patients, sural harvesting was done bilaterally), 27 men and 8 women. Thirty-one sural nerve harvests were done by closed technique (i.e., harvesting of sural nerve only by two incisions, one in the posterior of the lateral malleolus and the other in popliteal fossa), in 8 others by limited open technique, and in 2 cases, there was early laceration of the sural nerve at the beginning of the study. The contralateral sural nerve was harvested in one patient and medial antebrachial nerve in another by open technique.
RESULTS
The mean length of the retrieved sural nerve was 34.5 cm in the closed technique group and 35 cm in the limited open technique group. We detected advancing Tinel's sign in all nerve stripper-assisted sural nerve harvested group members in both the closed and limited open groups.
CONCLUSION
Sural nerve harvesting by the nerve stripper is a reliable and simple technique, and it is applicable as a routine technique. Applying controlled rotatory movements of the nerve stripper instead of pushing can result in satisfactory harvesting of the sural nerve without early laceration.
Topics: Adolescent; Adult; Child; Female; Humans; Male; Nerve Transfer; Sural Nerve; Tissue and Organ Harvesting; Treatment Outcome; Young Adult
PubMed: 23397128
DOI: 10.1055/s-0032-1330117 -
Microsurgery Nov 2023Sural nerve harvest causes paraesthesia to the lateral heel of the foot, which can debilitate those with already compromised proprioception. To circumvent this, we...
INTRODUCTION
Sural nerve harvest causes paraesthesia to the lateral heel of the foot, which can debilitate those with already compromised proprioception. To circumvent this, we investigated an alternative donor nerve, branch of the lateral sural nerve complex called the sural communicating nerve (SCoNe), for its harvest and use as a vascularized nerve graft, in cadaver.
METHODS
The SCoNe was visualized by dissection in 15 legs from 8 human cadavers and the relationship of the SCoNe to the overall sural nerve complex was documented. The surface markings, dimensions, and the micro-neurovascular anatomy in the super-microsurgery range (up to 0.30 mm) of the SCoNe was recorded and analyzed.
RESULTS
SCoNe graft surface marking was confined within a triangle drawn between the fibular head laterally, the popliteal vertical midline medially and the tip of the lateral malleolus inferiorly. The proximal end of the SCoNe was situated at a mean intersection distance of 5 cm from both the fibular head and popliteal midline respectively. The mean length of the SCoNe was 226 ± 43 mm with a mean proximal diameter of 0.82 mm and mean distal diameter of 0.93 mm. In 53% of the cadavers, an arterial input was present in the proximal third of the SCoNe and veins were predominantly (87%) present in the distal third. In 46% and 20% of the 15 legs respectively, there was a nutrient artery and vein perfusing the SCoNe in its central segment. The external mean diameter of this artery was 0.60 ± 0.30 mm, while the vein was slightly larger with a mean diameter of 0.90 ± 0.50 mm.
DISCUSSION
SCoNe graft may preserve lateral heel sensation, compared to sural nerve harvest, pending clinical studies. It may have wide applications as a vascularized nerve graft, including being ideal as a vascularized cross-facial nerve graft because its nerve diameter is similar to the distal facial nerve branches. The accompanying artery is a good anastomotic match to the superior labial artery.
Topics: Humans; Sural Nerve; Leg; Peripheral Nerves; Lower Extremity; Cadaver
PubMed: 37226423
DOI: 10.1002/micr.31068 -
Journal of Plastic, Reconstructive &... Nov 2021Understanding the morbidity of sural nerve harvest is important when counselling patients regarding nerve grafts. Existing data consist of small studies with varying...
BACKGROUND
Understanding the morbidity of sural nerve harvest is important when counselling patients regarding nerve grafts. Existing data consist of small studies with varying degrees of follow-up and a wide range of reported donor site outcomes. The objective of this study was to systematically review the literature and pool the current data for postoperative outcomes after sural nerve graft harvest.
METHODS
A systematic review of literature was conducted to identify studies that examined donor site outcomes of sural nerve graft harvests.
RESULTS
Five-hundred and fourteen studies were identified through a literature search, and nine studies met inclusion criteria. There were 240 patients who underwent sural nerve grafts. The most common methods for sensory evaluation were patient survey (44.4%) and Semmes-Weinstein evaluation (33.3%). Five studies reported surface areas of sensory loss, and this generally decreased over time after sural nerve grafting. Overall, 87.2% of patients (n = 190) reported sensory loss, 25.6% (n = 42) of patients reported pain, 22.2% (n = 28) of patients reported cold sensitivity, and 10% (n = 20) of patients reported functional impairment at follow-up. When the proximal sural nerve was spared during harvest, the extent of sensory loss and pain were less than harvest at the popliteal fossa (87.4% vs 95.7%, p = 0.0407 and 9.1% vs 35.5%, p = 0.0004, respectively).
CONCLUSIONS
In this study, we present the extent of sensory loss and rates of pain, cold sensitivity, and functional impairment after sural nerve harvest. These data should be discussed prior to surgery in order for patients and surgeons to make an informed decision.
Topics: Humans; Neurosurgical Procedures; Pain Measurement; Postoperative Complications; Sensation Disorders; Sural Nerve; Tissue and Organ Harvesting; Transplant Donor Site
PubMed: 33985927
DOI: 10.1016/j.bjps.2021.03.096 -
Annals of Anatomy = Anatomischer... Nov 2015The sural nerve (SN) is a sensory nerve in the lower extremity which branches to supply the skin on the distal posterolateral third of the lower limb. Typically, the... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The sural nerve (SN) is a sensory nerve in the lower extremity which branches to supply the skin on the distal posterolateral third of the lower limb. Typically, the medial sural cutaneous nerve (MSCN) and the peroneal communicating nerve (PCN) unite to form the SN. Other variations in the formation, course, and morphometry of the SN have also been described in the literature.
