Spontaneous Incomplete Recovery of Peroneal Palsy After a Sealbite

Incomplete recovery of peroneal palsy, after a sealbite during swimming has not been reported. A 58-year-old woman was bitten into the right knee by a seal during swimming, resulting in incomplete division of the right profound branch of the peroneal nerve and complete division of the superficial branch of the peroneal nerve. Initial drop-foot, absent foot eversion, and hypaesthesia of the lateral lower leg were followed by almost complete clinical recovery of motor functions within four month by spontaneous re-innervation from the proximal nerve stump, despite severely abnormal electrophysiological findings. Re-evaluation 6 years after the accident revealed only discrete weakness for foot and toe extension, slight distal hypaesthesia, but still increased distal latency, reduced compound muscle action potential, slowed nerve conduction velocity of the right peroneal nerve, and neurogenic electromyography of the right anterior tibial and long peroneal muscles. Nerve conduction studies were hampered by co-innervation of the extensor digitorum brevis muscles by the tibial nerves. This case shows that peroneal palsy from a sealbite may recover spontaneously almost completely, but may go along with residual, subclinical, electrophysiological abnormalities. The later may be enhanced by innervation variants.     

Spontaneous incomplete recovery of peroneal palsy after a sealbite

Incomplete recovery of peroneal palsy, after a sealbite during swimming has not been reported. A 58-year-old woman was bitten into the right knee by a seal during swimming, resulting in incomplete division of the right profound branch of the peroneal nerve and complete division of the superficial branch of the peroneal nerve. Initial drop-foot, absent foot eversion, and hypaesthesia of the lateral lower leg were followed by almost complete clinical recovery of motor functions within four month by spontaneous re-innervation from the proximal nerve stump, despite severely abnormal electrophysiological findings. Re-evaluation 6 years after the accident revealed only discrete weakness for foot and toe extension, slight distal hypaesthesia, but still increased distal latency, reduced compound muscle action potential, slowed nerve conduction velocity of the right peroneal nerve, and neurogenic electromyography of the right anterior tibial and long peroneal muscles. Nerve conduction studies were hampered by co-innervation of the extensor digitorum brevis muscles by the tibial nerves. This case shows that peroneal palsy from a sealbite may recover spontaneously almost completely, but may go along with residual, subclinical, electrophysiological abnormalities. The later may be enhanced by innervation variants.     

Atypical deep peroneal neuropathy in the setting of an accessory deep peroneal nerve

We report a case of deep peroneal neuropathy resulting in foot drop with preserved toe extension. These unexpected findings were the result of the presence of an accessory deep peroneal nerve that provided total innervation of the extensor digitorum brevis. We review the literature on total innervation of the extensor digitorum brevis by the accessory deep peroneal nerve with and without an associated deep peroneal nerve lesion. Muscle Nerve 40: 313–315, 2009     

Soleus nerve transfer to deep peroneal nerve for treatment of foot drop

Different mechanisms including knee dislocation, replacement surgery, nerve tumor, lumbar disc herniation, sharp injury, and gunshot wound lead to foot drop. Several surgical techniques have been used for treatment of foot drop, however, they have had sub-optimal outcomes. Soleus branch of tibial nerve is a good donor for nerve transfer for treatment of foot drop. In this is retrospective study, we reviewed medical records of 6 consecutive patients with sustained foot drop following injury to lumbar root or peroneal nerve, who underwent transfer of the soleus branch of tibial nerve to deep peroneal nerve during 2014–2016. The mean age of the patients was 44.8 years and duration of injury to surgery and follow-up was 8.3 and 14.6 months, respectively. At the end of the follow-up, ankle dorsiflexion force was M4 in two patients (with traumatic peroneal nerve injury with M3 toe extension) and was M2 in one patient. There were three patients with lumbar degenerative disease. Of these patients, two showed M0 and one patient experienced M1 ankle dorsiflexion. We recommend that transfer of soleus nerve to deep peroneal nerve is used as an alternative technique for treatment of foot drop.     

