Peripheral Nerve Compression Syndrome

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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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Peripheral Nerve Compression Syndrome

  1. 1. NeuropathyvsPeripheral Nerve Compression Syndrome<br />Michael E. Graham, DPM, FACFAS<br />
  2. 2. Neuropathy<br />What do we know?<br />Nothing- no solution<br />Your situation will only get worse<br />We don’t like seeing these patients in our office <br />Chronic complainers<br />Hopeless<br />20 million Americans with symptoms<br />
  3. 3. Peripheral Neuropathy<br />What is the etiology?<br />Over 100 etiologies of peripheral neuropathy<br />Diabetes ?<br />Alcohol ?<br />Chemotherapy ?<br />Heavy Metal Poisoning ?<br />Hereditary ?<br />Idiopathic ?<br />WE REALLY DON’T KNOW <br />
  4. 4. Diabetic Peripheral Neuropathy<br />28 to 60% of Type I or II diabetics develop Neuropathy <br /> (Young et al 1993)<br />Sorbital Accumulation- not proven, theoretical<br />PolyolPathyway: oxidative stress, mitochondrial dysfunction, and ischemic nerve damage<br />Treatment aimed at:<br />Controlling hyperglycemia<br />Foot inspection<br />Controlling pain<br />End result- Continued progression and worsening of the condition<br />
  5. 5. Diabetic Peripheral NeuropathySymptoms<br />Numbness or insensitivity to pain or temperature<br />Tingling, burning, or prickling sensation<br />Sharp pains or cramps<br />Extreme sensitivity to touch, even a light touch<br />Loss of balance and coordination<br />Symptoms are worse at night<br />Muscle weakness (intermetatarsal)- digital deformities<br />
  6. 6. Diabetic Neuropathy<br />Loss of Sensory Protection<br />15% develop ulceration<br />12-24% require amputation<br />80% of diabetics who present with ulceration have decreased sensation in there foot/feet.<br />
  7. 7. Alcoholic Neuropathy<br />Persons who consumed large quantities of alcoholic beverages over an extended period of time.<br />Symptoms are the same as diabetic and other neuropathy-<br />Incidence - unknown<br />Treatment- basically the same as DPN and “Stop Drinking”<br />
  8. 8. Drug-Induced & Toxic Neuropathy<br />Medications<br />Disulfiram<br />Metronidazole<br />Phenytoin<br />Cisplatin<br />Statins<br />Rare- 2-4%<br />Symptoms- Same as other<br />Forms of neuropathy<br />Lead & Heavy Metals <br />Arsenic<br />Mercury<br />Thallium<br />Symptoms resemble the same as other forms of metabolic, compression, etc. <br />
  9. 9.
  10. 10. What Do We Know?<br />Damaged microvasculature<br />Decreased oxygen to specific parts of the nerve<br />Areas of chronic flattening<br />Signs of chronic inflammation<br />Perineurial swelling<br />Sites of specific nerve damage<br />Sites of nerve repair<br />
  11. 11. What IF….<br />A Patient presents with heel pain.<br />Diagnosis of Plantar Fasciitis<br />What if they are also a history of:<br />Diabetic<br />Alcoholic<br />had a family member with a history of plantar fasciitis<br /> worked with heavy metal<br /> had chemotherapy.<br />What difference does it make?<br />
  12. 12. What if someone with chronic condition was told that nothing could be done for them?<br />Patient is hopeless<br />Treatment options are useless<br />We can help try to relieve the pain<br />It will only get worse <br />We don’t know why you have developed this<br />
  13. 13. Let’s Rethink the situation<br />
  14. 14. Peripheral Nerve CompressionSyndrome <br />I think that this is going to make a lot of sense<br />Let’s change the way we think about neuropathy!<br />
  15. 15. Peripheral Nerve CompressionSyndrome<br />Chronic Damage to a peripheral nerve<br />Mild<br />Moderate<br />Severe<br />Ever heard of Carpal Tunnel Syndrome?<br />
  16. 16. Carpal Tunnel Syndrome<br />Chronic Repetitive Compression & Overstretching<br />Leads to Median Nerve Damage<br />
  17. 17. Symptoms<br />Pain<br />Numbness<br />Tingling<br />Pain to palpation of the carpal tunnel<br />Sound familiar<br />
  18. 18. Carpal Tunnel Syndrome<br />Conservative measures<br />NSAIDS<br />Immobilizing braces<br />Physiotherapy<br />Localized steroid injections<br />Long term efficacy usually alter/eliminate motion.<br />
  19. 19. Surgery<br />Treatment of choice<br />Better out comes than wrist splinting<br />Claim 90% success in eliminating symptoms<br />
  20. 20. What are the Patient’s Symptoms?<br />Feet feel best in the morning<br />As the day goes on they get worse<br />“The more active I am the worse the symptoms”<br />At night when I go to bed they really start acting up<br />Numbness/burning in my toes/ball of foot<br />Travels into my arch and up my leg<br />Top of the foot feels fine, no problems there<br />Used to happen after walking on the treadmill/mall but would stop after resting.<br />
