Two Cases of Popliteal Artery Entrapment Syndrome / 日本心臓血管外科学会雑誌

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication. Optimal strategies and management have been debated. We report two cases of PAES that were treated with respective different procedures. Case 1 : A 53-year-old male with intermittent claudication was referred to our department with PAES with a decrease in the ankle brachial index (ABI) with plantar flexion. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) showed medial deviation and compression of the popliteal artery by the medial head of the gastrocnemius muscle. The patient received excision of the medial head of the gastrocnemius muscle and thrombectomy of the popliteal artery. The diagnosis was confirmed as PAES type 2 during the procedure. Case 2 : A 37-year-old male presenting intermittent claudication and declining ABI in his left lower extremity was diagnosed with PAES by contrast CT. MRI and CT indicated that a fibrous band was compressing the popliteal artery. The findings of the imaging studies were confirmed during the subsequent surgical procedure and it was diagnosed as PAES type 4. In addition to removal of the band, popliteal artery interposition using a saphenous vein graft was performed due to severe stenosis with intimal hyperplasia. Pathological findings of the excised artery showed intimal hyperplasia and degeneration of elastic fibers in the media due to chronic compression. Although a large volume of retrospective data exists on PAES, recommendation of a particular operative procedure has not yet been derived. Thus, the treatment for PAES should be individually determined based on etiology and status of affected vessels.

Rare case of median nerve and brachial artery entrapment by an abnormal musculo-fascial tunnel in the arm: possible cause of neurovascular compression syndrome / 대한해부학회지

Entrapment neuropathies of the peripheral nervous system are frequently encountered due to anatomical variations. Median nerve is the most vulnerable nerve to undergo entrapment neuropathies. The clinical complications are mostly manifested by median nerve impingement in forearm and wrist areas. Median nerve entrapment could also occur at the arm, due to the presence of ligament of Struthers. Here we report a rare case of proximal entrapment of median nerve and brachial artery in the arm by an abnormally formed musculo-fascial tunnel. The tunnel was formed by the muscle fibers of brachialis and medial intermuscular septum in the lower part of arm. Due to this, the median nerve coursed deep, below the tunnel and continued distally into the forearm, underneath the pronator teres muscle and hence did not appear as a content of cubital fossa. The present entrapment of neurovascular structures in the tunnel might lead to pronator syndromes or other neurovascular compression syndromes.

Treatment of Clunial Nerve Entrapment Syndrome with Needle Knife Based on Principle of "Staging, Segmenting and Layering" / 中国中医药信息杂志

Treatment of clunial nerve entrapment syndrome with needle knife has the advantages of quick efficacy and easy application. However, because of the surgeons' lack of knowledge of the disease and the operation of different proficiency, there are differences in the treatment effects. This article introduced the guidance principle of"staging, segmenting and layering", which can improve the efficacy during treatment and be beneficial to the clinical application of all levels of clinical doctors.

Muscular Variations of Extensor Digitorum Brevis Muscle Related with Anterior Tarsal Tunnel Syndrome / 체질인류학회지

During routine dissection, additional muscular head of extensor digitorum brevis muscle attaching to the third toe and accessory muscle perforated by the branch of the deep peroneal nerve were observed in the right foot of a 71-year-old male cadaver. The additional muscular head originated from the dorsal surface of cuboid bone, and ran parallel with the third tendon of the extensor digitorum brevis muscle. It was conjoined with the third tendon of extensor digitorum brevis at the middle of its course. The accessory muscle was a small muscle which was covered with the muscle belly of the extensor hallucis brevis muscle. It originated from the dorsal surface of the calcaneus, and inserted to the lateral one-third of transverse retinacular band. These two variants were innervated by the branches of deep peroneal nerve. The branches of deep peroneal nerve were compressed under the tendon of extensor hallucis brevis and around the site where the nerve branch perforated the small muscle. The clinical significances of these variations and tendon of extensor hallucis brevis muscle were discussed.

