改良微创胫后神经减压术治疗跗管综合征

目的探讨改良微创胫后神经减压手术（显微镜结合关节镜技术）治疗跗管综合征。方法采用独创的单切口微创胫后神经减压手术对跗管综合征患者进行手术治疗,术中采用与屈肌支持带和拇展肌之间的平行于屈肌支持带的直切口,在显微镜和关节镜下同时对胫后神经主干及其分支进行满意松解,同时显著减轻了手术损伤。结果患者足底疼痛麻木症状均明显缓解120侧,缓解14侧患肢,麻木缓解28侧,缓解程度达85%以上,胫神经传导速度明显上升。结论微创胫后神经减压手术为跗管综合征的治疗提供了一条有效的新途径。     

MR imaging of the tarsal tunnel and related spaces: normal and abnormal findings with anatomic correlation

The tarsal tunnel syndrome may be caused by extrinsic or intrinsic pressure on the posterior tibial nerve or its terminal branches. The specific symptoms depend on the extent of nerve involvement, and compression distal or proximal to the tarsal tunnel may result in variants of the syndrome. To define better the capability of MR imaging for evaluating this entity, we performed MR imaging on three normal subjects and correlated the images with cryomicrotome sections. Six patients with symptoms suggestive of tarsal tunnel syndrome also were studied with MR. In all normal subjects, MR images showed the flexor retinaculum and the structures passing deep to the retinaculum: the tibialis posterior tendon, flexor digitorum longus tendon, flexor hallucis longus tendon, and the posterior tibial neurovascular bundle. The medial calcaneal sensory branch(es) and the medial and lateral plantar nerves also were delineated. Mechanical causes of compression were shown in all six symptomatic patients. The pathologic entities included two neurilemomas, tenosynovitis involving all three tendons, a ganglion cyst arising from the flexor hallucis longus tendon sheath, posttraumatic fibrosis, and post-traumatic fibrosis with associated posttraumatic neuroma. The MR findings were confirmed surgically in five cases. MR imaging can accurately depict the contents of the tarsal tunnel and the courses of the terminal branches of the posterior tibial nerve. In our small series, MR imaging accurately showed the lesions responsible for tarsal tunnel syndrome.     

MR imaging in tarsal tunnel syndrome.

Magnetic resonance imaging was used to demonstrate the normal anatomy of the tarsal tunnel in two volunteers and to evaluate 33 feet in 27 patients with tarsal tunnel syndrome. The tarsal tunnel is a fibroosseous channel extending from the ankle to the midfoot, through which the medial tendons and the posterior tibial neurovascular bundle pass. Tarsal tunnel syndrome is a compression neuropathy of the posterior tibial nerve or one of its branches and may be caused by a variety of pathologic lesions. Magnetic resonance imaging demonstrated a mass lesion in five feet, dilated veins or varicosities in eight feet, fracture or soft tissue injury in five feet, fibrous scar in two feet, flexor hallucis longus tenosynovitis in six feet, and abductor hallucis muscle hypertrophy in one foot. Six feet were normal on MR imaging. The findings of MR imaging were confirmed in 17 of 19 patients that went to surgery. Magnetic resonance is useful for localizing lesions within the tarsal tunnel and for determining the lesion extent and relationship to the posterior tibial nerve and its branches.     

Tarsal tunnel syndrome in runners.

Tarsal tunnel syndrome has only recently been noted to be a cause of foot and ankle pain in runners. The tarsal tunnel is located just posterior to the medial malleolus and may compress the posterior tibial nerve as it passes through it, producing numbness and paraesthesia in the foot. While the aetiology of this condition is frequently multifactorial, abnormal foot and ankle mechanics and excessive training tend to be the most commonly cited aetiological factors. Successful treatment of tarsal tunnel syndrome requires an accurate diagnosis by differentiating it from plantar fasciitis and Achilles tendinitis and then making proper biomechanical and training changes in the runner. Conservative treatment is generally successful, but occasionally surgical treatment is required to decompress the nerve.     

Anatomical variations within the deep posterior compartment of the leg and important clinical consequences.

