peripheral nerve compression syndrome

Neuropathyvs

Peripheral Nerve Compression Syndrome

Michael E. Graham, DPM, FACFAS

Neuropathy

What do we know?

› Nothing- no solution› Your situation will only get worse› We don’t like seeing these patients in

our office › Chronic complainers› Hopeless› 20 million Americans with symptoms

Peripheral Neuropathy

What is the etiology?Over 100 etiologies of peripheral

neuropathy› Diabetes ?› Alcohol ?› Chemotherapy ?› Heavy Metal Poisoning ?› Hereditary ?› Idiopathic ?

› WE REALLY DON’T KNOW

Diabetic Peripheral Neuropathy› 28 to 60% of Type I or II diabetics develop

Neuropathy(Young et al 1993)

› Sorbital Accumulation- not proven, theoretical› Polyol Pathyway: oxidative stress, mitochondrial

dysfunction, and ischemic nerve damage› Treatment aimed at:

Controlling hyperglycemia Foot inspection Controlling pain

› End result- Continued progression and worsening of the condition

Diabetic Peripheral NeuropathySymptoms

Numbness or insensitivity to pain or temperature

Tingling, burning, or prickling sensation Sharp pains or cramps Extreme sensitivity to touch, even a light

touch Loss of balance and coordination

Symptoms are worse at night Muscle weakness (intermetatarsal)-

digital deformities

Diabetic Neuropathy

Loss of Sensory Protection› 15% develop

ulceration› 12-24% require

amputation› 80% of diabetics who

present with ulceration have decreased sensation in there foot/feet.

Alcoholic Neuropathy

Persons who consumed large quantities of alcoholic beverages over an extended period of time.

Symptoms are the same as diabetic and other neuropathy-

Incidence - unknown Treatment- basically the same as

DPN and “Stop Drinking”

Drug-Induced & Toxic Neuropathy Medications

› Disulfiram› Metronidazole› Phenytoin› Cisplatin› Statins

Rare- 2-4%Symptoms- Same as

otherForms of neuropathy

Lead & Heavy Metals › Arsenic› Mercury› Thallium

› Symptoms resemble the same as other forms of metabolic, compression, etc.

SameSympto

ms

Diabetes

IdiopathicHereditar

y

Medications

Heavy Metals

Alcohol

What Do We Know?

Damaged microvasculature

Decreased oxygen to specific parts of the nerve

Areas of chronic flattening

Signs of chronic inflammation

Perineurial swelling

Sites of specific nerve damage

Sites of nerve repair

What IF….A Patient presents with heel pain.

Diagnosis of Plantar Fasciitis

What if they also a history of:› Diabetic› Alcoholic› had a family member with a history of plantar fasciitis› worked with heavy metal› had chemotherapy.

What difference does it make?

What if someone with chronic condition was told that nothing could be done for them?

Patient is hopeless

Treatment options are useless

We can help try to relieve the pain

It will only get worse

We don’t know why you have developed this

Let’s rethink the situation

Peripheral Nerve CompressionSyndrome

I think that this is going to make a lot of sense

Let’s change the way we think about neuropathy!

Peripheral Nerve Compression

Syndrome

Chronic Damage to a peripheral nerve Mild Moderate Severe

Ever heard of Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome Chronic Repetitive

Compression & Overstretching

Leads to Median Nerve Damage

Symptoms

Pain Numbness Tingling

Pain to palpation of the carpal tunnel

Sound familiar

Carpal Tunnel Syndrome

Conservative measures

› NSAIDS› Immobilizing braces› Physiotherapy› Localized steroid injections

› Long term efficacy usually alter/eliminate motion.

Surgery

Treatment of choice

Better out comes than wrist splinting

Claim 90% success in eliminating symptoms

What are the Patient’s Symptoms?

Feet feel best in the morning

As the day goes on they get worse

“The more active I am the worse the symptoms”

At night when I go to bed they really start acting up

Numbness/burning in my toes/ball of foot

Travels into my arch and up my leg

Top of the foot feels fine, no problems there

Used to happen after walking on the treadmill/mall but would stop after resting.

Typical Patient

Usually has been to many other doctors first. (even though it is a foot symptom).

Has had many expensive tests with or without abnormal findings

Frustrated Very fearful

Middle aged or older

Have a history of excessive walking/standing› House wife› Postal worker› Etc.

WHY WHY WHY WHY WHY WHY

Do their feet feel their best in the morning?

