Extrinsic compression neuropathy of the tibial nerve secondary to accessory soleus muscle in a young teenager

Compression neuropathy of the tibial nerve or one of its terminal branches (tarsal tunnel syndrome) is relatively uncommon. Accessory musculature on the posteromedial aspect of the ankle is a rare extrinsic cause of compression. Therefore, it should be considered in patients with prolonged manifestations of tibial nerve compression. A detailed history and physical examination, together with proper radiological evaluation, allow for accurate diagnosis. In this case report, a 13-year old female teenager on history, physical examination, and imaging studies was diagnosed as compression neuropathy of the tibial nerve secondary to accessory soleus muscle. After surgical excision of the accessory soleus muscle with no tarsal tunnel release, the patient presented with complete resolution of her manifestations continued free of symptoms for one and half year postoperatively. The accessory soleus muscle is a potential extrinsic cause for tibial nerve compression neuropathy.

LEVEL OF CLINICAL EVIDENCE

5.

A study protocol on nerve mobilization induced diffusion tensor imaging values in posterior tibial nerve in healthy controls and in patients with diabetic neuropathy-multigroup pretest posttest design

Background

Diabetic neuropathy is the commonest chronic disabling complication of diabetes which may lead to amputation and compromising patient’s quality of life. It is characterized by pain, sensation loss associated with neural edema. Diffusion tensor imaging parameter i.e. fraction anisotropy determines the free water proton diffusion in the healthy nerve. Since the diabetes leads to altered mechanosensitivity of the posterior tibial nerve thereby, might interferes with the water molecules movement. Therefore the present clinical trial will provide the evidence of improving the diffusion tensor imaging in the diabetic neuropathy directly by targeting the nerve through nerve mobilization treatment.

Methods

Participants with Type II Diabetes Mellitus induced peripheral neuropathy will be selected randomly on the basis of eligibility criteria and informed consent will be taken. Participants will be recruited into three groups. Group A (experimental group A) will receive neural mobilization technique, Group B (experimental group B) will receive conventional therapy and Group C (control group) will receive sham treatment for 3 weeks. MRI technique, Visual analogue scale and neuropathy specific quality of life questionnaire will be used as assessment tools. Assessment will be taken at baseline and post intervention.

Conclusion

this clinical trial will provide the evidence of efficacy of nerve mobilization in determining the diffusion tensor imaging (DTI) changes in the posterior tibial nerve in patients with diabetic neuropathy. This trial will also be the first one in itself to look at the treatment induced DTI changes in the peripheral nerve.

Trial Registration

Clinical Trial Registry of India (CTRI/2019/06/019552).

Posterior Tibial Nerve Stimulation in Fecal Incontinence: A Systematic Review and Meta-Analysis

Introduction:

The present systematic review and meta-analysis aims to investigate the role of Posterior Tibial Nerve Stimulation (PTNS) in the control of Fecal Incontinence (FI).

Methods:

Two independent reviewers extensively searched in the electronic databases of Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, CINAHL, and Scopus for the studies published until the end of 2016. Only randomized clinical trials were included. The studied outcomes included FI episodes, FI score, resting pressure, squeezing pressure, and maximum tolerable pressure. The data were reported as Standardized Mean Differences (SMD) with 95% confidence interval.

Results:

Five articles were included in the present study (249 patients under treatment with PTNS and 239 in the sham group). Analyses showed that PTNS led to a significant decrease in the number of FI episodes (SMD=−0.38; 95% CI: −0.67–0.10; P=0.009). Yet, it did not have an effect on FI score (SMD=0.13; 95% CI: −0.49–0.75; P=0.68), resting pressure (SMD=0.12; 95% CI: −0.14–0.37; P=0.67), squeezing pressure (SMD=−0.27; 95% CI: −1.03–0.50; P=0.50), and maximum tolerable pressure (SMD=−0.10; 95% CI: −0.40–0.24; P=0.52).

Conclusion:

Based on the results, it seems that the prescription of PTNS alone cannot significantly improve FI.

CT can stratify patients as low risk for tibial neuropathy following a talus fracture

OBJECTIVE

Determine the incidence of tibial neuropathy following talus fractures and CT's ability to stratify patients at risk for developing post-traumatic neuropathy.

MATERIALS AND METHODS

In this IRB-approved retrospective analysis, 71 talus fractures and 8 contralateral control ankle CTs were reviewed by one observer blinded to clinical information. CT evidence suggestive of tibial neurovascular bundle injury included nerve displacement, perineural fat effacement/edema, and bone touching nerve. The association between these CT findings and clinically evident tibial neuropathy was analyzed. A semi-quantitative likelihood score was assigned based on the degree of the CT findings around the nerve. Interobserver agreement was calculated between 2 other readers.