The management of musculoskeletal conditions makes up a large part of a sports medicine practitioner's practice. A thorough knowledge of anatomy is an essential component of the armament necessary to decipher the large number of potential conditions that may confront these practitioners. To cloud the issue further, anatomical variations may be present, such as supernumerary muscles, thickened fascial bands or variant courses of nerves and blood vessels, which can themselves manifest as acute or chronic conditions that lead to significant morbidity or limitation of activity. There are a number of contentious areas within the literature surrounding the anatomy of the leg, particularly involving the deep posterior compartment. Conditions such as chronic exertional compartment syndrome, tibial periostitis (shin splints), peripheral nerve entrapment and tarsal tunnel syndrome may all be affected by subtle anatomical variations. This paper primarily focuses on the deep posterior compartment of the leg and uses the gross dissection of cadaveric specimens to describe definitively the anatomy of the deep posterior compartment. Variant fascial attachments of flexor digitorum longus are documented and potential clinical sequelae such as chronic exertional compartment syndrome and tarsal tunnel syndrome are discussed.     

Ultrasound of the tarsal tunnel: Normal and pathological imaging features

Tarsal tunnel syndrome is a condition that is caused by compression of the tibial nerve or its associated branches. Diagnosis is based on clinical findings but imaging is performed to exclude a cause of compression, identified in 60 to 80% of cases. Ultrasound is a useful examination because of its high spatial resolution and ability to rapidly perform an axial survey of the nerves. The ultrasound imaging features of the tarsal tunnel are described. The etiologies and different types are illustrated through a review of clinical cases.     

MR imaging of flexor digitorum accessorius longus

Objective The flexor digitorum accessorius longus muscle (FDAL), an anomalous muscle about the ankle, has recently been implicated in tarsal tunnel syndrome. The purpose of this study is to document the prevalence of the FDAL, its MR appearance and its relation to the neurovascular bundle in the tarsal tunnel. Design and patients The prevalence of the FDAL was determined from 100 ankle MR examinations in asymptomatic individuals. The appearance of the FDAL was summarized from 20 examples of FDAL: six gathered from the asymptomatic group and 14 acquired from a group of randomly collected cases of patients with ankle complaints. Results The prevalence of the FDAL was 6%, calculated from the group of 100 asymptomatic individuals. Possessing a dominant fleshy component in the tarsal tunnel, the FDAL accompanies the posterior neurovascular bundle as it descends the ankle. Conclusion The FDAL is encountered in 6% of asymptomatic individuals. Its prominent fleshy component in the tarsal tunnel and its close proximity to the posterior tibial neurovascular bundle readily differentiate the FDAL from other medial anomalous muscles on MR imaging. Received: 29 September 1998 Revision requested: 6 November 1998 Revision received: 30 November 1998 Accepted: 30 November 1998     

Nerve disorders in dancers

Dancers are required to perform at the extreme of physiologic and functional limits. Under such conditions, peripheral nerves are prone to compression. Entrapment neuropathies in dance can be related to the sciatic nerve or from a radiculopathy related to posture or a hyperlordosis. The most reproducible and reliable method of diagnosis is a careful history and clinical examination. This article reviews several nerve disorders encountered in dancers, including interdigital neuromas, tarsal tunnel syndrome, medial hallucal nerve compression, anterior tarsal tunnel syndrome, superficial and deep peroneal nerve entrapment, and sural nerve entrapment.     

Tarsal tunnel syndrome in athletes

BACKGROUND: The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition. HYPOTHESIS: Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months. RESULTS: Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment. CONCLUSION: Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.     