Cold-induced peripheral nerve damage: involvement of touch receptors of the foot

A 31-year-old male developed paresthesia and numbness of mainly the right foot following exposure to nonfreezing temperatures under moist conditions over a period of 1 week. The symptoms gradually improved over several months. When seen for electrophysiological studies 6 months after the injury, there was no sensory loss on clinical examination, although he continued to complain of distal numbness of the right foot. The right extensor digitorum brevis muscle was atrophic, and the distal motor latency in the peroneal nerve was prolonged. Conduction studies of the right sural nerve showed a predominantly distal diminution of the SAP evoked by electrical stimulation at the dorsum pedis. Action potentials evoked by tactile stimulation of Pacinian corpuscles showed a prolonged latency on the symptomatic side, suggesting that the most pronounced pathological changes in immersion injury may be localized to the very distal portion of the nerve at the nerve fiber-receptor junction.     

Bed footboard peroneal and tibial neuropathy. A further unusual type of Saturday night palsy

An uncommon cause of bilateral tibial and peroneal compression neuropathy is reported. After taking alcohol and drugs, a young heroin-addicted man lay unconscious overnight in supine position, with both legs crossing the wooden board at the end of the bed, the posterior aspect of the flexed knees pressing against its edge. The following day, he had weakness of foot flexion and extension and a sensory loss consistent with a bilateral tibial and peroneal neuropathy. Symptoms resolved rapidly in the left side; in the right side, a conduction block was still demonstrable 3 weeks later.     

Prior Collateral Sprouting of Sensory Axons Delays Recovery of Pain Sensitivity after Subsequent Nerve Crush

Regeneration of motor axons is enhanced if they have sprouted prior to nerve injury. We examined whether sensory axon regeneration and recovery of pain response was affected by previous collateral sprouting. In the experimental group of rats, the right saphenous, tibial, and sural nerves were transected and ligated. The peroneal nerve was left to sprout into the adjacent denervated skin. Two months later, the axons of the peroneal nerve were crushed in the sciatic nerve. In the control group, the right sciatic nerve was crushed at the same time that the saphenous, tibial, and sural nerves were transected. Recovery of pain response in the foot was determined by the skin pinch test. Sensory axon elongation rate was measured by the nerve pinch test. The number of myelinated axons was determined in nerve cross sections stained by Azur blue. Recovery of pain sensitivity in the animals of the experimental group was delayed for 2–3 weeks in comparison to the control group. Moreover, the spatial pattern of pain response in the experimental group was irregular, displaying residual regions of insensitive skin which were not present in controls. The elongation rate of regenerating sensory axons in the experimental group was not decreased, and the number of myelinated axons in the peroneal nerves was even about 10% higher than in the control group. Therefore, we assume that the terminal arborization of the neurilemmal tubes pertaining to the former axon sprouts delayed regrowth of sensory axon terminals in the skin.     

Migrant sensory neuritis--electrophysiological and pathological study]

Migrant sensory neuritis, which was first proposed by Wartenberg, is very uncommon and only a few case reports have ever been published. We described one case of migrant sensory neuritis and discussed the pathogenesis of this disease. A 44-year-old man noticed numbness in the lateral aspect of the dorsum of the left foot in February 1985. Physically, there was hypoesthesia in the region of left sural nerve with positive Tinel's sign. During the next 4 years, pain, tingling sensation or hypoesthesia appeared in the regions of the right superficial radial nerve, right axillary nerve, left intercostal nerve, left lateral plantar nerve, digital nerve of the right second digit, left saphenous nerve, right superficial peroneal nerve, left superficial radial nerve, bilateral ulnar nerves and bilateral median antebrachial cutaneous nerves one after another in a migrating fashion. Tinel's sign was also positive at the right superficial radial nerve. In some occasions, decreased deep tendon reflexes were observed, but there had been no muscle weakness. Some nerves showed complete recovery, but others showed persistent involvement. Some nerves were affected repeatedly. Laboratory examination failed to clarify underlying disease except for mild liver dysfunction. Electrophysiological study showed reduced amplitude of the sensory nerve action potential (SNAP) of right sural nerve, left ulnar nerve, right superficial radial nerve and digital branch of right median nerve with preserved sensory nerve conduction velocity. SNAP of left sural nerve was absent. These findings mean the cause of the sensory disturbance is axonal degeneration rather than segmental demyelination. There were no abnormalities in motor nerve conduction study.(ABSTRACT TRUNCATED AT 250 WORDS)     