Clinical effect of ropivacaine intrathecal injection on carpal tunnel syndrome with nervi medianus entrapment syndrome / 中国生化药物杂志

Objective To investigate the effect of intrathecal injection of ropivacaine in the treatment of carpal tunnel syndrome with nervi medianus entrapment syndrome. Methods 164 patients with carpal tunnel syndrome were selected and divided into two groups, 82 cases in the control group were given intrathecal injection of lidocaine + methylprednisolone + vitamin B1, 82 cases in the experimental group received injection of ropivacaine + methylprednisolone + vitamin B1, the symptom score, nerve electrophysiological examination index, high frequency ultrasound quantitative parameters, the clinical effect and total recurrence rate were compared after treatment. Results The effective rate in the control group(74.39%)was lower than the experimental group(87.81%)(P<0.05); compared with the control group, the visual analogue scale (VAS), global symptom score (GSS), fatigue severity scale (FSS) and Levine carpal tunnel syndrome questionnaire score were lower in the experimental group after treatment, the nervi medianus distal motor latency (DML) level was lower, sensory nerve action potential (SNAP) and sensory conduction velocity (SCV) levels were higher after treatment, the diameter of the nervi medianus, the transverse diameter (a), anteroposterior diameter (b) of nervi medianus and cross sectional area (CSA) were lower after treatment, with significant difference (P<0.05); the total recurrence rate in the control group(53.66%)was higher than the experimental group(37.80%), with significant difference (P<0.05). Conclusion The clinical effect of intrathecal injection of ropivacaine in the treatment of carpal tunnel syndrome with nervi medianus entrapment syndrome was obvious, can effectively alleviate pain, improve the symptoms of nervi medianus entrapment, restore the nervi medianus conduction velocity and function, and reduce the recurrence rate.

Clinical observation of superior gluteal nerve entrapment syndrome treated with needle-in-row combined with herb-partition moxibustion / 中国针灸

<p><b>OBJECTIVE</b>To compare the effects of need-in-row combined with herb-partition moxibustion,need-in-row and conventional acupuncture for superior gluteal nerve entrapment syndrome.</p><p><b>METHODS</b>Totally 105 patients were randomly assigned into a combination group,a need-in-row group and an acupuncture group,35 cases in each one. In the combination group and needle-in-row group,needle-in-row therapy was used at the pain tendon region of the pathological waist-hip part,and TDP was combined. Also,herb-partition moxibustion was applied at the same part after needle-in-row in the combined group. In the acupuncture group,conventional acupuncture was implemented at Weizhong(BL 40),Yanglingquan(GB 34),Zhibian(BL 54),Huantiao(GB 30),Sanyinjiao(SP 6) and Jiaji of L-L(EX-B 2),and TDP was applied. All the treatment was given once a day for four weeks. The changes of pain scores were compared after treatment.</p><p><b>RESULTS</b>The pain scores decreased obviously after treatment in all the groups(all<0.05). The scores of the combination group and the needle-in-row group declined more apparently than that of the acupuncture group(both<0.05). The score of the combination group reduced more obviously than that of the needle-in-low group(<0.05). The markedly effective rates of the combination group and the needle-in-row group were 88.6%(31/35) and 68.6%(24/35),which were higher than 40.0%(14/35) of the acupuncture group(both<0.05),and the markedly effective rate of the combination group was better than that of the needle-in-row group(<0.05).</p><p><b>CONCLUSIONS</b>Need-in-row combined with herb-partition moxibustion show definite effect for superior gluteal nerve entrapment syndrome,and it is better than those of simple needle-in-row therapy and conventional acupuncture.</p>

Pudendal Nerve Entrapment Syndrome due to a Ganglion Cyst: A Case Report

Pudendal nerve entrapment syndrome is an unusual cause of chronic pelvic pain. We experienced a case of pudendal neuralgia associated with a ganglion cyst. A 60-year-old male patient with a tingling sensation and burning pain in the right buttock and perineal area visited our outpatient rehabilitation center. Pelvis magnetic resonance imaging showed the presence of multiple ganglion cysts around the right ischial spine and sacrospinous ligament, and the pudendal nerve and vessel bundle were located between the ischial spine and ganglion cyst at the entrance of Alcock's canal. We aspirated the lesions under ultrasound guidance, and consequently his symptoms subsided during a 6-month follow-up. This is the first report of pudendal neuralgia caused by compression from a ganglion cyst around the sacrospinous ligament.