MR imaging features of radial tunnel syndrome: initial experience

PURPOSE: To retrospectively assess magnetic resonance (MR) imaging features of radial tunnel syndrome. MATERIALS AND METHODS: Institutional review board approval was obtained, and informed consent was waived for the retrospective HIPAA-compliant study. MR images of 10 asymptomatic volunteers (six men, four women; mean age, 30 years) and 25 patients (11 men, 14 women; mean age, 49 years) clinically suspected of having radial tunnel syndrome were reviewed for morphologic and signal intensity alterations of the posterior interosseous nerve and adjacent soft-tissue structures. MR images of the asymptomatic volunteers were reviewed to establish the normal appearance of the radial tunnel. MR images of the symptomatic patients were evaluated for the following: signal intensity alteration and morphologic alteration of the posterior interosseous nerve; the presence of mass effect on the posterior interosseous nerve such as the presence of bursae, a thickened leading edge of the extensor carpi radialis brevis, or prominent radial recurrent vessels; signal intensity alteration within the depicted forearm musculature such as edema or atrophy; and signal intensity changes at the origin of the common extensor and common flexor tendons, which would suggest a diagnosis of epicondylitis. RESULTS: All images of volunteers demonstrated normal morphology and signal intensity within the posterior interosseous nerve and adjacent soft tissues. Two volunteers had borderline thickening of the leading edge of the extensor carpi radialis brevis. Thirteen patients (52%) had denervation edema or atrophy within muscles (supinator and extensors) innervated by the posterior interosseous nerve. One patient had isolated pronator teres edema. Seven (28%) patients had the following mass effects along the posterior interosseous nerve: thickened leading edge of the extensor carpi radialis brevis (n = 4), prominent radial recurrent vessels (n = 1), schwannoma (n = 1), or bicipitoradial bursa (n = 1). The rest of the patients had either normal MR imaging findings (n = 4) or lateral epicondylitis (n = 2). CONCLUSION: Muscle denervation edema or atrophy along the distribution of the posterior interosseous nerve is the most common MR finding in radial tunnel syndrome.     

Role of magnetic resonance imaging in entrapment and compressive neuropathy—what,where, and how to see the peripheral nerves on the musculoskeletal magnetic resonance image: part 1. Overview and lower extremity

The diagnosis of nerve entrapment and compressive neuropathy has been traditionally based on the clinical and electrodiagnostic examinations. As a result of improvements in the magnetic resonance (MR) imaging modality, it plays not only a fundamental role in the detection of space-occupying lesions but also a compensatory role in clinically and electrodiagnostically inconclusive cases. Although ultrasound has undergone further development in the past decades and shows high resolution capabilities, it has inherent limitations due to its operator dependency. We review the general concepts that should be known to evaluate the entrapment and compressive neuropathy in MR imaging. We also review the course of normal peripheral nerves, as well as various clinical demonstrations and pathological features of compressed and entrapped nerves in the lower extremities on MR imaging, according to the nerves involved. The common sites of nerve entrapment of the lower extremity are as follows: sciatic nerve around the piriformis muscle; tibial nerve at the popliteal fossa and tarsal tunnel, common peroneal nerve around the fibular neck, and digital nerve near the metatarsal head. Although MR imaging can depict the peripheral nerves in the extremities effectively, radiologists should be familiar with nerve pathways, common sites of nerve compression, and common space-occupying lesions resulting in nerve compression in MR imaging.     

Entrapment neuropathies III: lower limb

Clinicians frequently encounter compressive neuropathies of the lower extremity. The clinical history and physical examination, along with electrodiagnostic testing and imaging studies, lead to the correct diagnosis. The imaging characteristics of the compression neuropathies can include acute and chronic changes in the nerves and the muscles they innervate. We provide a detailed review of compression neuropathies of the lower extremity with an emphasis on magnetic resonance (MR) imaging characteristics. We discuss the clinical presentation, etiology, anatomical location, and MR imaging appearance of these neuropathies, including the piriformis syndrome, iliacus syndrome, saphenous neuropathy, obturator neuropathy, lateral femoral cutaneous neuropathy (meralgia paresthetica), proximal tibial neuropathy, common peroneal neuropathy, deep peroneal neuropathy, superficial peroneal neuropathy, tarsal tunnel syndrome, Baxter's neuropathy, jogger's foot, sural neuropathy, and Morton's neuroma.     

Disfunción del tendón tibial posterior: ¿qué otras estructuras están implicadas en el desarrollo del pie plano adquirido del adulto?

Objective

To evaluate the association of posterior tibial tendon dysfunction and lesions of diverse ankle structures diagnosed at MRI with radiologic signs of flat foot.