Epilepsia Partialis Continua in Sjögren''s Syndrome

Epilepsia partialis continua with Sj?gren's syndrome is reported. The patient had extensive involvement of the nervous system with left middle cerebral artery occlusive stroke, mononeuritis multiplex, right partial sensory motor seizures and epilepsia partialis continua involving the right big toe and foot. The EEG showed nonspecific bilateral theta slowing. The epilepsia partialis continua did not respond to antiepileptic drugs.     

A family of von Recklinghausen's neurofibromatosis complicated by mononeuritis multiplex, bilateral acoustic neurinomas, and falx and spinal meningiomas

A family of von Recklinghausen's disease complicated by multiple diverse primary brain tumors was reported. Case 1. The proband, born in 1923, was admitted to the Nagasaki University Hospital on March 11, 1974, for evaluation of headache and hearing loss. Neurological examination disclosed: decreased visual acuity on the right: bilateral choked discs; anisocoria, right pupil wider than left; right blepharoptosis; artificially fixed right eye; right facial palsy; markedly impaired hearing with negative vestibular responses to caloric test; paralysis of the right soft palate and vocal cord; atrophy of the right side of the tongue; right claw hand with positive Froment's sign; left drop foot; loss of deep reflexes on the left arm and legs; positive Babinski on the right. Nerve conduction studies revealed failure to evoke muscle action potential in response to electric nerve stimulation on the left ulnar and right superficial peroneal nerves. Needle electromyography showed no motor unit potentials in the left first dorsal interosseus and right anterior tibial muscles. Sensory nerve action potentials could not be evoked on any nerves tested. X-ray films showed enlargement of the internal auditory passages, falx tumor on brain scan and carotid angiography, and spinal tumor on myelography. At craniotomy, a 7 X 5.5 X 4 cm falx meningioma was removed. At suboccipital craniotomy performed five weeks later, right acoustic neurinoma measuring 1.5 cm in diameter was removed. Case 2. This relative, born in 1945, was the son of the proband. A spinal meningioma at C 7-T 1 was removed in 1957. However, he could not walk after operation and died of pneumonia two years later.(ABSTRACT TRUNCATED AT 250 WORDS)     

Distal sensory nerve conduction of the superficial peroneal nerve: new method and its clinical application

The superficial peroneal nerve subserves sensation on the entire surface of the dorsum of the foot, except in small areas. All previously reported techniques for evaluating nerve conduction along this nerve tested a proximal portion of the nerve. We report a new method for evaluating sensory nerve conduction of the four branches of the distal superficial peroneal nerve. Two branches to the second and third toes of the medial dorsal cutaneous nerve and two branches to the fourth and fifth toes of the intermediate dorsal cutaneous nerve were studied orthodromically and antidromically in 37 feet of 21 normal volunteers using surface stimulating and recording electrodes and with a distance of 10 cm between the stimulating and recording electrodes. Maximum nerve conduction velocities (NCV) ranged from 41.8 to 46.9 m/s, and mean response amplitude ranged from 6.5 to 7.6 microV with the orthodromic technique. Values for NCV were almost identical when elicited by antidromic and orthodromic techniques, but response amplitudes were higher with the antidromic technique. Mean amplitudes of the distal superficial peroneal nerve were about 50% of the proximal superficial peroneal, and the conduction velocity in the distal superficial peroneal was slower than that in the proximal superficial peroneal nerve, by 8-14 m/s. In seven cases, distal superficial peroneal neuropathy was confirmed with this technique: two with proper digital neuropathy, two with medial dorsal cutaneous neuropathy, and three with intermediate dorsal cutaneous neuropathy.     

