LE nerve pathology

ajkim1's version from 2015-05-08 12:09


Question Answer
Localization?Ability to define location of a neurologic lesion based on the physical exam of a patient
Types of entrapmentAnatomic, function, and iatrogenic
What is associated with anatomic entrapment?Canals/foramina, ligaments/retinacula, fascia
What is associated with functional entrapment?Increased compartmental pressures, muscle function, foot function
What is associated with iatrogenic entrapment?Scar tissue
Positive Sullivan's signToes will separate looking like a peace sign due to enlarging neuroma
Sullivan's sign indicationMorton's neuroma in 3rd interspace
How do we test for Sullivan's sign?Press 3rd interspace while moving MT heads up and down
Mulder's sign/click indicationNeuroma
Positive Mulder's sign/clickPalpable click (usually painful) at the site of the neuroma
How do we test for a Mulder's sign/click?Apply medial/lateral compression to the MT heads and plantar/dorsal pressure to the 3rd intermetatarsal space to feel for soft tissue
Positive Gauthier's testPain of sensory abnormality
How do we test for Gauthier's test?Compress MT heads and actively dorsiflex/plantarflex toes for 30 seconds
Tinel's sign indicationEntrapped nerve
How do we test for Tinel's signPercuss the nerve
Positive Tinel's signDistal tingling sensation
Villeaux's phenomenon indicationMore proximal pathology
How do we test for Villeaux's phenomenon?Percuss the nerve
Positive Villeaux's phenomenonProximal tingling sensation
Purpose of NCVMeasures electrical activity of the nerves of the body
4 components of an NVCSenosry, motor, F wave, H reflex
Sensory component of NCVSensory component of the nerve in the limb
LatencyTime it takes for the electricity to travel from stimulation site to recording site
AmplitudeSize of the response
Motor component of NCVMotor component of the nerve in the limb
F wave component of NCVSupramaximal stimulation of motor nerve and a measure of the resulting action potential, conduction velocity between the spinal cord, and the limb
Is the F wave a reflex?No
How does electricity travel in F wave?Site of stimulation through ventral horn and to the muscle
H reflex component of NCVElectrical discharge of the muscle, stimulating the nerve distally, connection between the limb and the spinal cord
Is the H reflex a reflex?Yes
4 ways to treat nerve pathology (broad)Alleviate external pressure/friction, topical medications, injections, release the entrapment
Topical medications for nerve pathologyCapsaicin cream and compounded medications
Capsaicin creamPatient must be compliant and the results are dependent upon the capsaicin sensitive C-fiber afferents
Oral medications for nerve pathologyLyrica (Pregabalin), Cymbalta, (Duloxetine delayed-release capsules), Neurontin (Gabapentin), Savella (Milnacipran)
Injections for nerve pathologyDexamethasone, Kenalog, steroids, B12, local anesthetics
NeuromaNerve tumor, or a dense proliferation of fibrous tissue and irregular proliferation of neural tissue
Process to become a Morton's neuromaDegeneration of myelinated nerve fibers with associated histopathological changes
Histological components of a Morton's neuromaEndoneural edema, abnormally abundant collagen (prolonged compression), infiltration of leukocytes (local inflammatory response), wall thickening, sclerosis of endoneurium, thickening of periosteum
Signs of a Morton's neuromaPositive Mulder's and Sullivan's sign, POP of interspace, palpable mass
Symptoms of a Morton's neuromaPain to 2 toes, pain radiating to entire FF, pain progressing to numbness, cramping, relief with shoe removal
Sufficient way of diagnosing a Morton's neuroma?Clinically
Is non-surgical management helpful for a Morton's neuroma?Not really..