RESULTS

Twenty-five percent of patients in this cohort had clinical evidence of tibial neuropathy. There was a high specificity (0.87-0.93) and negative predictive value (0.83-0.87), a moderate accuracy (0.80-0.82), but a lower sensitivity (0.33-0.56) associated with the CT findings. Among the CT findings, nerve displacement (p < 0.0001) and bone touching nerve (p = 0.01) were associated with tibial neuropathy. A likelihood score of 2-5 was associated (p = 0.007-0.015) with tibial neuropathy. The presence of tibial neuropathy and nerve recovery were not associated with hospital length of stay, while CT findings were. There was substantial agreement between the three readers: likelihood scores 2+ (k = 0.78) and 3+ (k = 0.72).

CONCLUSIONS

Tibial neuropathy occurs following talus fractures, and CT findings may help surgeons narrow down the number of patients requiring close neurological follow-up.

Optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK) for posterior knee pain after total knee arthroplasty: an anatomical and clinical study

Background

This study aimed to determine the optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK), using the anatomical pattern of the articular branch of tibial nerve (ABTN). We hypothesized that injection at the level of ABTN forming a popliteal plexus would mainly spread throughout the popliteal fossa without contacting the tibial or peroneal nerves.

Methods

The anatomical study included 30 soft cadavers. Ultrasound-guided dye injection was performed in legs of 10 cadavers after identifying the position of the ABTN and surrounding structures, followed by dissection to assess its spread. Clinical study was conducted in 15 patients undergoing total knee arthroplasty (TKA) with ultrasound-guided injection in the iPACK. All patients also received continuous adductor canal block. Sensorimotor function of the tibial and common peroneal nerves was determined.

Results

In the distal portion of the popliteal fossa, the tibial nerve and popliteal vessels ran superficially and closely together. The trajectory of ABTN ran lateral to the popliteal vasculature, forming a plexus towards the posterior capsule of the knee below the medial side of the upper edge of lateral femoral condyle. In cadavers, the ABTN and surrounding area of the popliteal plexus were stained with dye after injection. In the clinical study, no patients experienced complete motor or sensory blocks.

Conclusions

We described a modified iPACK technique injection at the level of the ABTN forming the popliteal plexus, and it may constitute an optional anesthetic regimen to promote early ambulation following TKA.

Superficial course of the medial plantar nerve: case report

The medial and lateral plantar nerves are branched from the tibial nerve and move to the tip of the toes. A variation of medial plantar nerve was found on the left side of a 78-year-old Korean male cadaver. The tibial nerve was divided into the lateral and medial plantar nerves beneath the plantar flexor. The medial plantar nerve passed deep to plantar aponeurosis and superficial to the flexor digitorum brevis. It gave off a common plantar digital nerve and then divided into three proper plantar digital nerves near the metatarsal bases. In this article, we report a superficial course of the medial plantar nerve and describe its unique morphology and discuss the clinical significance of this variation.

Translocation of the soleus muscular branch of the tibial nerve to repair high common peroneal nerve injury

BACKGROUND

This study was performed to evaluate the clinical effect of translocating the soleus muscular branch of the tibial nerve to repair the deep peroneal nerve.

METHODS

Eight patients were treated for high common peroneal nerve injury. The deep peroneal nerve was separated out from the common peroneal nerve if no injury occurred upon opening the epineurium of the common peroneal nerve. The soleus muscular branch of the tibial nerve was then translocated to the deep peroneal nerve.

RESULTS

The average follow-up duration was 21.75 months. Electromyography revealed newly appearing electric potentials in the tibialis anterior, extensor hallucis longus, and extensor toe longus muscle at 8 to 10 months postoperatively. Four patients showed good functional recovery after surgery; functional recovery was poor in other patients.

CONCLUSIONS

Translocation of the soleus muscle branch is a feasible method to treat high common peroneal nerve injuries. A full understanding of the indications for this operation is required.

[COMPARISON OF HEALING RESULTS BETWEEN TIBIAL NERVE AND COMMON PERONEAL NERVE AFTER SCIATIC NERVE INJURY REPAIR IN RHESUS MONKEY]

OBJECTIVE

To investigate the regularity of myelin degeneration and regeneration and the difference of axonal density between tibial nerve and common peroneal nerve after sciatic nerve injury repair in rhesue monkey.