Why do their feet become more symptomatic as the day goes on or with increased activity?

Why are the symptoms worse at night?

The symptoms first started in the toes/ball of the feet

Slowly after months/years went to the arches and up the leg

There really is no mystery.

This is a nerve problem. What nerve supply is being affected?

Do you ever have these patients stand or walk?

Walking- the 2nd most common thing we do.

Excessive Rearfoot Motion

Symptomatology

The outer part of the posterior tibial nerve fibers lead to the tip of the plantar part of the toes

Deeper fibers correlate to the ball/arch of the foot.

Road Map to Diagnosis

IF the patient can tell us where the symptoms are occurring then we should be able to figure out which nerve is being affected.

Keep It Simple

Can you tell me which blood vessels are not working?

Let’s use the same rational with the nerves

Nerve Anatomy

Peripheral Nerve Parts

Peripheral Nerve Damage(Double Whammy)

A nerve can only stretch so far

Chronic overstretching will lead to damaged blood flow

A nerve can only be compressed so many times until there is partial nerve impairment

Chronic compression leads to direct nerve damage (myelin).

Just like any other soft tissue of the

body

A peripheral nerve can take SOME trauma without

completely falling apart

HOWEVER it can only take so much before pathology

ensues.

If ignored or left untreated or improperly

diagnosed the symptoms as well as the damage to

the structure will progress.

Nerve Pathology

Graham International Implant Institute, Inc.

Functional Anatomy

Entire weight of body travels through the talus.

Redirected from the tibia and fibula to the

Calcaneus and Navicular bones.


Sinus Tarsi

Fulcrum point Should always stay

“open” Abnormal closure of

this space leads to deformity.


PathoMechanics

Obliteration of the sinus tarsi

Plantar flexion of the talus

Abnormal forces directed throughout the foot.


Abnormal Talar DeviationLeads to Excessive Rearfoot Motion.

Medial Anterior Plantarflexion

Excessive Rearfoot MotionLeads to:

Chronic Overstretching of the soft tissue to the rearfoot

Can lead to compression of the posterior tibial nerve and it’s terminal branches.

We are familiar with the Tarsal Tunnel.

Actually 2 areas of Compression

Posterior Tibial Nerve

1st Area of Damage

2nd Area of Damage

So what’s the Good Newsis there any hope left.

Peripheral Nerves Can REGENERATE.

Putting the whole puzzle together

Nerve Damage Cycle

The most common thing we do besides breathing is walking

Excessive rearfoot motion leads to chronic overstretching and compression of the posterior tibial nerve and its terminal brances

By 50 years of age we have taken 180,000,000 steps

PN Damage- continued

This is a gradual onset problem If left untreated will continue to

develop more nerve damage Exercise/walking/standing leads to

further damage At night we are not traumatizing the

nerves which is why these patients symptoms are not as bad when they get out of bed in the morning

As the day progresses, more damage is caused to the nerve due to increased activity until….nerve goes numb

At night when going to be the patient stops traumatizing the nerves and the “wake-up” with a vengeance.

Some patients have to get out of bed and find if they walk for a while the pain subsides. Why?

They are “re-numbing” their nerves.

The

Fix

First part is to release the fibers that are “strangling” the nerves.

Surgical Decompression

Soft Tissue DecompressionPart One

Release the Lacinent Ligament-Proximal to Distal, start in the middle and work out from there. Use your pinkie

Do not need to necessarily work your way to dissect the PTN and its terminal branches.

Surgical DecompressionPart Two

Go distal through the porta pedis.

Usually have to create an opening, I use tenotomy scissors. Stick your pinkie into the porta pedis.

To show what effect hyperpronation has maximally pronate the foot with your pinkie in the porta pedis- carefully

(I am not responsible for crushed pinkies!)

I feel that it isn’t essential to go in and dissect out the nerves. As long as we “free-up” the neurovascular bundle the nerves will no long be crushed.

If we perform too much dissection around the nerve it is possible to form scar tissue

If we don’t do enough dissection it is possible to miss some of the fibers that are destroying the nerves.

How do we control the Excessive Rearfoot Motion?

Closer look at excessive hindfoot motion-hyperpronation

Weightbearing AP FluoroscopyRCSP showing transverse plane correction


NWB to WB

Hologic Insight Mini C-arm


Minimal weight with foot in ideal position versus full weight and abnormal position.