  21. 21. Typical Patient<br />Usually has been to many other doctors first. (even though it is a foot symptom).<br />Has had many expensive tests with or without abnormal findings<br />Frustrated<br />Very fearful<br />Middle aged or older<br />Have a history of excessive walking/standing<br />House wife<br />Postal worker<br />Etc.<br />
  22. 22. WHY WHYWHYWHYWHYWHY<br />Do their feet feel their best in the morning?<br />Why do their feet become more symptomatic as the day goes on or with increased activity?<br />Why are the symptoms worse at night?<br />Thesymptoms first started in the toes/ball of the feet<br />Slowly after months/years went to the arches and up the leg<br />
  23. 23. There really is no mystery.<br />This is a nerve problem.<br />What nerve supply is being affected?<br />
  24. 24. Do you ever have these patients stand or walk?<br />
  25. 25. Walking- the 2nd most common thing we do.<br />
  26. 26. Excessive Rearfoot Motion<br />
  27. 27. Symptomatology<br />The outer part of the posterior tibial nerve fibers lead to the tip of the plantar part of the toes<br />Deeper fibers correlate to the ball/arch of the foot.<br />
  28. 28. Road Map to Diagnosis<br />IF the patient can tell us where the symptoms are occurring then we should be able to figure out which nerve is being affected.<br />
  29. 29. Keep It Simple<br />Can you tell me which blood vessels are not working?<br />Let’s use the same rational with the nerves<br />
  30. 30. Nerve Anatomy<br />
  31. 31. Peripheral Nerve Parts<br />
  32. 32.
  33. 33.
  34. 34.
  35. 35. Peripheral Nerve Damage(Double Whammy)<br />A nerve can only stretch so far<br />Chronic overstretching will lead to damaged blood flow<br />A nerve can only be compressed so many times until there is partial nerve impairment<br />Chronic compression leads to direct nerve damage (myelin). <br />
  36. 36. Just like any other soft tissue of the body <br />A peripheral nerve can take SOME trauma without completely falling apart<br />HOWEVER it can only take so much before pathology ensues. <br />
  37. 37. If ignored or left untreated or improperly diagnosed the symptoms as well as the damage to the structure will progress.<br />
  38. 38. Nerve Pathology<br />
  39. 39.
  40. 40. Graham International Implant Institute, Inc.<br />Functional Anatomy<br />Entire weight of body travels through the talus.<br />Redirected from the tibia and fibula to the<br />Calcaneus and Navicular bones.<br />
  41. 41. Graham International Implant Institute, Inc.<br />Sinus Tarsi<br />Fulcrum point <br />Should always stay “open”<br />Abnormal closure of this space leads to deformity.<br />
  42. 42. Graham International Implant Institute, Inc.<br />PathoMechanics<br />Obliteration of the sinus tarsi<br />Plantar flexion of the talus<br />Abnormal forces directed throughout the foot.<br />
  43. 43. Graham International Implant Institute, Inc.<br />Abnormal Talar DeviationLeads to Excessive Rearfoot Motion.<br />Medial<br />Anterior<br />Plantarflexion<br />
  44. 44. Excessive Rearfoot MotionLeads to:<br />Chronic Overstretching of the soft tissue to the rearfoot<br />Can lead to compression of the posterior tibial nerve and it’s terminal branches.<br />
  45. 45. We are familiar with the Tarsal Tunnel. <br />
  46. 46. Actually 2 areas of Compression<br />Posterior Tibial Nerve<br />1st Area of Damage<br />2nd Area of Damage<br />
  47. 47. So what’s the Good Newsis there any hope left.<br />
  48. 48. Peripheral Nerves Can REGENERATE.<br />
  49. 49. Putting the whole puzzle together<br />
  50. 50. Nerve Damage Cycle<br />The most common thing we do besides breathing is walking<br />Excessive rearfoot motion leads to chronic overstretching and compression of the posterior tibial nerve and its terminal brances<br />By 50 years of age we have taken 180,000,000 steps<br />
  51. 51. PN Damage- continued<br />This is a gradual onset problem<br />If left untreated will continue to develop more nerve damage<br />Exercise/walking/standing leads to further damage<br />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<br />
  52. 52. As the day progresses, more damage is caused to the nerve due to increased activity until….nerve goes numb<br />At night when going to be the patient stops traumatizing the nerves and the “wake-up” with a vengeance. <br />Some patients have to get out of bed and find if they walk for a while the pain subsides. Why? <br />They are “re-numbing” their nerves.<br />
  53. 53. The Fix<br />
  54. 54. First part is to release the fibers that are “strangling” the nerves.<br />
  55. 55. Surgical Decompression<br />
  56. 56. Soft Tissue DecompressionPart One<br />Release the Lacinent Ligament-Proximal to Distal, start in the middle and work out from there. Use your pinkie<br />Do not need to necessarily work your way to dissect the PTN and its terminal branches.<br />