METHODS

Nine adult rhesue monkeys (male or female, weighing 3.5-4.5 kg) were selected to establish the model of rat sciatic nerve transaction injury. The tibial nerve and common peroneal nerve of 5 mm in length were harvested at 5 mm from injury site as controls in 3 monkeys; the distal tibial nerve and common peroneal nerve were repaired with 9-0 suture immediately in the other 6 monkeys. And the gross observation and neural electrophysiological examination were performed at 3 and 8 weeks after repair respectively. Then, distal tibial nerve and common peroneal nerve at anastomotic site were harvested to observe the myelin sheath changes, and to calculate the number of axon counts and axonal density by staining with Luxol Fast Blue.

RESULTS

Atrophy of the lower limb muscle and various degrees of plantar ulcer were observed. Gross observation showed nerve enlargement at anastomosis site, the peripheral connective tissue hyperplasia, and obvious adhesion. The compound muscle action potential (CMAP) of tibial nerve and common peroneal nerve could not be detected at 3 weeks; the CMAP amplitude of common peroneal nerve was less than that of the tibial nerve at 8 weeks. Different degrees of axonal degeneration was shown in the tibial nerve and common peroneal nerve, especially in the common peroneal nerve. The average axonal density of common peroneal nerve was lower than that of tibial nerve at 3 weeks (13.2% vs. 44.5%) and at 8 weeks (10.3% vs. 35.3%) after repair.

CONCLUSIONS

The regeneration of tibial nerve is better and faster than that of common peroneal nerve, and gastrocnemius muscle CMAP recovers quicker, and amplitude is higher, which is the reason of better recovery of tibial nerve.

Electrostimulation of the posterior tibial nerve in individuals with overactive bladder: a literature review

[Purpose] This study aims to gather scientific evidence to identify whether clinical trials on Electrostimulation of the Posterior Tibial Nerve (ESPTN) in individuals with overactive bladder present an adequate methodological standard according to the PEDro (Physiotherapy Evidence Database) criteria. [Methods] Integral literature review, including randomized controlled clinical trials found in PEDro. [Results] We found 16 articles, of which only one did not meet the inclusion criteria. This article has shown that ESPTN is a conservative tool of physiotherapy that is less invasive than other therapies, is well tolerated by patients and has been shown to be effective in the treatment of overactive bladder. However, few standardized clinical studies have been conducted, and only 26.6% of the articles included in this review obtained a score of more than five items on the PEDro scale. [Conclusion] This article has shown that ESPTN is a conservative tool of physiotherapy that is less invasive than other therapies, is well tolerated by patients and has been shown to be effective in the treatment of overactive bladder. Thus, there is a need for more clinical articles that follow the quality criteria for randomized clinical trials, allowing more reliable scientific results.

Guiding Treatment for Foot Pain

In the electrodiagnostic (EDX) approach of the patient who presents with foot pain, numbness, and/or tingling, it is important to consider a broad differential diagnosis of both neuropathic and nonneuropathic conditions, including focal and systemic causes. This article assists the electromyographer in the selection and utilization of the most appropriate EDX studies for evaluation. The EDX findings and impression can then help guide potential treatment options for the patient with foot pain and other symptoms. Moreover, this discussion demonstrates the added value that EDX evaluation of the foot provides to the comprehensive assessment of foot pain.

Ultrasound facilitates the diagnosis of tarsal tunnel syndrome: intraneural ganglion cyst of the tibial nerve

The tibial nerve intraneural ganglion cyst-which presents with fluid accumulated inside the nerve epineurium-is a rare etiology of tarsal tunnel syndrome. We report a case with insidious onset of numbness over his left medial ankle. Ultrasound imaging revealed that the tibial nerve was encircled by crescent-shaped anechoic substances, spanning from the distal leg to the sole. Magnetic resonance imaging disclosed a thickened tibial nerve wrapped by hyperintense materials in the tarsal tunnel. Some effusion was observed besides the tibialis posterior and flexor digitorum tendons as well. The patient underwent a surgical treatment and an intraneural ganglion cyst was confirmed. This report elaborated the clinical and imaging presentations of a tibial nerve intraneural ganglion cyst and highlighted the usefulness of ultrasound in exploring the cause of compressive neuropathy at the ankle region.

Characterizing the transcutaneous electrical recruitment of lower leg afferents in healthy adults: implications for non-invasive treatment of overactive bladder

BACKGROUND

As a potential new treatment for overactive bladder (OAB), we investigated the feasibility of non-invasively activating multiple nerve targets in the lower leg.

METHODS

In healthy participants, surface electrical stimulation (frequency = 20 Hz, pulse width = 200 μs) was used to target the tibial nerve, saphenous nerve, medial plantar nerve, and lateral plantar nerve. At each location, the stimulation amplitude was increased to define the thresholds for evoking (1) cutaneous sensation, (2) target nerve recruitment and (3) maximum tolerance.

