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HV Chapter 28-Entrapment Neuropathies 28 Entrapment Neuropathies STEPHEN J. MILLER DEFINITIONS pingement by an anatomic neighbor causing a local- ized entrapment.8 Entrapment may also be caused by Peripheral neuropathy is defined as deranged function scarring or fibrosis from local trauma, bleeding, or and structure of peripheral, motor, sensory, and auto- traction that tends to bind the nerve down, thus re- nomic neurons, involving either the entire neuron or stricting normal mobility within the tissues. selected levels.1,2 The major categories of peripheral Traumatic neuropathies are the result of either neuropathies are seen in Table 28-1. Because this closed injuries or open injuries to peripheral nerves. chapter is concerned with nerve problems seen in the Early treatment usually involves prophylaxis and re- foot that are most amenable to local treatment, only pair, while later attention is directed toward the pain- the last four categories are considered. ful neuromas or nerve entrapments that result from A true neuroma consists of an unorganized mass of the body's healing processes. ensheathed nerve fibers embedded in scar tissue that Nerve sheath tumors are named according to their originate from the proximal end of a transected pe- structure derivation. They can be benign or malignant. ripheral nerve.3 Neuromas are always the result of Nerve sheath tumors fall under another general cate- trauma. When the injury is incomplete (partial lacera- gory known as parenchymatous disorders because tion, traction) or the result of blunt trauma the lesion they can involve excessive growth of specific neural will form within the epineurium and produce a fusi- elements: neuron or axon, Schwann cell, perineurial form or eccentric nodular swelling termed "neuroma- cell, and endoneurial fibroblast. This is in contrast to in-continuity."4 In either case, the axonal elements are the lesions described previously, termed interstitial disrupted such that they are arranged in a somewhat disorders, in which external factors cause the derange- haphazard fashion. ments.12 Morton's neuroma, the interdigital or intermetatar- sal lesion accurately described initially by the English chiropodist Louis Durlacher,5 is actually a misnomer. It is neither a true neuroma nor a neoplasm. Rather, it ANATOMY is best defined as a mechanical neuropathy with com- pression, stretching, and entrapment components in Neuralgic pain in the foot and ankle can be traced to its etiology. Pathologically, this lesion is a progressive problems with the peripheral nerves. When the pre- degenerative, and at times regenerative, process in senting symptoms—burning, tingling, numbness and which early and late changes may be found. Character- other paresthesias—sound as though there is nerve istic histologic findings support this etiology (Table involvement, it is important to exclude proximal and 28-2). As a result, Morton's neuroma might be more systemic causes of neuropathy. Examples include accurately termed a perineural fibroma. 6,7 radiculopathy, compression syndromes, entrapment Mechanical peripheral neuropathies are caused by neuropathies, autonomic dysfunction, diabetes melli- local or extrinsic compression phenomena or im- tus, ischemia, pernicious anemia, polycythemia vera, 401 402 HALLUX VALGUS AND FOREFOOT SURGERY Table 28-1. Peripheral Neuropathies Table 28-3. Motor Innervation to the Leg and Foot Vascular-ischemic Spinal Metabolic Muscle Perpheral Nerve Level Nutritional Tibialis anterior Deep peroneal L4,5 Infectious Toxic Extensor digitorum longus Deep peroneal L4,5 Hereditary Extensor hallucis longus Deep peroneal L4,5 Inflammatory demyelinating Peroneus tertius Deep peroneal L Mechanical 4,5 Compression Gastrocnemius Tibial S1,2 Entrapment Soleus Tibial S1,2 Traumatic Plantaris Tibial S1,2 Closed injuries Open injuries Popliteus Tibial L4,5,S1, Painful neuromas Flexor hallucis longus Tibial S Nerve sheath tumors 2,3 Flexor digitorum longus Tibial S2,3 Tibialis posterior Tibial L4,5 Peroneus longus Superficial peroneal hypothyroidism, erythromelalgia, and alcoholism and L5,S1,2 other systemic diseases. Peroneus brevis Superficial peroneal L5,S1,2 To further isolate problems within the nerves of the Extensor digitorum brevis Deep peroneal S1,2 foot, a thorough understanding of the peripheral neu- Abductor hallucis Medial plantar S2,3 roanatomy and cord level innervation is essential. Six Flexor digitorum brevis Medial plantar S2,3 nerves cross the ankle joint into the foot: the saphe- First lumbricalis Medial plantar S2,3 nous nerve, the medial dorsal cutaneous nerve, the Flexor hallucis brevis Medial plantar S2,3 intermediate dorsal cutaneous nerve, the deep pero- Abductor digiti quinti brevis Lateral plantar S2,3 neal nerve, the posterior tibial nerve, and the lateral