peripheral nerve compression syndrome
DESCRIPTION
Neuropathy is a generic term and is untreatable. Peripheral nerve compression is more specific and is cureable. Lets end Neuropathy.TRANSCRIPT
![Page 1: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/1.jpg)
Neuropathyvs
Peripheral Nerve Compression Syndrome
Michael E. Graham, DPM, FACFAS
![Page 2: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/2.jpg)
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
![Page 3: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/3.jpg)
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
![Page 4: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/4.jpg)
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
![Page 5: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/5.jpg)
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
![Page 6: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/6.jpg)
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.
![Page 7: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/7.jpg)
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”
![Page 8: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/8.jpg)
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.
![Page 9: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/9.jpg)
SameSympto
ms
Diabetes
IdiopathicHereditar
y
Medications
Heavy Metals
Alcohol
![Page 10: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/10.jpg)
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
![Page 11: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/11.jpg)
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?
![Page 12: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/12.jpg)
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
![Page 13: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/13.jpg)
Let’s rethink the situation
![Page 14: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/14.jpg)
Peripheral Nerve CompressionSyndrome
I think that this is going to make a lot of sense
Let’s change the way we think about neuropathy!
![Page 15: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/15.jpg)
Peripheral Nerve Compression
Syndrome
Chronic Damage to a peripheral nerve Mild Moderate Severe
Ever heard of Carpal Tunnel Syndrome?
![Page 16: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/16.jpg)
Carpal Tunnel Syndrome Chronic Repetitive
Compression & Overstretching
Leads to Median Nerve Damage
![Page 17: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/17.jpg)
Symptoms
Pain Numbness Tingling
Pain to palpation of the carpal tunnel
Sound familiar
![Page 18: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/18.jpg)
Carpal Tunnel Syndrome
Conservative measures
› NSAIDS› Immobilizing braces› Physiotherapy› Localized steroid injections
› Long term efficacy usually alter/eliminate motion.
![Page 19: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/19.jpg)
Surgery
Treatment of choice
Better out comes than wrist splinting
Claim 90% success in eliminating symptoms
![Page 20: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/20.jpg)
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.
![Page 21: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/21.jpg)
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.
![Page 22: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/22.jpg)
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
![Page 23: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/23.jpg)
There really is no mystery.
This is a nerve problem. What nerve supply is being affected?
![Page 24: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/24.jpg)
Do you ever have these patients stand or walk?
![Page 25: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/25.jpg)
Walking- the 2nd most common thing we do.
![Page 26: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/26.jpg)
Excessive Rearfoot Motion
![Page 27: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/27.jpg)
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.
![Page 28: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/28.jpg)
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.
![Page 29: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/29.jpg)
Keep It Simple
Can you tell me which blood vessels are not working?
Let’s use the same rational with the nerves
![Page 30: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/30.jpg)
Nerve Anatomy
![Page 31: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/31.jpg)
Peripheral Nerve Parts
![Page 32: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/32.jpg)
![Page 33: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/33.jpg)
![Page 34: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/34.jpg)
![Page 35: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/35.jpg)
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).
![Page 36: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/36.jpg)
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.
![Page 37: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/37.jpg)
If ignored or left untreated or improperly
diagnosed the symptoms as well as the damage to
the structure will progress.
![Page 38: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/38.jpg)
Nerve Pathology
![Page 39: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/39.jpg)
![Page 40: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/40.jpg)
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.
![Page 41: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/41.jpg)
Graham International Implant Institute, Inc.
Sinus Tarsi
Fulcrum point Should always stay
“open” Abnormal closure of
this space leads to deformity.
![Page 42: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/42.jpg)
Graham International Implant Institute, Inc.
PathoMechanics
Obliteration of the sinus tarsi
Plantar flexion of the talus
Abnormal forces directed throughout the foot.
![Page 43: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/43.jpg)
Graham International Implant Institute, Inc.
Abnormal Talar DeviationLeads to Excessive Rearfoot Motion.
Medial Anterior Plantarflexion
![Page 44: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/44.jpg)
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.
![Page 45: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/45.jpg)
We are familiar with the Tarsal Tunnel.
![Page 46: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/46.jpg)
Actually 2 areas of Compression
Posterior Tibial Nerve
1st Area of Damage
2nd Area of Damage
![Page 47: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/47.jpg)
So what’s the Good Newsis there any hope left.
![Page 48: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/48.jpg)
Peripheral Nerves Can REGENERATE.
![Page 49: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/49.jpg)
Putting the whole puzzle together
![Page 50: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/50.jpg)
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
![Page 51: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/51.jpg)
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
![Page 52: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/52.jpg)
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.
![Page 53: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/53.jpg)
The
Fix
![Page 54: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/54.jpg)
First part is to release the fibers that are “strangling” the nerves.
![Page 55: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/55.jpg)
Surgical Decompression
![Page 56: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/56.jpg)
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.
![Page 57: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/57.jpg)
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!)
![Page 58: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/58.jpg)
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.
![Page 59: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/59.jpg)
How do we control the Excessive Rearfoot Motion?
![Page 60: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/60.jpg)
Closer look at excessive hindfoot motion-hyperpronation
![Page 61: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/61.jpg)
Weightbearing AP FluoroscopyRCSP showing transverse plane correction
![Page 62: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/62.jpg)
Graham International Implant Institute, Inc.
NWB to WB
![Page 63: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/63.jpg)
Hologic Insight Mini C-arm
Graham International Implant Institute, Inc.
![Page 64: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/64.jpg)
Graham International Implant Institute, Inc.
![Page 65: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/65.jpg)
Minimal weight with foot in ideal position versus full weight and abnormal position.
Graham International Implant Institute, Inc.
![Page 66: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/66.jpg)
Graham International Implant Institute, Inc.
![Page 67: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/67.jpg)
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.
![Page 68: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/68.jpg)
Before/After
Graham International Implant Institute, Inc.
![Page 69: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/69.jpg)
Graham International Implant Institute, Inc.
Right Foot- Before & After
Weight bearing- 2 weeks post-opBefore After
![Page 70: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/70.jpg)
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
![Page 71: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/71.jpg)
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
![Page 72: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/72.jpg)
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
![Page 73: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/73.jpg)
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
![Page 74: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/74.jpg)
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.
![Page 75: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/75.jpg)
Cross Over Effect
This is real not imaginary. The damaged nerves of one foot affect
the opposite foot. Scenarios:
› Good-› Bad-› Ugly-
![Page 76: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/76.jpg)
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
![Page 77: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/77.jpg)
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.
![Page 78: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/78.jpg)
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.
![Page 79: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/79.jpg)
Complications of Surgery
Wound dehiscence Scar tissue formation
Hematoma Infection Temporary increase in nerve symptoms
?% revision rate
![Page 80: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/80.jpg)
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
![Page 81: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/81.jpg)
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
![Page 82: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/82.jpg)
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
![Page 83: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/83.jpg)
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
![Page 84: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/84.jpg)
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
![Page 85: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/85.jpg)
My Results
Claim 80% effective within a year› 20% will either just take > 1 year are the
nerves are just too severely damaged.
![Page 86: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/86.jpg)
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
![Page 88: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/88.jpg)
www.hyprocure.com
View our on-line trainingwww.hyprocuredoctors.com
“Changing Lives, One Step at a Time”
![Page 89: Peripheral Nerve Compression Syndrome](https://reader036.vdocuments.mx/reader036/viewer/2022081514/554e3f7db4c90518468b511e/html5/thumbnails/89.jpg)