RESULTS

All participants were able to tolerate stimulation amplitudes that were 2.1 ± 0.2 (range = 2.0 to 2.4) times the threshold for activating the target nerve.

CONCLUSIONS

Non-invasive electrical stimulation can activate neural targets at levels that are consistent with evoking bladder-inhibitory reflex mechanisms. Further work is needed to test the clinical effects of stimulating one or more neural targets in OAB patients.

Trifurcation of the tibial nerve within the tarsal tunnel

The tibial nerve is the larger terminal branch of the sciatic nerve and it terminates in the tarsal tunnel by giving lateral and medial plantar nerves. We present a rare case of trifurcation of the tibial nerve within the tarsal tunnel. The variant nerve curves laterally after branching from the tibial nerve and courses deep to quadratus plantae muscle. Interestingly, posterior tibial artery was also terminating by giving three branches. These branches were accompanying the terminal branches of the tibial nerve.

Anatomical Localization of Motor Points of the Abductor Hallucis Muscle: A Cadaveric Study

OBJECTIVE

To identify the anatomical motor points of the abductor hallucis muscle in cadavers.

METHODS

Motor nerve branches to the abductor hallucis muscles were examined in eight Korean cadaver feet. The motor point was defined as the site where the intramuscular nerve penetrates the muscle belly. The reference line connects the metatarsal base of the hallux (H) to the medial tubercle of the calcaneus (C). The x coordinate was the horizontal distance from the motor point to the point where the perpendicular line from the navicular tuberosity crossed the reference line. The y coordinate was the perpendicular distance from the motor point to the navicular tuberosity.

RESULTS

Most of the medial plantar nerves to the abductor hallucis muscles divide into multiple branches before entering the muscles. One, two, and three motor branches were observed in 37.5%, 37.5%, and 25% of the feet, respectively. The ratios of the main motor point from the H with respect to the H-C line were: main motor point, 68.79%±5.69%; second motor point, 73.45%±3.25%. The mean x coordinate value from the main motor point was 0.65±0.49 cm. The mean value of the y coordinate was 1.43±0.35 cm. All of the motor points of the abductor hallucis were consistently found inferior and posterior to the navicular tuberosity.

CONCLUSION

This study identified accurate locations of anatomical motor points of the abductor hallucis muscle by means of cadaveric dissection, which can be helpful for electrophysiological studies in order to correctly diagnose the various neuropathies associated with tibial nerve components.

Transcutaneous stimulation of the posterior tibial nerve for treating refractory urge incontinence of idiopathic and neurogenic origin

OBJECTIVE

To assess the efficacy of treatment with transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with urge urinary incontinence, of neurogenic or nonneurogenic origin, refractory to first-line therapeutic options.

MATERIAL AND METHODS

We included 65 patients with urge urinary incontinence refractory to medical treatment. A case history review, a urodynamic study and a somatosensory evoked potentials (SEP) study were conducted before the TPTNS, studying the functional urological condition by means of a voiding diary. The treatment consisted of 10 weekly sessions of TPTNS lasting 30minutes.

RESULTS

Some 57.7% of the patients showed abnormal tibial SEPs, and 42% showed abnormal pudendal SEPs. A statistically significant symptomatic improvement was observed in all clinical parameters after treatment with TPTNS, and 66% of the patients showed an overall improvement, regardless of sex, the presence of underlying neurological disorders, detrusor hyperactivity in the urodynamic study or SEP disorders. There were no adverse effects during the treatment.

CONCLUSIONS

TPTNS is an effective and well tolerated treatment in patients with urge incontinence refractory to first-line therapies and should be offered early in the treatment strategy. New studies are needed to identify the optimal parameters of stimulation, the most effective treatment protocols and long-term efficacy, as well as its applicability to patients with a neurogenic substrate.

An Enhanced Method of Transcutaneously Stimulating the Tibial Nerve for the Treatment of Overactive Bladder

Transcutaneous electrical nerve stimulation (TENS) can be used to electrically stimulate the tibial nerve for the purpose of treating overactive bladder. Although clinical benefits can be achieved, the overall therapeutic efficacy of TENS is limited. Inconsistent activation of the intended neural target and co-activation of cutaneous sensory fibers are considered key limiting factors. In this study, we propose a novel approach that combines TENS with an implanted, electrically-conductive nerve cuff to reduce the stimulation amplitude needed to activate the tibial nerve. This enhanced version of TENS (called eTENS) was designed using a computational model of the rat tibial nerve and subsequently tested in anesthetized rats. Our computational model showed that eTENS can reduce the nerve activation threshold by a factor of up to 2.6. Similar effects were also achieved by in vivo experiments (1.4 ± 0.1-fold decrease, n = 5). Among various design parameters, spatial alignment between the surface electrode and the nerve cuff was identified as an important factor. Our results show that eTENS can improve the selective activation of the rat tibial nerve, but further work is needed to evaluate its use in clinical therapies.

