Combining reverse end-to-side neurorrhaphy with rapamycin treatment on chronically denervated muscle in rats.

This preliminary research determines whether a combination of reverse end-to-side neurorrhaphy and rapamycin treatment achieves a better functional outcome than a single application after prolonged peripheral nerve injury. We found that the tibial nerve function of the reverse end-to-side + rapamycin group recovered better, with a higher tibial function index value, higher amplitude recovery rate, and shorter latency delay rate (P < 0.05). The reverse end-to-side + rapamycin group better protected the gastrocnemius muscle with more forceful contractility, tetanic tension, and a higher myofibril cross-sectional area (P < 0.05). Combining reverse end-to-side neurorrhaphy with rapamycin treatment is a practical approach to promoting the recovery of chronically denervated muscle atrophy after peripheral nerve injury.

The injection site in the tarsal tunnel to minimize neurovascular injury for heel pain: an anatomical study.

INTRODUCTION: The aim of this study was to investigate the location and distribution patterns of neurovascular structures and determine the effective injection point in the tarsal tunnel for heel pain. METHODS: Fifteen adult non-embalmed cadavers with a mean age of 71.5 years were studied. The most inferior point of the medial malleolus of the tibia (MM) and the tuberosity of the calcaneus (TC) were identified before dissection. A line connecting the MM and TC was used as a reference line. The reference point was expressed in absolute distance along the reference line using the MM as the starting point. For measurements using MRI, the depth from the skin was measured to inferior at an interval of 1 cm from the MM. RESULTS: The posterior tibial artery, lateral plantar nerve, and medial plantar nerve were located from 29.0 to 37.3% of the reference line from the MM. The distribution frequencies of the medial calcaneal nerve on the reference line from the MM were 0%, 8.60%, 37.15%, 37.15%, and 17.10%, respectively. The mean depth of the neurovascular structures was 0.3 cm. DISCUSSION: This study recommended an effective injection site from 45.0 to 80.0% of the reference line.

Monomelic Ischemic Neuropathy of the Tibial and Peroneal Nerve After Onyx Embolization of Vasa Nervorum Supplying a Surgically Excluded Popliteal Artery Aneurysm.

Ischemic neuropathy is an exceedingly rare complication after peripheral artery embolization. We report a case of ischemic damage to the tibial and peroneal nerve after embolization of the vasa nervorum that served as feeding collaterals to a surgically excluded popliteal artery aneurysm.

Lower extremity nerve entrapments in athletes.

Nerve entrapments are a potential cause of lower extremity pain in athletes. Signs and symptoms suggestive of nerve entrapment include anesthesia, dysesthesias, paresthesias, or weakness in the distribution of a peripheral nerve. The physical examination may reveal an abnormal neurologic examination finding in the distribution of a peripheral nerve, positive nerve provocative testing, and positive Tinel sign over the area of entrapment. Electrodiagnostic studies, radiographs, magnetic resonance imaging studies, and sonographic evaluation may assist with the diagnosis of these disorders. Initial treatment usually involves conservative measures, but surgical intervention may be required if conservative treatment fails. This article discusses the diagnosis and treatment of common lower extremity nerve entrapments in athletes. A high index of suspicion for nerve entrapments enables the clinician to identify these conditions in a timely manner and institute an appropriate management program, thus improving patient outcomes.

[Tibial nerve paresis in eight dairy cows: symptomatic therapy with a synthetic resin cast]. / Nervus-tibialis-Parese bei acht Milchkühen - symptomatische Therapie mithilfe eines Kunstharzverbands.

OBJECTIVE: Tibial paresis is commonly seen in bovine practice as a sequel to dystocia. The tibial nerve supplies the extensor muscles of the hock joint and the flexor muscles of the digits; affected cows are lame and have a dropped hock and knuckling of the fetlock. Complete functional recovery occurs not consistently after a conservative "wait and see" approach. The aim of this study was to investigate the usefulness of a cast applied to the lower portion of the affected limb as a supportive treatment of tibial nerve paresis in cows. MATERIALS AND METHODS: Eight dairy cows with tibial nerve paresis from different farms were presented for treatment. Seven cows had unilateral tibial nerve paresis and one cow, which was barely able to stand, had bilateral tibial paresis. The affected legs of the seven cows with unilateral paresis and the more severely affected leg of the remaining cow were stabilized using a cast made of synthetic resin. The claws and the skin of the affected limbs were cleaned and a thick layer of cotton was applied to pad the leg from the foot to the hock. A cast was then applied with the foot and metatarsus aligned in a straight line. The cast included the entire foot and extended to the hock. The cast was removed after 4 weeks. RESULTS: All of the eight cows could be kept in their normal environment. They were able to walk well with the cast and were only mildly lame. Feed intake and milk yield increased. After removal of the cast, seven of the eight cows walked normally, including the cow of which both legs had been affected. One cow was slightly lame with a dropped hock after cast removal but showed a normal gait 3 weeks later. CONCLUSIONS AND CLINICAL RELEVANCE: In cows with tibial paresis, casting of the lower portion of the leg was a useful supportive treatment that resulted in restoration of normal gait. In seven of eight treated cows limb function was normal after 4 weeks, and in one cow after 7 weeks. This supportive therapeutic procedure is straightforward, minimizes aftercare and allows the cow to be kept in her normal environment.