Buttock mass and malignant sciatic nerve tumor

Malignant peripheral nerve sheath tumors (MPNST) are rare. We report a case of a MPNST of the proximal sciatic nerve in the thigh, unassociated with pre-existing type 1 neurofibromatosis or history of radiation therapy. A 71-year-old man had a 6 month history of constant, severe, burning pain affecting the sole of the left foot. One month after the onset, the pain radiated to the left calf, posterior aspect of the thigh and buttock, and distal leg weakness followed. Three months prior to admission, the patient developed a large and painful mass in the buttock, that occupied the entire left gluteal region on examination. There was severe weakness of ankle and toe dorsiflexion and plantarflexion, decreased sensation on the lateral and posterior aspect of the left leg as well as on the dorsal and plantar surfaces of the foot, and absent ankle jerk. EMG showed denervation and motor unit loss in the short head of biceps femoris and muscles supplied by tibial and peroneal nerves on the left side. Magnetic resonance imaging revealed a 10-cm enhancing mass of the left sciatic nerve from the upper thigh to the greater sciatic notch. In surgery, a large MPNST with a high Ki67 labeling index (> 60 %) was subtotally removed from the sciatic nerve, and adjuvant radiation therapy was administered. In the ensuing months the tumor invaded the entire pelvic region. A high sciatic malignant tumor can present with a rapidly growing buttock mass and unilateral, neuropathic foot pain imitating the tarsal tunnel syndrome.     

Real Time Foot Drop Correction using Machine Learning and Natural Sensors

The objective of this study was to investigate and test a real time system implemented for Functional Electrical Stimulation (FES) assisted foot drop correction, deriving control timing from signals recorded from a peripheral sensory nerve. A hemiplegic participant was attached with a cuff electrode on the sural nerve connected to a telemetry controlled implanted neural amplifier, and a stimulation cuff electrode on the peroneal nerve connected to an implanted stimulator. An input domain was derived from the recorded electroneurogram (ENG) and fed to a detection algorithm based on an Adaptive Logic Network (ALN) for controlling the timing of the peroneal stimulation. The detection system was tested in real time over a period of 392 days, covering a variety of walking tasks. The detection system's ability to detect heel strike and foot lift without errors and to detect the difference between walking and standing proved to be stable for the duration of the study. We conclude that using ALNs and natural sensors provide a stable and accurate control signal for FES foot drop correction.     

Migration of lumbar disc herniation: an unusual case.

We illustrate a patient with a migrating lumbar disc fragment that caused a change in radicular symptoms from the L3 nerve root on one side to the L5 nerve root on the contralateral side, documented by magnetic resonance imaging (MRI). Our patient presented with 3 months of L3 pain on the right side with sensory and motor changes. Over a 24-hour time period, the right leg pain disappeared and he developed left leg pain attributable to left L5 nerve root compression. Investigation with MRI revealed an epidural mass, which was hypointense on Tl-weighted and T2-weighted images that had migrated, initially compressing the right L3 nerve root, to now compress the left L5 nerve root. The patient did not wish to pursue surgery. Disc fragment migration patterns are discussed. We conclude that extruded disc fragments may migrate distant from their initial origin.     

Clinical Effect Analysis of Spinal Cord Electrical Stimulator Implantation for Diabetic Foot

ObjectiveTo investigate the clinical effect of spinal cord electrical stimulator implantation in the treatment of a diabetic foot (DF).Materials and MethodsWe recruited 19 patients with DF who were admitted to Shengjing Hospital of China Medical University between January 2018 and May 2020. All the patients were treated with spinal cord electrical stimulator implantation. Skin temperature, degree of pain, quality of life (QOL) score, limb (toe) preservation, and nerve conduction velocity of the patients were compared pre- and postoperatively.ResultsThe diameter and peak velocity of multisegment arteries in the lower limbs had significantly increased post surgery. Foot skin temperature significantly increased in patients with good effect. The postoperative visual analog scale score of the patients was significantly lower than that noted preoperatively (p < 0.05). The conduction velocities of the lower limb sensory nerves (eg, superficial peroneal nerve and sural nerve) and motor nerves (eg, common peroneal nerve and tibial nerve) had improved post surgery. Moreover, patients' QOL score had significantly improved postoperatively (p < 0.05). The limb (toe) salvage rate was 94.74%.ConclusionThe implantation of a spinal cord electrical stimulator for treating DF can effectively relieve pain and other associated symptoms. Additionally, this device can promote nerve function recovery and lower limb blood supply and reduce the risk of toe amputation; therefore, it is clinically effective and should be considered in the treatment of DF.     