Mechanism of physical stress-induced inhibition of ovarian estradiol secretion in anesthetized rats

This study examined the site of main integration center in the physical stress-induced inhibition of ovarian estradiol secretion because of ovarian sympathetic nerve (superior ovarian nerve: SON) activation in anesthetized rats. In central nervous system-intact rats, electrical stimulation of the tibial afferent nerve at 10V increased the efferent activity of the SON by 39±13% and reduced the ovarian secretion of estradiol by 34±7%. These responses were observed in decerebrate rats but were abolished in spinal rats. Thus, the main integration center for this ovarian hormonal response is located in the brain stem.

A soft ankle brace increases soleus Hoffman reflex amplitude but does not modify presynaptic inhibition during upright standing

External ankle supports, such as ankle braces, may improve postural stability by stimulating cutaneous receptors. It remains unknown whether these supports have an effect on the posture central regulation. The aim of this study was to determine the effect of wearing a soft ankle brace on soleus H-reflex amplitude and presynaptic inhibition during standing. Sixteen subjects stood on a rigid floor with their eyes opened, either barefoot or wearing a soft ankle brace. H-reflex amplitude was measured on the soleus muscle by stimulating the tibial nerve electrically. Modulation of presynaptic inhibition was assessed by conditioning the H-reflex with fibular nerve (D1 inhibition) and femoral nerve (heteronymous facilitation) electrical stimulations. The unconditioned H-reflex amplitude was significantly greater when wearing the ankle brace than barefoot, whereas D1 and HF conditioned soleus H-reflex did not differ significantly between bracing conditions. These results suggest that the ankle brace increased the soleus motoneuron excitability without altering presynaptic mechanisms, potentially because of increased cutaneous mechanoreceptors afferent signals provided by the soft ankle brace.

Age-related morphological regression of myelinated fibers and capillary architecture of distal peripheral nerves in rats

BACKGROUND

Regression of myelinated peripheral nerve fibers in the lower extremities contributes to sarcopenia and balance dysfunction in normal aging. This subclinical regression of myelinated fibers (MFs) is heavily influenced by alterations in microvasculature, though the mechanism underlying these age-related degenerative phenomena remains unclear. The aim of the present study was to examine age-related regressions in myelinated distal peripheral nerve fibers as well as capillary architecture in rats using both morphological and histochemical methods.

RESULTS

MFs were categorized into tertiles of 'large', 'medium', and 'small' sizes based on the distribution of MF diameters. A two-way ANOVA was used to assess effects of fiber size (large/medium/small) and group (young/elderly) on myelin thickness, axon diameter, myelin perimeter, axon perimeter, and G-ratio (axon diameter/fiber diameter). Significant main effects were observed for both MF size and group with respect to all dimensions except for G-ratio. Values for fiber diameter (P < 0.01), myelin thickness (P < 0.01), axon diameter (P < 0.01), myelin perimeter (P < 0.01), and axon perimeter (P < 0.01) were significantly lower than those in the young group. Additionally, mean capillary diameter and number of microvascular branch points were significantly lower in the elderly group than in the young group.

CONCLUSIONS

The present study demonstrated that spontaneous age-related regression predominantly occurs for all fiber sizes in the distal peripheral nerves and the capillary architecture. The results of the present study further suggest that both the distal MFs and capillaries in the peripheral nerve may simultaneously regress with aging.

[Reticular perineurioma of the tibial nerve]

Reticular (retiform) perineurioma is a rare variant of soft tissue perineurioma developed from the perineurium. This benign tumor is characterized by strands of spindle cells in a fibro-myxoid matrix surrounding pseudocystic mucoid spaces. We report a tibial nerve reticular perineurioma in a 35-year-old patient.

Proposed Sonographic Criteria for the Diagnosis of Idiopathic Tarsal Tunnel Syndrome

OBJECTIVE

To propose new sonographic criteria for the diagnosis of idiopathic tarsal tunnel syndrome (TTS).

DESIGN

Prospective case-control study.

SETTING

Academic referral center.