Common peroneal and tibial nerve paralysis secondary to herpes zoster infection: a case report.

BACKGROUND: The usual presentation of herpes zoster (HZ) is a self-limiting vesicular rash, often accompanied by post-herpetic neuralgia. However, HZ can give rise to other complications, that have unusual presentations and serious sequelae like segmental motor paralysis of the limbs that is a relatively rare complication. CASE: A 68-year-old man presented with foot drop on the right side had a history of HZ infection on and around the knee and the popliteal fossa. He was treated with acyclovir by a dermatologist and 10 days after the inital symptoms he developed weakness on the right ankle and on the muscles distal to the knee. In a few days foot drop has developed and he was unable to walk without help. Three months later he was admitted to the neurology out patient clinic. On his electrophysiological examination common peroneal nerve could not be stimulated on the right side. The distal latency of the tibial nerve has prolonged, CMAP amplitude has diminished and the nerve conduction velocity has slowed down. Latency of the sural nerve has prolonged with a small SNAP amplitude and a slow nerve conduction velocity on the right side. Electromyography revealed denervation on the muscles inervated by tibialis anterior and common peroneal nerves distal to the knee. CONCLUSION: The double mononeuropathy of the tibial and common peroneal nerves secondary to HZ was not found in the published data. HZ should be considered as a possible cause of the paralysis of peripheral nerves and more attention should be paid to it.

Acute electroacupuncture inhibits nitric oxide synthase expression in the spinal cord of neuropathic rats.

OBJECTIVES: To examine the effects of electroacupuncture stimulation on behavioral changes and neuronal nitric oxide synthase expression in the rat spinal cord after nerve injury. METHODS: Under pentobarbital anesthesia, male Sprague-Dawley rats were subjected to neuropathic surgery by tightly ligating and cutting the left tibial and sural nerves. Behavioral responses to mechanical stimulation were tested for 2 weeks post-operatively. At the end of behavioral testing, electroacupuncture stimulation was applied to ST36 (Choksamni) and SP9 (Eumleungcheon) acupoints. Immunocytochemical staining was performed to investigate changes in the expression of neuronal nitric oxide synthase-immunoreactive neurons in the L4-5 spinal cord. RESULTS: Mechanical allodynia was observed by nerve injury. The mechanical allodynia was decreased after electroacupuncture stimulation. Neuronal nitric oxide synthase expression was also decreased in L4-5 spinal cord by electroacupuncture treatment. DISCUSSION: These results suggest that electroacupuncture relieves mechanical allodynia in the neuropathic rats possibly by the inhibition of neuronal nitric oxide synthase expression in the spinal cord.

The effect of autogenous vein grafts on nerve repair with size discrepancy in rats: an electrophysiological and stereological analysis.

Aside from anatomical repairs, the reestablishment of sensory and motor innervations for proper functional recovery is one of the fundamental objectives of reconstructive surgery. The heterotopic transfer of autologous tissues is likely to result in a size discrepancy between the donor and recipient nerves, which will have a negative influence on regeneration. Twenty Wistar albino female rats were used in a study that was divided into two main groups: tibial-peroneal (TP) and peroneal-tibial repair (PT). Both types of nerves were exposed on the hind legs with the nerves cut on the right side, while the proximal stump of the tibial nerve and distal stump of the peroneal nerve were sutured to each other. These groups are also called end-to-end neurorrhaphy groups (EtoE). On the left side, the tibial and peroneal nerves were cut on the same level as on the right side. After the end-to-end epineural suturing of the nerve, the vein graft was slid over to the repair zone under irrigation. These are called the vein graft group (VG). All processes mentioned above were also done for the PT group. On the 90th postoperative day, anesthetized animals were fixed prone on a board, with the nerves carefully dissected for electrophysiological recording. Stereological methods for an estimation of the total number of myelinated fiber, a mean axonal cross-section area and the thickness of the myelin sheet were used. In TP and PT groups, nerve conduction velocities were found to be higher within the VG group. Nevertheless; the difference was only significant in the PT group. In both TP and PT groups, the increase in the axon number, axon area and myelin thickness were statistically different in favor of the vein graft sides. An appearance of vacuoles and degenerated pertinacious material within the myelin sheath of EtoE sides was seen. A histomorphological examination of the sections proximal to, from, and distal to the repair zone over three months revealed less epineural scarring, a thinner epineurium, more regenerated axons and fewer inflammatory cells in groups where vein grafting was used, because the vein graft provided additional mechanical and chemical support in the size discrepancy of the nerve regeneration.