OBJECTIVE
To study anatomical variations in the formation and course of the SN and establish a new classification system for formation patterns of the SN.
METHODS
A systematic search of all major databases identified articles that studied the prevalence of variations in the formation of the SN. No date or language restrictions were set. Anatomical data was extracted according to our new classification system where the SN is formed by: union of the MSCN and the PCN (Type 1); union of the MSCN and the Lateral Sural Cutaneous Nerve (LSCN) (Type 2); continuation of the MSCN with absent PCN (Type 3); the PCN alone (Type 4); the LSCN (Type 5); or the Sciatic Nerve (SCN) directly (Type 6). Pooled prevalence rates were calculated using MetaXL 2.0.
RESULTS
A total of 39 studies (n=3974 limbs) were included in the meta-analysis. The most common patterns were Type 1, Type 3, and Type 2 with a pooled prevalence of 51.5% (95% CI: 0.293-0.591), 31.2% (95% CI: 0.143-0.410), and 13.8% (95% CI: 0.035-0.234), respectively. The rest of the patterns were rare, with pooled prevalence of Types 4, 5, and 6 calculated to be 1.8% (95% CI: 0-0.063), 1.1% (95% CI: 0-0.050), and 0.7% (95% CI: 0-0.041), respectively. In 83.7% (95% CI: 0.765-0.899) of limbs, the site of union was in the lower half of the lower extremity. The pooled mean length of the SN from the formation to the lateral malleolus was 14.78 (±5.76) cm, while the mean diameter of the SN was 0.28 (±0.03) cm.
CONCLUSIONS
Anatomical variations in the formation and course of the SN are common in the population. Clinicians, especially surgeons, should be aware of these variations to avoid iatrogenic injury to the nerve during operative procedures.
Topics: Humans; Leg; Lower Extremity; Peroneal Nerve; Skin; Sural Nerve
PubMed: 26342158
DOI: 10.1016/j.aanat.2015.08.002 -
Annals of Anatomy = Anatomischer... Nov 2021The sural nerve (SN) is a cutaneous sensory nerve innervating the posterolateral leg. The SN is formed from a highly variable set of contributing nerves called the sural...
BACKGROUND
The sural nerve (SN) is a cutaneous sensory nerve innervating the posterolateral leg. The SN is formed from a highly variable set of contributing nerves called the sural nerve complex (SNC). The SNC is made up of the lateral sural cutaneous nerve, medial sural cutaneous nerve, sural communicating branch, and SN. The SN is frequently cited as the most common donor nerve graft and is commonly injured in procedures of the lower extremity. Recent meta-analysis standardized six morphologies of the SNC and established a required reporting criterion for the group of nerves forming the SN. Due to the inconsistencies in previous literature, this study will group observed SNC's by one of these six SNC morphologies to assess and validate the meta-analysis grouping criteria. This study will also collect the same morphometric data previously outlined in order to grow the number of samples that are reported in a standardized fashion.
METHODS
100 formalin and 4 Theil preserved cadavers (n = 208) lower limbs were bilaterally dissected at Kansas City University and Creighton University School of Dentistry to observe the SNC in its entirety on the posterolateral leg. Anatomic data was captured utilizing the standardized morphologies types 1-6 with two sub-typing. Nerves that were found to be outside of this categorization were placed in an unassigned grouping.
RESULTS
The most prevalent SNCs were type 1 at 41.35% (n = 86) and type 3 nerves at 34.62% (n = 72). Type 2 was found 8.65% (n = 18), type 4 and 5 were found each at 0.48% (n = 1). Type 6 was not observed. When comparing the present studies frequency of nerve types 1-6 to the meta-analysis a sub-grouping of "North American" cadaveric studies a X = .903 p = .030 was found. Two distinct and previously unassigned formations of the SNC were 10.58% (n = 20) and 3.85% (n = 8) of data. These two SNC are termed type 7 & 8, these represent two formations of SN that are outside of what was previously reported. 15.87% (n = 33) did not match visual descriptions based on nerve origin of a type 1 SNC but met written definitions. These were termed type 1A1 and type 1A2. The SNC was asymmetrical in 57.69% (n = 120). The pooled mean length of the SN was 32.97 ± 14.12 cm (31.05-34.88), mean diameter was 2.31 ± 0.83 mm (2.20-2.42, and the distance of the posterior border of the lateral malleolus to the SN was found to be 1.72 ± 0.70 cm (1.63-1.80).
CONCLUSION
Anatomic variation in the SNC is highly variable, yet is consistent with previously observed literature. This study demonstrates two unaccounted formations of the SNC as well as two additional subcategories of SNC that were not included in the previous meta-analysis. These four variants warrant inclusion as standard formations of the SNC due to the high prevalence observed in this study as well as historical consistency observed in previous literature and case reports. These two SNC formations increase the risk of iatrogenic injury during surgical interventions of the lower extremity. Morphometric data describing the spatial relationship of this nerve complex on the posterolateral leg is consistent with previously reported data and aids in generating a large data set for future studies to characterize spatial properties of this nerve complex.
Topics: Cadaver; Fibula; Humans; Leg; Lower Extremity; Sural Nerve
PubMed: 33932499
DOI: 10.1016/j.aanat.2021.151742