Surgical methods for a Morton's neuromaOpen resection, EDINS + MINDS, cryosurgery, neurolysis
Minimally invasive surgical methods for a Morton's neuromaEDINS (endoscopic decompression of intermetatarsal neuroma) and MIND (minimally invasive nerve decompression), or releasing the DTML without resecting the nerve
CryosurgeryNO in cryoprobe tip to form an ice ball, this is stuck in the nerve
External neurolysisFreeing nerve from external adhesions, adherent fibrous tissue, and the DTML
Internal neurolysisMicrosurgical technique that separates the epineurium from perineurium and funiculi from each other
Most common technique to cure a Morton's neuromaOpen resection
Process of open resectionDorsal incision, dissect out the nerve, free from all surround tissue, resect nerve and associated bursa, flush, and close
Post-op for Morton's neuromaBandage and surgical shoe until skin is healed, limited activity for 6 wks
Complications of a Morton's neuroma resection procedureFailure of procedure, stump neuroma, vascular complications, hammertoes, splay toes
Causes of dorsal nerve entrapment?Anterior tarsal tunnel syndrome or an entrapment of the deep peroneal nerve at the dorsal MF
Anterior tarsal tunnel syndromeEntrapment of the deep peroneal nerve at the dorsal MF
Causes of anterior tarsal tunnel syndromeDorsal exostoses, dorsal osteophytes, EHB tendon, tying shoes too tight
Patient complaint with anterior tarsal tunnel syndromeTingling, burning, numbness, pain at the dorsal MF, worse with certain shoe types, alleviated with removal of certain shoes
Physical exam of anterior tarsal tunnel syndromeNeurologically intact, (+/-) Tinel's sign of the deep peroneal nerve, dorsal osteophytes across the MF
Conservative treatments for anterior tarsal tunnel syndromeShoe gear changes, orthotics to support MF, cortisone injection, topical/oral medications
Surgical treatments for anterior tarsal tunnel syndromeResection of the exostoses, release of EHB
Post-op anterior tarsal tunnel syndromeDress and surgical shoe for 7-10 days, (+/-) CAM water, loose gym shoes, activities to tolerance
Complications of anterior tarsal tunnel syndrome surgeryFurther nerve injury, vascular compromise, need for further surgery
Tarsal tunnel syndromeEntrapment of the posterior tibial nerve at the level of the flexor retinaculum/lacinate ligament
Signs of tarsal tunnel syndromeEntrapment of the medial calcaneal nerve, plantar fasciitis, radiculopathy, lower back pain
Symptoms of neurological painWorse when standing still, worse throughout the day, rest/night/positional pain, orthotics/shoes don't really help, no morning pain, severe bilateral heel pain
Causes of tarsal tunnel syndromeTenosynovitis, varicose veins, tendinopathy, ganglion cyst, hypertrophic sustentaculum coalition, thickened retinaculum, other masses
Conservative treatment of tarsal tunnel syndromeTreat plantar fasciitis and radiculopathy if it's there, oral medications, steroid/vitamin B12 injections
Post-op tarsal tunnel syndromeNWB 7-10 days, transition to AFTR brace and gym shoe, continue phase I-III treatment for plantar fasciitis
Location of common peroneal nerve entrapmentHead of the fibula
What does a common peroneal nerve entrapment cause?Sensory and motor problems
Location of a sural nerve entrapmentScar tissue
Location of a saphenous nerve entrapment1st MTPJ
RadiculopathyOne or more nerves is not working properly and the pathology originates from the nerve root and manifests as back pain, referred pain, or both
Symptoms of radiculopathyInflammation, impingement, degenerative disc disease, degenerative vertebral disease, muscle spasms
Radiculopathy treatmentNCV/EMG study, MRI/CT of spine, epidural, steroid facet injections, physical therapy, neurosurgery consult
Spinal stenosisAbnormal narrowing of the spinal canal that can lead to sensory/motor los
Symptoms of spinal stenosisLoss of sensation, loss of motor control (foot drop), pain, parasthesias
Causes of spinal stenosisHerniated discs, degenerative disc disease, degenerative vertebral disease, facet disease, tumors
Spinal stenosis diagnosisGood H&P, x-rays, MRI/CT
Spinal stenosis treatmentWeight loss, physical therapy, exercise, oral medication, epidurals
CMTHereditary sensory motor neuropathy
CMT presentationMale, peroneal and thenar weakness, bilateral cavus foot
CMT physical examinationCavus/cavo-varus foot, stork leg deformity, decreased muscular function, decreased sensorium, LOPS
CMT common problemsRigid cavo-varus deformity, hammer/clawtoes, muscle weakness, ulcerations, infection, OM
PoliomyelitisAcute, viral (poliovirus), infectious disease spread from person to person by the fecal oral route
Polio physical examUnilateral/bilateral caves foot, sensation is intact, muscular function is not
Polio treatmentBracing and/or surgical intervention