PARTICIPANTS

Adult healthy volunteers (n=17) and adult patients (n=14) with electrodiagnostically proven idiopathic TTS (mean age, 43.4±8.7y; height, 161.4±7.0cm; weight, 90.6±13.9kg) (N=31). The exclusion criteria were patients with diabetes, neurological disorders, associated ankle and/or foot disorders, electrodiagnostic evidence of a widespread lesion, or feet that were electrophysiologically negative for TTS or with structural abnormalities detected via ultrasound imaging.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Tibial nerve CSA at the proximal tarsal tunnel, tibial nerve CSA within the tunnel, within tunnel-to-proximal tunnel CSA ratio.

RESULTS

There was a significant difference in the within tunnel CSA and within tunnel-to-proximal tunnel CSA ratio between the TTS group and controls (P=.002 and P=.001, respectively). The optimum cutoff value was 19mm(2) for the within tunnel CSA and 1 for the within tunnel-to-proximal tunnel CSA ratio. Sensitivities were 61% and 74%, respectively.

CONCLUSIONS

The within tunnel-to-proximal tunnel CSA ratio and the within tunnel CSA are the most accurate sonographic parameters and can be helpful in the assessment of idiopathic TTS.

Topography of human ankle joint: focused on posterior tibial artery and tibial nerve

Most of foot pain occurs by the entrapment of the tibial nerve and its branches. Some studies have reported the location of the tibial nerve; however, textbooks and researches have not described the posterior tibial artery and the relationship between the tibal nerve and the posterior tibial artery in detail. The purpose of this study was to analyze the location of neurovascular structures and bifurcations of the nerve and artery in the ankle region based on the anatomical landmarks. Ninety feet of embalmed human cadavers were examined. All measurements were evaluated based on a reference line. Neurovascular structures were classified based on the relationship between the tibial nerve and the posterior tibial artery. The bifurcation of arteries and nerves were expressed by X- and Y-coordinates. Based on the reference line, 9 measurements were examined. The most common type I (55.6%), was the posterior tibial artery located medial to the tibial nerve. Neurovascular structures were located less than 50% of the distance between M and C from M at the reference line. The bifurcation of the posterior tibial artery was 41% in X-coordinate, -38% in Y-coordinate, and that of the tibial nerve was 48%, and -10%, respectively. Thirteen measurements and classification showed statistically significant differences between both sexes (P<0.05). It is determined the average position of neurovascular structures in the human ankle region and recorded the differences between the sexes and amongst the populations. These results would be helpful for the diagnosis and treatment of foot pain.

Successful enucleation of large multinodular/plexiform schwannoma of the foot and ankle

Background

It is often challenging to completely resect multinodular/plexiform schwannomas involving important deep nerves using minimally invasive surgically techniques.

Case description

A 32-year-old woman presented with a 5-year history of a slowly growing, painful mass in the medial aspect of the right ankle. Magnetic resonance imaging (MRI) demonstrated multiple nodular lesions with iso-signal intensity relative to skeletal muscle on T1-weighted sequences and heterogeneous high signal intensity on T2-weighted sequences. Mild to moderate enhancement was identified after gadolinium administration. All 58 tumors were completely enucleated using an intracapsular technique. Histological examination confirmed the diagnosis of schwannoma consisting mainly of Antoni A areas. The burning sensation was relieved immediately after surgery. The patient had no aggravated neurological deficit and was very satisfied with the outcome of the treatment at final follow-up.

Discussion and evaluation

We experienced a very rare case of a large multinodular/plexiform schwannoma arising from the posterior tibial nerve and its larger terminal branch. Our case had the characteristic MRI features of this condition. It is extremely important to differentiate multinodular/plexiform schwannoma from plexiform neurofibroma and malignant peripheral nerve sheath tumor, with complete surgical enucleation being curative.

Conclusions

MRI is a clinically useful modality in the evaluation and detection of deep-seated multinodular/plexiform schwannoma. Intracapsular enucleation seems to be an acceptable treatment for this peculiar tumor located in the foot and ankle.

[Tibial nerve transcutaneous stimulation for refractory idiopathic overactive bladder in children and adolescents]

INTRODUCTION

The purpose of this study was to evaluate safety and tolerability of transcutaneous tibial nerve stimulation (TENS) in patients under 15years of age with refractory overactive bladder.

MATERIALS AND METHODS

A retrospective analysis was conducted on outcomes of TENS (1daily 20-minute session, 10Hz) in patients with refractory overactive bladder, excluding patients with neurogenic bladder. Treatment efficacy was evaluated on symptomatic improvement and voiding schedule. Healing was defined as following: no recurrence of urinary tract infection, normal urodynamic voiding parameters, no nighttime continence disorder, normal uroflowmetry.