Bony Suprascapular Foramen, A Potential Site for Suprascapular Nerve Entrapment: A Morphological Study on Dried Human Scapulae.

Introduction: The superior transverse scapular ligament (STSL) is present above the suprascapular notch . It joins the two superior corners of this notch and converts it into suprascapular foramen through which passes the suprascapular nerve , while the suprascapular artery and vein usually pass above the ligament . The anterior coracoscapular ligament (ACSL) runs in the suprascapular notch, below the superior transverse scapular ligament. Narrowed bony foramen by ossification of STSL and ACSL is one of the predisposing factor of suprascapular nerve entrapment as well as with an injury to the suprascapular nerve in arthroscopic procedures. Aim: The aim of present study was to know the prevalence of suprascapular foramen in Indian dry scapulae and provide a knowledge on the variations along the course of suprascapular nerve which is essential to understanding the source of entrapment syndrome. Methods and Results: The present study was carried out on 73 dried human scapulae irrespective of age and sex. Visual observation revealed that 3 scapulae (4.1%) had completely ossified superior transverse scapular ligament and 2 scapulae (2.7 %) had partially ossified STSL. The incidence of ossified anterior coracoscapular ligament is 1.3 % ( 1 scapula ) in our study. Conclusion: The knowledge of variations in the suprascapular region and ossification of STSL & ACSL is important for anatomists, orthopaedicians, radiologists and neurosurgeons to obtain a safe zone which would be useful to avoid iatrogenic nerve lesion and for better diagnosis and management of the nerve entrapment syndrome.

Neuralgic Amyotrophy Manifesting as Mimicking Posterior Interosseous Nerve Palsy

The upper trunk of the brachial plexus is the most common area affected by neuralgic amyotrophy (NA), and paresis of the shoulder girdle muscle is the most prevalent manifestation. Posterior interosseous nerve palsy is a rare presentation in patients with NA. It results in dropped finger on the affected side and may be misdiagnosed as entrapment syndrome or compressive neuropathy. We report an unusual case of NA manifested as PIN palsy and suggest that knowledge of clinical NA phenotypes is crucial for early diagnosis of peripheral nerve palsies.

Anatomical Popliteal Artery Entrapment Syndrome Caused by an Aberrant Plantaris Muscle

PURPOSE: We report on cases of anatomical popliteal artery entrapment syndrome (PAES) caused by an aberrant plantaris muscle and highlight the involvement of this muscle in PAES. MATERIALS AND METHODS: Seven symptomatic PAES legs in six patients treated at The Division of Vascular Surgery, Asan Medical Center, Seoul, Korea, between 1995 and 2011 were included in this study. We retrospectively analyzed patient records, magnetic resonance imaging (MRI) and/or computed tomography (CT) scans of the knee joint, Doppler pressure studies, CT angiographies, and conventional femoral arteriographies. RESULTS: Five males and one female patient with a median age of 32 (18-53) years old were enrolled in the study. All patients complained of intermittent claudication of the affected leg. All aberrant plantaris muscles were higher and more medially located than normal plantaris muscles, causing occlusion of the popliteal artery upon forced plantar flexion of the ankle. For arterial lesions, five occlusions of the popliteal artery and two patent popliteal arteries with positive provocation were noted. As for treatment, myotomy of the aberrant plantaris muscle was done for two non-occlusive PAES legs. For occlusive PAES legs, one thrombectomy, one saphenous vein graft interposition of the popliteal artery followed by myotomy, and two below-knee femoro-popliteal bypasses were performed. The median follow-up period was 88 (7-148) months. CONCLUSION: An aberrant plantaris muscle can cause anatomical PAES. Classification or diagnosis of PAES should be based on axial studies using CT scans or MRI using various reconstruction methods. Treatment, including myotomy of the plantaris muscle, should be individualized.

Bilateral Anomalous Muscle In the Popliteal Fossa & Its Clinical Significance.

