DIAGNOSIS AND TREATMENT OF PERIPHERAL NERVE ENTRAPMENTS AND NEUROPATHY Foreword Vincent J. Mandracchia xi Preface Babak Baravarian xv From There to Here: A Personal Viewpoint after Three Decades of Neuropathy Research 497 A. Lee Dellon Currently there is unprecedented interest in research, writing, and clinical experience related to lower extremity peripheral nerve surgery. Its time is here, now. Application of the concepts for diagnosis and treatment of nerve compression, painful neuroma, and neuropathy has been a direct extension from the upper extremity to the lower extremity. By the end of 2005, there were more than a dozen studies demonstrating that the basic neuropathy causes metabolic changes that render the peripheral nerve susceptible to chronic nerve compressions. My hypothesis continues to assert that surgical decompression of known sites of compression can relieve symptoms of neuropathy that are caused by superimposed nerve compressions. Conservative Treatment of Peripheral Neuropathy and Neuropathic Pain 509 David A. Francis, Anne T. Christopher, and Bradley D. Beasley There are many types of peripheral nerve disorders that lead to peripheral neuropathy. Symptoms associated with peripheral neuropathy lack consistent, easy to treat qualities, and provide a VOLUME 23 Æ NUMBER 3 Æ JULY 2006 v
constant challenge for physicians who encounter the sequelae of neuropathy. This review discusses medications, nutritional supplements, and topical and physical modalities that are effective in treating neuropathy associated with diabetes. Electromyography and Nerve Conduction Studies of the Lower Extremity: Uses and Limitations 531 William G. Buxton and Justin E. Dominick Electrodiagnostic testing (EDX), the combination of electromyography and nerve conduction studies, is a useful extension of the physical exam. In the proper clinical context, it can help distinguish between the various nerve processes that may contribute to foot pain. This article discusses those processes, their clinical presentation, and the relative usefulness of EDX for each. Quantitative Sensory Testing 545 David Soomekh The diagnosis and treatment of peripheral neuropathy from any cause has come to the forefront of the research community in the past few years. Both past and new diagnostic and treatment options have been and are being studied to better understand and properly treat this debilitating and sometimes devastating disease. One such advancement is the clinical use of quantitative sensory testing. To identify etiology of the neuropathy early, the testing instrument would need to identify changes throughout the course of the disease, have a normative database, and show a clear distinction between the absence or presence of disease. The pressure specified sensory device (PSSD) was developed in 1992 to painlessly investigate the cutaneous pressure thresholds quantitatively and accurately. Prognostic Ability of a Good Outcome to Carpal Tunnel Release for Decompression Surgery in the Lower Extremity 559 Christopher T. Maloney, Jr, A. Lee Dellon, Christopher Heller, Jr, and Joshua R. Olson For years, patients who were treated successfully with carpal tunnel release were told there was nothing that could be done about their lower extremity symptoms. Now that lower extremity nerve decompression has been accepted as an option to treat appropriate patients, the authors looked for correlations between a successful outcome with carpal tunnel syndrome and its predictive value of success for lower extremity nerve decompression. Data from a vi
recent study demonstrate that a good result from upper extremity peripheral nerve surgery predicts the outcome for lower extremity peripheral nerve surgery in 88% of patients, and is, therefore, information valuable for prognosis and clinical decision-making. Intermetatarsal Compression Neuritis 569 Justin Franson and Babak Baravarian Intermetatarsal compression neuritis can be a disabling condition. Individuals who don t respond well to initial treatments are left with persistent pain and frustration. The conservative approach to the treatment of neuromas includes shoe modifications, padding, orthotics, cortisone injections, and serial alcohol sclerosing injections. When a person has failed conservative treatment for a forefoot neuroma, surgery can be considered to alleviate pain and treat the condition. This article describes several different surgical approaches such as neurectomy, carbon dioxide laser, and neurolysis. Results to date show that decompression is similar to neurectomy surgery, if not more