Material and methods

We retrospectively compared 29 patients that had posterior tibial tendon dysfunction (all 29 studied with MRI and 21 also studied with weight-bearing plain-film X-rays) with a control group of 28 patients randomly selected from among all patients who underwent MRI and weight-bearing plain-film X-rays for other ankle problems.In the MRI studies, we analyzed whether a calcaneal spur, talar beak, plantar fasciitis, calcaneal bone edema, Achilles’ tendinopathy, spring ligament injury, tarsal sinus disease, and tarsal coalition were present. In the weight-bearing plain-film X-rays, we analyzed the angle of Costa-Bertani and radiologic signs of flat foot. To analyze the differences between groups, we used Fisher's exact test for the MRI findings and for the presence of flat foot and analysis of variance for the angle of Costa-Bertani.

Results

Calcaneal spurs, talar beaks, tarsal sinus disease, and spring ligament injury were significantly more common in the group with posterior tibial tendon dysfunction (P<.05). Radiologic signs of flat foot and anomalous values for the angle of Costa-Bertani were also significantly more common in the group with posterior tibial tendon dysfunction (P<.001).

Conclusion

We corroborate the association between posterior tibial tendon dysfunction and lesions to the structures analyzed and radiologic signs of flat foot. Knowledge of this association can be useful in reaching an accurate diagnosis.     

MRI findings in patients with tibial nerve compression near the knee

The soleus sling has been recently identified as a site of compression of the tibial nerve resulting in tibial neuropathy. Diagnosis of soleal sling syndrome is difficult, and has been based mainly on clinical examination. Advances in MR imaging with high-resolution 3-Tesla scanners have made direct visualization of nerve pathology possible. With the use of high-resolution imaging and fat-suppression protocols, tibial nerve compression at the soleal fascial arch can be demonstrated in a subset of patients presenting with idiopathic tibial neuropathy. The purpose of this paper is to confirm the ability of MR imaging to demonstrate pathologic changes in the tibial nerve in patients presenting with soleal sling syndrome. Additionally, patients presenting with tibial neuropathy and ganglion cysts, both extra- and intraneural, were examined to determine if the site of compression corresponded to the region of the soleus sling. Nine patients were included in the study, two with idiopathic soleus sling syndrome, four with extraneural, and three with intraneural ganglion cysts. In the patients presenting with idiopathic soleus sling syndrome, MR imaging demonstrated a thickened soleus sling with T2 hyperintensity of the tibial nerve at the level of the sling and denervation changes in muscles of the posterior compartment of the leg. In patients with extraneural ganglion cysts, MR imaging demonstrated a “sandwich”-like compression of the tibial nerve between the cyst and the soleus sling with corresponding tibial nerve T2 hyperintensity and denervation change in posterior compartment muscles. No compression of the tibial nerve at the soleus sling was found in the intraneural ganglion population. We conclude that MR imaging is effective in demonstrating pathologic changes in the tibial nerve at the soleus sling. Based on the MRI findings, we also believe that the soleus sling is a component of the compression when patients present with extraneural ganglion cysts and tibial neuropathy near the knee; in these patients, we recommend release of the soleus sling as part of the definitive management.     

神经肌电图在诊断糖尿病早期周围神经病变中的应用

目的探讨几种神经肌电图检测方法在早期糖尿病患者诊断周围神经损害中的敏感指标。方法对271例不同病程糖尿病患者的正中神经、尺神经、腓浅神经、腓总神经运动神经传导速度（MCV）与感觉神经传导速度（SCV）、尺神经f波、胫神经H反射等,采用神经电生理方法进行测定。结果271例患者胫神经的H反射平均异常率为77．5％,且随着病程的增加,异常率明显增加;双下肢腓总神经MCV与腓浅神经SCV≥10年组中异常率超过40％,其他组的异常率均在20％～30％之间。本组患者中,伴腕管综合征的有37例、65侧,总检出率13．7％。综合几项神经肌电图检测方法对糖尿病周围神经病的诊断异常率,随病程延长,异常发生率逐渐增加,在〈1年组中,异常发生率达63．2％;在〉10年组中,异常率更是高达95．6％。结论胫神经H反射是糖尿病早期周围神经病变最敏感指标,且随病程延长,肌电图检查的异常率随之增高。此外,不应忽视糖尿病腕管综合征的诊断,在报告结果的时候,要综合神经肌电图几项检查结果,正确评价糖尿病周围神经功能状态。     