Muscle variation may occur due to genetic or developmental causes. Some variations may compromise the vascular, muscular or nervous system in the region. Bilateral muscle variation in popliteal fossa is very rare. In present study an instance of bilateral muscle variation in popliteal fossa, arising from different muscles like gastrocnemius and from biceps femoris is recorded. There is no report of such variations. These observations are rare of its kind because of bilateral asymmetrical presence and difference in the origins in different legs. This is the first report as for the literatures available. Clinical and functional importance of such variation is discussed with the morphological aspects of this anomalous muscle.

Clinical Features of Wrist Drop Caused by Compressive Radial Neuropathy and Its Anatomical Considerations

OBJECTIVE: Posture-induced radial neuropathy, known as Saturday night palsy, occurs because of compression of the radial nerve. The clinical symptoms of radial neuropathy are similar to stroke or a herniated cervical disk, which makes it difficult to diagnose and sometimes leads to inappropriate evaluations. The purpose of our study was to establish the clinical characteristics and diagnostic assessment of compressive radial neuropathy. METHODS: Retrospectively, we reviewed neurophysiologic studies on 25 patients diagnosed with radial nerve palsy, who experienced wrist drop after maintaining a certain posture for an extended period. The neurologic presentations, clinical prognosis, and electrophysiology of the patients were obtained from medical records. RESULTS: Subjects were 19 males and 6 females. The median age at diagnosis was 46 years. The right arm was affected in 13 patients and the left arm in 12 patients. The condition was induced by sleeping with the arms hanging over the armrest of a chair because of drunkenness, sleeping while bending the arm under the pillow, during drinking, and unknown. The most common clinical presentation was a wrist drop and paresthesia on the dorsum of the 1st to 3rd fingers. Improvement began after a mean of 2.4 weeks. Electrophysiologic evaluation was performed after 2 weeks that revealed delayed nerve conduction velocity in all patients. CONCLUSION: Wrist drop is an entrapment syndrome that has a good prognosis within several weeks. Awareness of its clinical characteristics and diagnostic assessment methods may help clinicians make diagnosis of radial neuropathy and exclude irrelevant evaluations.

Incidences and clinical implications of communications between musculocutaneous nerve and median nerve in the arm: a cadaveric study / Incidencias e implicaciones clínicas de las comunicaciones entre el nervio musculocutáneo y nervio mediano en el brazo: un estudio cadavérico

OBJECTIVES: Variations such as communications between the median nerve and musculocutaneous nerve or in their abnormal branching pattern constitute a major concern in clinical and surgical field. Knowledge of these variations not only provides the clinician with a proper interpretation of the case, but also minimizes the complication in surgical approaches in this region. METHOD: We examined 50 isolated upper limbs to investigate the possible incidences of various types of communications between these two neighbouring peripheral nerves. RESULT: Twenty-eight per cent of limbs were found to have communication between these two nerves. When categorized according to Venieratos and Anagnostopoulou's classification method, 11 out of 14 cases (79%) showed type I communications, two out of 14 (14%) showed type II and the remaining one (7%) showed type III communication pattern. CONCLUSION: Prior knowledge of communications between these two neighbouring nerves, both in terms oftheir incidences and pattern ofcommunications, may be ofconsiderable significance to neurologists and orthopaedic surgeons in dealing with nerve entrapment syndromes in the upper limb of patients.

OBEJTIVOS: Las variaciones tales como las comunicaciones entre el nervio mediano y el nervio musculocutáneo o en su patrón de ramificación anormal constituyen un interés principal en el campo clínico y quirúrgico. El conocimiento de estas variaciones no sólo proporciona una interpretación adecuada del caso clínico, sino que también minimiza la complicación en abordajes quirúrgicos en esta región. MÉTODO: Se analizaron 50 miembros superiores aislados para investigar las posibles incidencias de diversos tipos de comunicaciones entre estos dos nervios periféricos vecinos. RESULTADO: Se halló que el veintiocho por ciento de los miembros tenía comunicación entre estos dos nervios. Cuando fueron categorizados según el método de clasificación de Venieratos y Anagnostopoulou, 11 de 14 casos (79%) mostró comunicaciones de tipo I, dos de 14 (14%) mostraron el tipo II, y el restante (7%) mostró un patrón de comunicación de tipo III. CONCLUSIÓN: El conocimiento previo de las comunicaciones entre estos dos nervios vecinos, en términos tanto de sus incidencias como patrones de comunicación, puede ser de una importancia considerable para los neurólogos y ortopédicos a la hora de tratar con el síndrome del atrapamiento del nervio en la extremidad superior de los pacientes.