Quadratus plantae Lateral plantar S2,3 9 dorsal cutaneous nerve or sural nerve (Figs. 28-1 Second, third, fourth lum- Lateral plantar S2,3 through 28-4). bricales There can be anatomic variations of all the periph- Adductor hallucis Lateral plantar S2,3 eral nerves, deviating somewhat from these descrip- Flexor digiti quinti brevis Lateral plantar S2,3 tions. However, the basic pattern must be understood Plantar interossei Lateral plantar S2,3 and applied in the clinical setting. Also required is a Dorsal interossei thorough knowledge of the neurodermatomes (Table First, second Deep peroneal, S1,2,3 lateral plantar 28-3; Figure 28-5) and muscle innervation by periph- Third, fourth Lateral plantar S eral nerve and spinal cord level. This battery of infor- 2,3 mation is essential so that the clinician can isolate and locate peripheral nerve pathology in the foot, ankle, and leg. PERIPHERAL NERVE ANATOMY A peripheral nerve is composed of many nerve fibers, which may vary in length from 0.5 mm. to 1 m. or Table 28-2. Histopathology of Morton's Neuroma 10,11 _______________(Perineural Fibroma)_______________ more. Each nerve fiber consists of the axon, with its thin outer layer or axolemma surrounding the vis- Venous congestion (early stages) Endoneural and neural edema (early stages). cous axoplasm, the Schwann cell, and Schwann cell Perineural, epineural, and endoneural fibrosis and hypertrophy sheath with or without myelin (Fig. 28-6A). Myelinated (late stages) nerves have one axon per Schwann cell, while unmy- Renaut's body formation (evidence of local pressure damage) Hyalinization of the walls of endoneurial blood vessels. elinated fibers have several axons surrounded by a Subintimal and perivascular fibrosis that may lead to occlusion of single Schwann cell (Fig. 28-6B). It should be noted, as local blood vessels (resembling healed vasculitis) conduction rates are directly related to fiber size, that Mucinous changes endoneurially and perineurally Demyelination with axonal loss the larger myelinated fibers conduct at a more rapid rate than unmyelinated axons. ENTRAPMENT NEUROPATHIES 403 Common peroneal n. Deep peroneal n. Lateral cutaneous n. Superficial peroneal n. Medial br. of superficial peroneal n . Lateral br. of superficial peroneal n. Sural n Fig. 28-1. Peripheral nerves of front and lateral side of leg and dorsum of foot. Each nerve fiber is surrounded by an endoneurial with local scar tissue in certain entrapment neurop- sheath (endoneurium), which includes the basal athies. membrane of the Schwann cell outside the myelin sheath as well as the reticular and collagen fibers that provide the supporting framework (Fig. 28-7). DIAGNOSIS OF NERVE INJURIES Within a peripheral nerve is a fascicle, a unit consist- AND ENTRAPMENTS ing of a group of nerve fibers surrounded by the peri- neurium. This perineurial sheath is composed of epi- Patients afflicted with nerve injuries or compression thelial-like cells as an inner layer and collagen problems tend to experience pain and paresthesia typ- connective tissue as an outer layer (Fig. 28-7). ical of nerves. Sometimes these are enhanced with Finally, a single fascicle or group of fascicles will bizarre symptoms, especially when the patient has an make up the peripheral nerve itself. The collagenous overly anxious or hysterical personality. The pain is connective support tissue surrounding these fascicles characteristically of a sharp or burning nature, local- is known as the epineurium, which may be external or ized over the sensory distribution of the involved interfascicular. It is this tissue that can become bound nerve. The extent of the area involved will depend on 404 HALLUX VALGUS AND FOREFOOT SURGERY Dorsal proper digital n. Deep peroneal n. Lateral dorsal cutaneous n. Intermediate dorsal Medial dorsal I cutaneous n. cutaneous n. Superficial peroneal n. Saphenous n. Fig. 28-2. Peripheral nerves on dorsum of foot. what portion of the nerve trunk is damaged or im- proximally. As the neuropathy persists over time, mus- pinged. cle tenderness can be found, leading eventually to pa- Early in the entrapment process the patient may resis and disuse atrophy. experience muscle cramps or a feeling of tight, heavy, Sensorimotor examination is central to objective or swollen feet. Dysesthesia, hyperesthesia, and hypes- evaluation. Decreased two-point tactile discrimination thesia can be extremely uncomfortable. The pain may greater than 6 mm is an early sign. When the nerve is then progress to altered sensations of tingling, burn- accessible, deep palpation may reveal enlargement or ing, or numbness that are often present at rest and elicit tenderness and paresthesia; often, it will repro- may increase in severity at night, causing restlessness. duce the patient's symptoms. Percussion
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