Magnetic resonance microscopy imaging of posterior interosseous nerve palsy

Posterior interosseous nerve palsy, also called deep radial nerve syndrome, is a neuropathy caused by radial nerve entrapment or compression at the level of the supinator muscle. Although imaging studies are not necessary for diagnosing this syndrome because of its characteristic clinical manifestations, the causes of palsy, which include mass lesions, or precise anatomical findings can sometimes be demonstrated by imaging. Magnetic resonance (MR) findings of posterior interosseous nerve palsy have been described as involving atrophy of related muscles caused by denervation, a common secondary change of this nerve disorder. We present a case in which the swollen posterior interosseous nerve itself could be directly depicted by MR imaging using a 4.7-cm microscopy coil in a patient with neuropathy.     

Preventing Heat Injury in Sports

Most of the common foot problems that bother active middle-aged people are self-limiting and easily treated if detected early. Reviewed here are the causes, symptoms, diagnosis, and treatment of hallux valgus and rigidus, lesser-toe deformities, corns, Morton's neuroma, metatarsal stress fractures, plantar fasciitis, posterior tibialis tenosynovitis and rupture, acquired pes planus, tarsal tunnel syndrome, and foot problems related to rheumatoid arthritis and diabetes. In most cases, conservative treatment will enable patients to return to activity relatively quickly.     

Value of computed tomography arthrography with delayed acquisitions in the work-up of ganglion cysts of the tarsal tunnel: report of three cases

Ganglion cysts are a common cause of tarsal tunnel syndrome. As in other locations, these cysts are believed to communicate with neighboring joints. The positive diagnosis and preoperative work-up of these cysts require identification and location of the cyst pedicles so that they may be excised and the risk of recurrence decreased. This can be challenging with ultrasonography and magnetic resonance (MR) imaging. We present three cases of symptomatic ganglion cysts of the tarsal tunnel, diagnosed by MR imaging, where computed tomography (CT) arthrography with delayed acquisitions helped to confirm the diagnosis and identify precisely the topography of the communication with the subtalar joint. These cases provide new evidence of the articular origin of ganglion cysts developing in the tarsal tunnel.     

Magnetic resonance imaging in the diagnosis of tarsal tunnel syndrome. Case report

In a patient suspected of having tarsal tunnel syndrome by clinical and electrophysiological exam, magnetic resonance imaging (MRI) was performed in an attempt to define the cause. Transverse and sagittal T1 and T2 images were obtained which demonstrated tubular T2 enhancing masses felt to be abnormally dilated and tortuous veins with slow flow. The nerve was displaced posteriorly from its usual position. Surgery confirmed these findings and the retinaculum was released with good results. In certain cases, therefore, MRI can be of help in the tarsal tunnel although its overall role has yet to be defined.     

Tibial tunnel placement in posterior cruciate ligament reconstruction: a systematic review

Purpose

Reconstruction of the posterior cruciate ligament (PCL) yields less satisfying results than anterior cruciate ligament reconstruction with respect to laxity control. Accurate tibial tunnel placement is crucial for successful PCL reconstruction using arthroscopic tibial tunnel techniques. A discrepancy between anatomical studies of the tibial PCL insertion site and surgical recommendations for tibial tunnel placement remains. The objective of this study was to identify the optimal placement of the tibial tunnel in PCL reconstruction based on clinical studies.

Methods

In a systematic review of the literature, MEDLINE, EMBASE, Cochrane Review, and Cochrane Central Register of Controlled Trials were screened for articles about PCL reconstruction from January 1990 to September 2011. Clinical trials comparing at least two PCL reconstruction techniques were extracted and independently analysed by each author. Only studies comparing different tibial tunnel placements in the retrospinal area were included.

Results

This systematic review found no comparative clinical trial for tibial tunnel placement in PCL reconstruction. Several anatomical, radiological, and biomechanical studies have described the tibial insertion sites of the native PCL and have led to recommendations for placement of the tibial tunnel outlet in the retrospinal area. However, surgical recommendations and the results of morphological studies are often contradictory.

Conclusions

Reliable anatomical landmarks for tunnel placement are lacking. Future randomized controlled trials could compare precisely defined tibial tunnel placements in PCL reconstruction, which would require an established mapping of the retrospinal area of the tibial plateau with defined anatomical and radiological landmarks.

Level of evidence

III.