Clinical Characteristics of Peroneal Nerve Palsy by Posture

OBJECTIVE: Posture induced common peroneal nerve (CPN) palsy is usually produced during the prolonged squatting or habitual leg crossing while seated, especially in Asian culture and is manifested by the onset of foot drop. Because of its similarity to discogenic foot drop, patients may be diagnosed with a lumbar disc disorder, and in some patients, surgeons may perform unnecessary examinations and even spine surgery. The purpose of our study is to establish the clinical characteristics and diagnostic assessment of posture induced CPN palsy. METHODS: From June 2008 to June 2012, a retrospective study was performed on 26 patients diagnosed with peroneal nerve palsy in neurophysiologic study among patients experiencing foot drop after maintaining a certain posture for a long time. RESULTS: The inducing postures were squatting (14 patients), sitting cross-legged (6 patients), lying down (4 patients), walking and driving. The mean prolonged neural injury time was 124.2 minutes. The most common clinical presentation was foot drop and the most affected sensory area was dorsum of the foot with tingling sensation (14 patients), numbness (8 patients), and burning sensation (4 patients). The clinical improvement began after a mean 6 weeks, which is not related to neural injury times. Electrophysiology evaluation was performed after 2 weeks later and showed delayed CPN nerve conduction study (NCS) in 24 patients and deep peroneal nerve in 2 patients. CONCLUSION: We suggest that an awareness of these clinical characteristics and diagnostic assessment methods may help clinicians make a diagnosis of posture induced CPN palsy and preclude unnecessary studies or inappropriate treatment in foot drop patients.

Clinical Bilateral Poplitear Artery Entrapment Syndrome Caused by a Anomalous Origin of the Gastrocnemius Muscle / 대한스포츠의학회지

Popliteal artery entrapment syndrome can result from abnormal branching patterns of the popliteal artery or the anatomically abnormal placement of nearby muscles and tendons leading to a sustained compression of the popliteal artery. This compression leads to chronic capillary damage and early arteriosclerosis and embolism that can lead to distal ischemia. Thus early treatment is required to prevent harm to the lower limb. This is a rare congenital disease that mostly affects young adults, usually presenting with intermittent claudication of the leg, coldness and edema. A case where a 16-year-old female presented with pain and coldness in the lower right limb that started 1 year ago will be discussed. In this case, magnetic resonance imaging and arterial angiography lead to a diagnosis of popliteal artery entrapment resulting from an abnormal origin of the medial head of Gastrocnemius.

Treatment of Superficial Peroneal Nerve Entrapment Syndrome under Local Anesthesia using Ultrasonogram / 대한족부족관절학회지

PURPOSE: To review the outcomes of surgical treatment for superficial peroneal nerve entrapment. MATERIALS AND METHODS: Ultrasonogram was used for diagnosis and surgical treatment. Seven superficial peroneal nerve entrapment were surgically treated with follow up of average 16 months (range, 6~29 months). Three patients were male and four patients were female with mean age 36.7 years (range, 19~51 years). Four cases developed after repetitive ankle sprain and three cases had no etiology. RESULTS: Operation was performed mini-open and subcutaneous fasciotomy under local anesthesia. The results were excellent in two cases, good in four cases, fair in one case. CONCLUSION: Ultrasonogram was useful for diagnosis and surgical treatment of superficial peroneal nerve entrapment syndrome.