HyProCure® Extra-Osseous TaloTarsal Stabilization Device

Threaded portion locks the implant into the cervical ligament in the canalis portion of the sinus tarsi

Tapered portion abuts the lateral aspect of the canalis tarsi for accurate placement.

Outer wider diameter prevents obliteration of the sinus tarsi.

Grooved section allows for fibrous tissue in-growth to prevent backing-out of the implant.

Made of medical grade titanium

Cannulated for guide wire insertion for accurate placement within the sinus tarsi.

Before/After



Right Foot- Before & After

Weight bearing- 2 weeks post-opBefore After

Extra-Osseous TaloTarsal Stabilization with HyProCureTarsal Tunnel Decompression,

Neurolysis of Posterior Tibial Nerve, Neurolysis of the Calcaneal Nerve,

Neurolysis of the Lateral Plantar Nerve

Neurolysis of the Medial Plantar Nerve

Surgery

TaloTarsal Stabilization with HyProCure› Take about 10

minutes to perform

› Takes about 10 – 15 stents placements before you really get comfortable

Tarsal Tunnel Decompression/Neurolysis› Take about 20 min› Should use loups› Takes about 25 before

you really feel comfortable in this area

› Take your time

Apply a tourniquet to the ankle I do not inflate the tourniquet unless

there is excessive bleeding Use 10 cc’s of 1:1 mix of 0.5%

marcaine with and without epi with 1 cc of dex. Phosphate

Close skin only

The Results

Depends on which fibers are being affected

How damaged the nerves are How compliant the patients are How good of job YOU did on

decompressing the nerves How much scar tissue the patient

forms after surgery

Results- continued

Pain is almost immediately alleviated. Restoration of sensation- will take the

longest to return Results may be felt in the recovery room Or may takes months to years

No matter, instead of the patient’s condition getting worse and worse, it will potentially get better and better.

Cross Over Effect

This is real not imaginary. The damaged nerves of one foot affect

the opposite foot. Scenarios:

› Good-› Bad-› Ugly-

Cross Over Effect - Good

By decompressing one foot not only is there is improvement on that side there is also improvement in the contra-lateral limb.

IF sensation/symptoms are restored to the contra-lateral limb there is not need for tarsal tunnel decompression or neurolysis of the nerves

Cross Over Effect - Bad

Surgery to the foot yield minimal results with no change in the contra-lateral limb

The opposite limb is the dominate nerve pathology and once that side is also decompressed there should be an additional effect on both feet.

Must warn patients about this prior to surgery.

Cross Over Effect - Ugly

Nerve decompressions are performed on both feet (one at a time) and no results are felt.

Don’t take the patient’s word for it. Must perform nerve testing prior to surgery and routinely post-op.

Their nerves may be so severely damaged that it was too late.

No matter how severe I will still attempt. It just may takes years for the results to be

felt.

Complications of Surgery

Wound dehiscence Scar tissue formation

Hematoma Infection Temporary increase in nerve symptoms

?% revision rate

Complications of:

Supervised Neglect

Increased Nerve Pain Loss of Sensation Ulceration Bone infection Amputation Charcot’s Foot

Decreased Activity Level

Decreased metabolism

Increased Weight (obesity)

Diabetes Hypertension Arterial Disease

Current Forms of Treatment

Biannual testing

Extra depth shoes NSAIDS Pain pills Nerve Pills Psychiatry Wheelchair/walker

Shows increased nerve damage

Prevent ulceration Do nothing Barely take off the edge See next slide Loosing battle Syndrome X- further

decrease in activity

Nerve Pills: Neurontin, Lyrica, Cymbalta

Mask the symptoms Do not help nerve

repair Expensive

Increased symptoms, increased dosage

Side-effects› Swelling/edema› Blurred vision› Drowsiness› Fatigue/muscle

weakness› Muscle cramps› Vomiting› Constipation/Diarrhea› Sexual dysfunction

Autonomic Neuropathy

Manifests after years of peripheral nerve symptoms

We really don’t know› Why› Who› when

Only get worse Really no help

Orthostatic hypotension

Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction

Comparison of Symptoms of Side effects from Nerve Pills and Autonomic Neuropathy.





My Results

Claim 80% effective within a year› 20% will either just take > 1 year are the

nerves are just too severely damaged.

Conclusion

Doing nothing leads to progression Complications of proposed surgical

treatment options have a better outcome than supervised neglect

I hope that I have open some eyes so that we can change our thinking on this extremely serious condition

For Further Information/Training

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peripheral nerve compression syndrome

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