RESULTS

Nineteen consecutive patients with refractory overactive bladder were treated from November 2010 to March 2012 (11girls, 8boys, age 12.1±2.7 years). Three patients reported only daytime voiding disorders, the others reported daytime and nighttime voiding disorders. Ten patients reported febrile urinary tract infection (1 boy, 9 girls). The average length of treatment was 6 months. Two patients were lost to follow-up. Thirteen patients had only tibial TENS; 3 patients had tibial TENS and trospium chloride or desmopressin. At 1-month assessment, 16 patients out of 17 (94%) reported symptomatic improvement. At the end of treatment, 12 patients out of 17 (70%) met healing criteria (5 boys, 7girls), without relapse within 9 months. Three boys (18%) had partial improvement (no daytime wetting, but increased daytime frequency). No patient reported side effects.

CONCLUSION

Tibial TENS is a safe, non invasive and effective treatment in refractory overactive bladder in children. The success rate is 70%, with no side effect and no relapse at the end of the treatment in our study.

Branching patterns of medial and inferior calcaneal nerves around the tarsal tunnel

Objective

To demonstrate the bifurcation pattern of the tibial nerve and its branches.

Methods

Eleven legs of seven fresh cadavers were dissected. The reference line for the bifurcation point of tibial nerve branches was an imaginary horizontal line passing the tip of the medial malleolus. The distances between the reference line and the bifurcation points were measured. The bifurcation branching patterns were categorized as type I, the pattern in which the medial calcaneal nerve (MCN) branched most proximally; type II, the pattern in which the three branches occurred at the same point; and type III, in which MCN branched most distally.

Results

There were seven cases (64%) of type I, three cases (27%) of type III, and one case (9%) of type II. The median MCN branching point was 0.2 cm (range, -1 to 3 cm). The median bifurcation points of the lateral plantar nerves and inferior calcaneal nerves was -0.6 cm (range, -1.5 to 1 cm) and -2.5 cm (range, -3.5 to -1 cm), respectively.

Conclusion

MCN originated from the tibial nerve in most cases, and plantar nerves were bifurcated below the medial malleolus. In all cases, inferior calcaneal nerves originated from the lateral plantar nerve. These anatomical findings could be useful for performing procedures, such as nerve block or electrophysiologic studies.

Recurrent tarsal tunnel syndrome

Recurrence of tarsal tunnel syndrome after surgery may be due to inadequate release, lack of understanding or appreciation of the actual anatomy involved, variations in the anatomy of the nerve(s), failure to execute the release properly, bleeding with subsequent scarring, damage to the nerve and branches, persistent hypersensitivity of the nerves, and preexisting intrinsic damage to the nerve. Approaches include more thorough release, use of barrier materials to decrease adherence of the nerve to surrounding tissues to avoid traction neuritis, excisions of neuromas using conduits, and consideration of nerve stimulators and systemic medications to deal with persistent neural pain.

Study on variant anatomy of sciatic nerve

INTRODUCTION

Sciatic Nerve (SN) is the nerve of the posterior compartment of thigh formed in the pelvis from the ventral rami of the L4 to S3 spinal nerves. It leaves the pelvis via the greater sciatic foramen below piriformis and divides into Common Peroneal Nerve (CPN) and Tibial Nerve (TN) at the level of the upper angle of the popliteal fossa. Higher division of the sciatic nerve is the most common variation where the TN and CPN may leave the pelvis through different routes. Such variation may lead to compression of the nerve and lead to Non-discogenic sciatica.

MATERIALS AND METHODS

Fifty lower limbs were used for the study from Department of Anatomy, J.J.M.M.C Davangere, Karnataka, India.

OBSERVATION AND RESULTS

In our study on 25 cadavers (50 lower limbs), we have observed 4 (8 %) lower limbs high division of sciatic nerve was noted. High division of sciatic nerve in the back of thigh was noted in one specimen (2%), while high division within the pelvis was noted in 3 specimens (6%), while in 46 (92%) it occurred outside the pelvis.

CONCLUSION

Knowledge regarding such variation and differences in the course of SN is important for the surgeons to plan for various surgical interventions pertaining to the gluteal region. The variant anatomy of SN may cause piriformis syndrome and failure of SN block. Hence present study is undertaken to know the level of division, exit, course, relationship to piriformis and variations in the branching pattern of SN.