Laparoscopic left renal vein extravascular stenting for treatment of left renal vein entrapment syndrome / 中华泌尿外科杂志

ObjectiveTo investigate the surgical management of left renal vein entrapment syndrome.MethodsEight cases with left renal vein entrapment syndrome (5 males and 3 female ; mean age 26 years) with history of gross hematuria for 3 to 46 months were reviewed.Doppler ultrasound reports suggested compression of the left renal vein at mesenteric angle in all cases.And the dilated segment of the left vein was three-fold than the stricture segment in diameter.CT scan showed the abnormal angle between aorta and superior mesentery artery in all cases.Bleeding from the left ureteral orifice was detected by cystoscopy in 6 cases.We treated 8 patients by extravascular stent immobilization with laparoscope.ResultsThe operation was successful in the 8 cases without surgical complications.The average operation time was 63 min.The average blood loss was 14 ml,and the average hospital stay after operation was 6 days.Follow-up of 3 -20 months,there was no hematuria relapse since been relieved in 7 cases,one case remained microscopic hematuria.Color Doppler ultrasound examination in all 8 cases showed the narrowest inner diameter of left renal vein was 7.4 mm (6.5 - 8.7 mm),the blood flow was smooth.The angle between abdominal aorta and superior mesenteric artery become normal.Conclusions Laparoscopic left renal vein extravascular stenting could be a new surgical method to treat left renal vein entrapment syndrome.The method of putting artificial blood vessel around renal vein is simple,safe and effective.

Expression and role of connective tissue growth factor in the peripheral nerve after chronic compression injury / 中华显微外科杂志

Objective To investigate the effects of connective tissue growth factor (CTGF) on the chronic peripheral nerve compression injury and explore the function of CTGF in peripheral nerve compression injury and repair. Methods From July 2010 to September 2010, fifty aduh male SD rats were randomly divided into group A and B: group A (sham-operated group): only exposed the sciatic nerve; group B (compression group): undergone sciatic nerve entrapment operation on the right hind leg according to the method which Mackinnon adopted when he established the model of chronic sciatic nerve compression.Electron microscopy,immunohistochemistry,RT-PCR and Western-blot were performed to observe the morphological changes of the compressed nerve tissue and to determine the level of CTGF,collagen- Ⅰ,Ⅲ (COL- Ⅰ,Ⅲ),2,4,6,8,10 weeks after the surgery,respectively. Results After sciatic nerve compression,the collagen in nerve increased ; The expression of CTGF and COL- Ⅰ, Ⅲ in sciatic nerve of compressed group increased, which was statistically different compared with the sham-operation group (P ＜ 0.05); In the meanwhile,the contents of CTGF and COL- Ⅰ,Ⅲ were positively correlated in a certain period. Conclusion Peripheral nerve fibrosis can be caused by chronic nerve compression.The expression of COL- Ⅰ,Ⅲ in sciatic nerve increased and CTGF get involved in the pathophysiological process, which suggests that CTGF plays an important role in the process of neural injury and fibrosis.

Total Popliteal Artery Occlusion after Stent Insertion Diagnosed as Popliteal Artery Entrapment Syndrome / 대한내과학회지

Entrapment of the popliteal artery is a rare cause of ischemia of the lower extremities in young males. The development of local occlusive or aneurysmal changes of the popliteal artery is caused by abnormal anatomical relationships between vascular and musculotendinous structures in the popliteal fossa. A 55-year-old male patient visited Yonsei University College of Medicine with the chief complaint of claudication in his right calf. He had undergone stent insertion in the right popliteal artery for peripheral artery occlusive disease 2 years earlier. Lower extremity CT angiography showed stent fracture and in-stent thrombosis. He underwent femoral-to-popliteal artery bypass surgery. Postoperative lower extremity CT angiography showed that the vein graft was compressed between the medial head of the gastrocnemius and the semimembranosus muscle. However, the blood flow was normal and his pain was relieved.

Caput tertium gastrocnemius: Its phylogenetic and clinical basis.

The third head of Gastrocnemius has gained significance in recent years due to the advent of sports and high stakes involved in this area. More cases of young athletes with popliteal artery entrapment are seen. Early diagnosis is of great importance in order to avoid vascular complications, and aid in athletes' early rehabilitation. Increased awareness of popliteal artery entrapment syndrome combined with improvements in investigative modalities has resulted in a more frequent diagnosis of this eminently treatable condition. Therefore, we report a case of caput tertium arising from medial head of Gastrocnemius muscle, observed during routine dissection of a 55-year old male cadaver and elaborate its embryologic and clinical aspects.