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Neuropathy is a generic term and is untreatable. Peripheral nerve compression is more specific and is cureable. Lets end Neuropathy.
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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.
Graham International Implant Institute, Inc.
Sinus Tarsi
Fulcrum point Should always stay
“open” Abnormal closure of
this space leads to deformity.
Graham International Implant Institute, Inc.
PathoMechanics
Obliteration of the sinus tarsi
Plantar flexion of the talus
Abnormal forces directed throughout the foot.
Graham International Implant Institute, Inc.
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
Graham International Implant Institute, Inc.
NWB to WB
Hologic Insight Mini C-arm
Graham International Implant Institute, Inc.
Graham International Implant Institute, Inc.
Minimal weight with foot in ideal position versus full weight and abnormal position.
Graham International Implant Institute, Inc.
Graham International Implant Institute, Inc.
Graham International Implant Institute, Inc.
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
Graham International Implant Institute, Inc.
Graham International Implant Institute, Inc.
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.
Orthostatic hypotension
Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction
Orthostatic hypotension
Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction
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
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