Role of ultrasound in posteromedial tarsal tunnel syndrome: 81 cases

Posteromedial tarsal tunnel syndrome is a disorder affecting the tibial nerve or its branches. Diagnosis is established on the basis of physical examination and can be confirmed by electrophysiological evidence. However, diagnostic imaging is always required to identify the possible site of compression. High-resolution ultrasound (US) is playing an increasingly important role in the study of the nerves thanks to a series of advantages over magnetic resonance imaging, such as lower costs and widespread availability, high spatial resolution, fast examination using axial scans, dynamic and comparative studies, possibility of carrying out a study with the patient in the standing position, US Tinel sign finding, and the contribution of color/power Doppler US. We present the results obtained in a series of 81 patients who underwent US imaging between 2008 and 2013 due to posteromedial tarsal tunnel syndrome.

The Morphological Changes in the Capillary Architecture of the Tibial Nerve Associated with Spontaneous Aging and Aerobic Exercise Intervention during Aging in Rats

[Purpose] Peripheral nerve degradation associated with aging is linked to failure of interactions in capillary metabolism. The aim of this study was to morphologically investigate the age-related changes in the capillary architecture of the tibial nerve in spontaneous aging and with aerobic exercise intervention in rats. [Subjects] Male Sprague-Dawley rats (n=15) were used in the present study. [Methods] The rats were divided into control (Cont, n=5), elderly (Elder, n=5), and elderly with aerobic exercise (Elder+Ex, n=5) groups. Aerobic training of low intensity was performed for 10 weeks using a treadmill starting at 96 weeks of age by the Elder+Ex group. The capillary diameter, cross-sectional area and number of microvascular ramifications in the tibial nerve were compared among the Cont (20-week-old), Elder (106-week-old) and Elder+Ex groups using three-dimensional images gained from confocal laser scanning microscopy. [Results] The capillary diameter, cross-sectional area and number of microvascular ramifications in the Elder group were significantly smaller than those observed in the Cont and Elder+Ex groups. [Conclusion] These findings suggest that the capillaries in the peripheral nerve degrade with spontaneous aging and that aerobic exercise of low intensity promotes angiogenesis, and protects the capillary from oxidative stress.

Study of tibial nerve regeneration in Wistar rats in primary neurorrhaphy with and without gap, wrapped in vein segments

Objective

This study compared nerve regeneration in Wistar rats, using epineural neurorrhaphy with a gap of 1.0 mm and without a gap, both wrapped with jugular vein tubes. Motor neurons in the spinal cord between L3 and S1 were used for the count, marked by exposure of the tibial nerve to Fluoro-Gold (FG).

Method

The tibial nerves on both sides were cut and sutured, with a gap on one side and no gap in the other. The sutures were wrapped with a jugular vein. Four months after surgery the tibial nerves were exposed to Fluoro-Gold and the motor neuron count performed in the spinal cord.

Results

The results were statistically analyzed by the paired Wilcoxon test. There was a statistical difference between the groups with and without gap in relation to the motor neuron count (p=0.013).

Conclusion

The epineural neurorraphy without gap wrapped with jugular vein showed better results for nerve regeneration than the same procedure with gap. Level of Evidence: Experimental Study.

Electrical and mechanical office-based neuromodulation

Overactive bladder (OAB) is commonly encountered in urologic practice. Treatment algorithms begin with conservative therapy and pharmacotherapy with antimuscarinics. Some patients do not receive adequate relief from these methods or they do not tolerate side effects from pharmacotherapy. A test stimulation for sacral neuromodulation and percutaneous tibial nerve stimulation are office-based techniques that are commonly used as the next step in the algorithm of care in patients with OAB. These techniques are efficacious and approved by the Food and Drug Administration for treatment of overactive bladder and its associated symptoms.

Clinical efficacy in the treatment of overactive bladder refractory to anticholinergics by posterior tibial nerve stimulation

Purpose

Overactive bladder (OAB) is a clinical syndrome that is currently treated initially with anticholinergics, although some other therapeutic alternatives exist, such as neuromodulation, botulinum toxin, and posterior tibial nerve stimulation (PTNS). The purpose of this study was to assess the efficacy of PTNS in patients with OAB refractory to anticholinergics.

Materials and Methods

We present a cohort study of 14 women with OAB to whom we applied PTNS. We assessed (before and after the treatment) the diurnal micturitional frequency, the nocturnal micturitional frequency, urgency episodes, and urge incontinence episodes. Results were analyzed by using the Wilcoxon test for nonparametric samples.

Results

We observed statistically significant improvement in the diurnal micturitional frequency (p=0.05), in episodes of micturitional urgency (p=0.03), and in episodes of urge incontinence (p=0.004). A total of 50% of the patients felt subjective improvement from their pathology.

Conclusions

PTNS is a valid, minimally invasive treatment option with minimum morbidity for patients with OAB refractory to treatment with anticholinergics.