successful. Endoscopic Nerve Decompression 579 Stephen L. Barrett Endoscopic decompression for forefoot nerve entrapments is discussed in this article from not only the perspective of preoperative indications, intraoperative technique, and postoperative management, but with reference to the changing paradigm for management of this condition. Surgical results are discussed and compared with other published reports. Complications of the surgical technique are also discussed, which will give the operating surgeon a frame of reference when comparing decompression procedures to those techniques involving nerve resection. There is also a valuable discussion of current methods of diagnosis that may help the practitioner improve patient outcomes. Tarsal Tunnel Syndrome: A Compression Neuropathy Involving Four Distinct Tunnels 597 Justin Franson and Babak Baravarian Tarsal tunnel syndrome is a complex and often under-diagnosed or misdiagnosed condition that affects the foot and ankle. It is a compression neuropathy of the posterior tibial nerve as it passes in the anatomic tarsal tunnel in the medial ankle under flexor retinaculum. This article reviews diagnosis, conservative treatment, and surgical outcomes, which have dramatically improved with more comprehensive release of the foot nerves in addition to the tibial nerve. Internal neurolysis facilitates a second level of nerve decompression in needed cases. Physical therapy protocols have made it possible for patients to return to ambulation with limited longterm down time. vii
Anterior Tarsal Tunnel Syndrome 611 Lawrence A. DiDomenico and Eric B. Masternick Compression of the deep peroneal nerve is commonly referred to as anterior tarsal tunnel syndrome. Although rare, this syndrome remains poorly diagnosed. The syndrome is characterized by pain, weakness, and sensory changes of the foot and ankle. Nonoperative measures should be attempted to reduce or remove the external compression along the anterior aspect of the foot and ankle. Other options include shoe modifications, cortisone injections, and physical therapy. If conservative management fails to relieve the symptoms, surgical decompression of the entrapped nerve can be performed. The deep peroneal nerve is released from compressive forces in the entrapment site. This can be performed at the more proximal level at the extensor retinaculum or more distally at the level of the tarsal metatarsal site. Surgical Decompression for Painful Diabetic Peripheral Nerve Compression and Neuropathy: A Comprehensive Approach to a Potential Surgical Problem 621 Babak Baravarian Diabetic nerve decompression is not for every patient. There is a definite learning curve to the surgery and recovery process and the surgeon must be available to the patient for concerns during the recovery period. The surgery itself is not very complex and can be mastered over time. Pain relief and return to activity results have been excellent and overall, the surgical decompression patients fair better in regard to ulcer formation and amputation risk than those without decompression. It is essential to select patients carefully and to make sure that the testing and examination findings discussed in the article are present before surgery. Chemotherapy-Induced Neuropathy 637 Gedge D. Rosson Increasingly, surgeons are becoming aware of the successful treatment of symptomatic peripheral neuropathy by surgical decompression of peripheral nerves. Armed with the knowledge that patients can have underlying neuropathy with overlying anatomic compressions, surgeons have affected improvement in diabetesinduced neuropathy, neuropathy of unknown etiology, and chemotherapy-induced neuropathy. This article details the most well-known culprits in chemotherapy-induced neuropathy and discusses the putative mechanisms of action, medical management, and surgical data. viii
Physical Therapy Following Peripheral Nerve Surgeries 651 Tamara J. Bond and Jim Lundy Post-operative care of the surgical patient significantly contributes to the success of the surgical procedure. Post-operative physical therapy is directed at reducing pain and inflammation, preventing or minimizing scar tissue, and returning the patient to full function. An individualized and well-planned therapeutic exercise program is an integral part of the post-operative care. Manual therapy techniques are utilized to break up scar tissue and reduce joint stiffness. Pain and inflammation can be addressed by modalities such as ultrasound, laser, and electrical stimulation in addition to cryotherapy. Index 667 ix