Chondrotinase ABC enhances axonal regeneration across nerve gaps.

We evaluated the effects of chondroitinase ABC on axonal regeneration across peripheral nerve gaps. We compared axonal regeneration after 15-mm tibial nerve resection and repair with a silicone tube filled with type I collagen gel (negative control group), with a silicone tube filled with type I collagen gel containing chondroitinase ABC at three different concentrations (2.5 units/mL, 5 units/mL, 10 units/mL) (chondroitinase ABC groups), and with an autologous nerve segment (nerve autograft group). Electrophysiological and histological assessments were carried out 12 weeks after surgery. In the electrophysiological study, compound muscle action potentials (CMAPs) and nerve conduction velocities (NCVs) were recorded in all groups except the negative control group. Although both CMAPs and NCVs were highest in the nerve autograft group, there were no significant differences among the three chondroitinase ABC groups in either parameter. Histological findings were consistent with electrophysiological results. Based on these findings, we conclude that topical injection of chondroitinase ABC can significantly increase the critical length of nerve gap repair by tubulization or artificial nerve placement.

A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers.

OBJECTIVE: The purpose of this study was to compare the effectiveness of a removable cast walker (RCW) rendered irremovable (iTCC) with the total contact cast (TCC) in the treatment of diabetic neuropathic plantar foot ulcers. RESEARCH DESIGN AND METHODS: In a prospective, randomized, controlled trial, 41 consecutive diabetic patients with chronic, nonischemic, neuropathic plantar foot ulcers were randomly assigned to one of two groups: a RCW rendered irremovable by wrapping it with a single layer of fiberglass casting material (i.e., an iTCC) or a standard TCC. Primary outcome measures were the proportion of patients with ulcers that healed at

Transplanted neural stem cells promote axonal regeneration through chronically denervated peripheral nerves.

Regeneration in the peripheral nervous system is impaired after prolonged periods of denervation. Currently, no interventions exist to alter the outcome after prolonged denervation. To examine the role of transplanted neural stem cells (NSC), we prepared chronically denervated distal tibial nerve segments. After 6 months of chronic denervation, we transplanted vehicle, C17.2 mouse NSCs, or C17.2 mouse NSCs engineered to overexpress GDNF to the distal tibial nerve and performed a peroneal nerve cross-suture. In animals transplanted with the NSCs, there was better regeneration of the peroneal axons into the tibial nerve as measured by counting the number of axons and by the emergence of compound motor action potentials in the tibial innervated foot muscles. Improved regeneration correlated with a reduction of chondroitin sulphate proteoglycan (CSPG) immunoreactivity in the extracellular matrix (ECM). In vitro, supernatant from C17.2 NSCs contained large quantities of secreted matrix metalloprotease-2 (MMP-2), degraded the CSPGs on chronically denervated tibial nerve sections, and reversed the CSPG-induced inhibition of neuritic outgrowth of DRG neurons. This reversal was inhibited by selective MMP-2 inhibitors. This is the first successful demonstration of regeneration through a chronically denervated nerve. These findings suggest that improved regeneration in the PNS can be accomplished by combining neurotrophic factor support and removal of axon growth inhibitory components in the extracellular matrix.

Differential diagnosis and treatment of subcalcaneal heel pain: a case report.

OBJECTIVE: To describe the examination and intervention strategy utilized in the differential diagnosis and treatment of a patient with subcalcaneal heel pain. BACKGROUND: The patient was a 44-year-old man with an 8-month history of left subcalcaneal heel pain. He presented with a chief complaint of limited standing and walking tolerance secondary to pain in the left heel. He had not responded to previous treatments of rest, anti-inflammatory medication, cortisone injections, and exercise prescription. MATERIALS AND METHODS: The patient's subcalcaneal heel pain was reproduced utilizing the straight leg raise (SLR) in combination with ankle dorsiflexion and eversion to sensitize the tibial nerve. These findings suggested a neurogenic component to the dysfunction. Because restricted ankle dorsiflexion, excessive pronation, and posterior tibialis weakness were also found, mechanical dysfunctions also likely contributed to the etiology of heel pain. The patient was treated for 10 visits over a period of 1 month. Treatment consisted of active and passive motions aimed at restoring pain-free soft-tissue motion along the course of the tibial nerve. In addition, low-dye taping and therapeutic exercises were utilized to control excessive pronation and reduce stress on the plantar structures of the foot. RESULTS: The patient's SLR increased from 42 degrees to 54 degrees and became pain-free. Dorsiflexion range of motion increased from 3 degrees to 8 degrees in the left ankle, and left posterior tibialis strength was normalized. Over a period of 1 month the patient's symptoms were resolved, and his standing and walking tolerance was fully restored. CONCLUSION: Assessment and potential contribution of neural dysfunction should be considered in patients with subcalcaneal heel pain.