Intraneural ganglionic cyst of the common peroneal nerve: case report and review of the literature.

The authors report a case of compression of the peroneal nerve by an intraneural ganglionic cyst. The chief complaint is generally a lateral upper leg pain occasionally associated with foot drop and swelling of the upper tibiofibular joint. In our case, the disease was revealed by a tentative intraarticular injection of betamethasone. Early microsurgical treatment remains the only way to avoid permanent motor sequellae.     

Feasibility of Using Peroneal Nerve Recordings for Deriving Stimulation Timing in a Foot Drop Correction System

The objective of this research was to demonstrate the potential of using peroneal nerve activity to derive timing control for stimulation in foot drop correction and to attempt recording and stimulation through the same electrode. Two subjects were implanted with cuff electrodes on the peroneal nerve. An input domain was derived from the recorded electroneurogram (ENG) and fed to a detection algorithm based on an Adaptive Logic Network (ALN) for predicting stimulation timing. A switching circuit was furthermore built for switching between stimulator and recorder for combined use of the cuff electrode. The detection was successful, but the accuracy depended on the signal to noise ratio of the recorded ENG. The switching circuit successfully allowed for simultaneous recording and stimulation through the same cuff electrode. We conclude that the peroneal nerve can potentially be used to record sensory information for derivation of a stimulator control signal in a foot drop application, while at the same time being stimulated to activate foot dorsiflexors.     

Tomaculous neuropathy. Electrophysiologic study

In two cases with recurrent palsies, the results of electrophysiological studies led to nerve biopsy showing typical tomacula. The first case was an inherited neuropathy with liability to pressure palsies. The second case was an apparently sporadic painless recurrent brachial neuropathy. Electrophysiological alterations were diffuse and sensory fibres of the median nerve between index and wrist were the most involved. Conduction blocks were observed without palsy in narrow anatomical passageways where nerve compressions are frequent (ulnar nerve at the elbow, peroneal nerve at the fibula). A compression by a neighbouring anatomical structure could make the prognosis worse and justify nerve decompression. The nerves with slowest conduction have the most important risk of palsy and the patients should be given advice to avoid their compression.     

Mononeuropathy of the medial branch of the deep peroneal nerve in a scuba diver.

Peripheral mononeuropathies occur only rarely in association with decompression illness. The sites previously reported to be affected are areas of potential entrapment in which a peripheral nerve traverses a confined area. In these instances, the pathophysiology has been presumed to be mechanical pressure in an enclosed space by a gas bubble. A rare case is now presented of a peripheral mononeuropathy of the medial branch of the deep peroneal nerve in a scuba diver following surfacing from a 195 foot dive. This case differs from prior reports of mononeuropathy in association with decompression illness in that the affected nerve does not traverse a confined site in which mechanical compression by a gas bubble is likely. The mechanism of injury is hypothesized to be a manifestation of decompression illness with a gas bubble causing blood flow obstruction and an ischemic infarct.     

A case of primary HIV infection presenting as mononeuritis multiplex]

A 34-year-old man presented with gait disturbance. He had a low grade fever and diarrhea for a few days prior to admission. Two weeks after he started to have diarrhea, he developed gait disturbance with a left foot drop. The cerebrospinal fluid obtained on admission showed pleocytosis (30/microl) and increased protein. The motor nerve conduction velocities (MCV) of the left peroneal nerve and the tibial nerve were slow, but the right peroneal and tibial MCVs were within normal limits. A test for human immunodeficiency virus (HIV) antibody was positive. The Western blot was positive with bands of gp160 and p24, confirming HIV infection. Seroconversion-related neuropathy of HIV was diagnosed. Acute HIV infection should be included in the differential diagnosis of mononeuritis multiplex. Before full-fledged AIDS development, it is important to find early stage of HIV infection in patients, so that we can treat them more effectively by means of anti-HIV drugs.