  57. 57. Surgical DecompressionPart Two<br /> Go distal through the portapedis.<br />Usually have to create an opening, I use tenotomy scissors. Stick your pinkie into the portapedis. <br />To show what effect hyperpronation has maximally pronate the foot with your pinkie in the portapedis- carefully<br />(I am not responsible for crushed pinkies!)<br />
  58. 58. 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. <br />If we perform too much dissection around the nerve it is possible to form scar tissue<br />If we don’t do enough dissection it is possible to miss some of the fibers that are destroying the nerves.<br />
  59. 59. How do we control the Excessive Rearfoot Motion?<br />
  60. 60. Closer look at excessive hindfoot motion-hyperpronation<br />
  61. 61. Weightbearing AP FluoroscopyRCSP showing transverse plane correction<br />
  62. 62. Graham International Implant Institute, Inc.<br />NWB to WB<br />
  63. 63. Hologic Insight Mini C-arm<br />Graham International Implant Institute, Inc.<br />
  64. 64. Graham International Implant Institute, Inc.<br />
  65. 65. Minimal weight with foot in ideal position versus full weight and abnormal position.<br />Graham International Implant Institute, Inc.<br />
  66. 66. Graham International Implant Institute, Inc.<br />
  67. 67. HyProCure®Extra-Osseous TaloTarsal Stabilization Device<br />Threaded portion locks the implant into the cervical ligament in the canalis portion of the sinus tarsi<br />Tapered portion abuts the lateral aspect of the canalis tarsi for accurate placement.<br />Outer wider diameter prevents obliteration of the sinus tarsi.<br />Grooved section allows for fibrous tissue in-growth to prevent backing-out of the implant.<br />Made of medical grade titanium<br />Cannulated for guide wire insertion for accurate placement within the sinus tarsi.<br />Graham International Implant Institute, Inc.<br />
  68. 68. Before/After<br />Graham International Implant Institute, Inc.<br />
  69. 69. Graham International Implant Institute, Inc.<br />Right Foot- Before & After<br />Weight bearing- 2 weeks post-op<br />After<br />Before<br />
  70. 70. Extra-Osseous TaloTarsal Stabilization with HyProCureTarsal Tunnel Decompression, Neurolysis of Posterior Tibial Nerve, Neurolysis of the Calcaneal Nerve, Neurolysis of the Lateral Plantar NerveNeurolysis of the Medial Plantar Nerve<br />
  71. 71. Surgery<br />TaloTarsal Stabilization with HyProCure<br />Take about 10 minutes to perform<br />Takes about 10 – 15 stents placements before you really get comfortable<br />Tarsal Tunnel Decompression/Neurolysis<br />Take about 20 min<br />Should use loups<br />Takes about 25 before you really feel comfortable in this area<br />Take your time<br />
  72. 72. Apply a tourniquet to the ankle<br />I do not inflate the tourniquet unless there is excessive bleeding <br />Use 10 cc’s of 1:1 mix of 0.5% marcaine with and without epi with 1 cc of dex. Phosphate<br />Close skin only <br />
  73. 73. The Results <br />Depends on which fibers are being affected<br />How damaged the nerves are<br />How compliant the patients are<br />How good of job YOU did on decompressing the nerves<br />How much scar tissue the patient forms after surgery<br />
  74. 74. Results- continued<br />Pain is almost immediately alleviated.<br />Restoration of sensation- will take the longest to return<br />Results may be felt in the recovery room<br />Or may takes months to years<br />No matter, instead of the patient’s condition getting worse and worse, it will potentially get better and better.<br />
  75. 75. Cross Over Effect<br />This is real not imaginary.<br />The damaged nerves of one foot affect the opposite foot.<br />Scenarios:<br />Good-<br />Bad-<br />Ugly-<br />
  76. 76. Cross Over Effect - Good<br />By decompressing one foot not only is there is improvement on that side there is also improvement in the contra-lateral limb.<br />IF sensation/symptoms are restored to the contra-lateral limb there is not need for tarsal tunnel decompression or neurolysis of the nerves<br />
  77. 77. Cross Over Effect - Bad<br />Surgery to the foot yield minimal results with no change in the contra-lateral limb<br />The opposite limb is the dominate nerve pathology and once that side is also decompressed there should be an additional effect on both feet.<br />Must warn patients about this prior to surgery.<br />
  78. 78. Cross Over Effect - Ugly<br />Nerve decompressions are performed on both feet (one at a time) and no results are felt.<br />Don’t take the patient’s word for it. Must perform nerve testing prior to surgery and routinely post-op.<br />Their nerves may be so severely damaged that it was too late.<br />No matter how severe I will still attempt.<br />It just may takes years for the results to be felt.<br />
  79. 79. Complications of Surgery<br />Wound dehiscence<br />Scar tissue formation<br />Hematoma<br />Infection<br />Temporary increase in nerve symptoms<br />?% revision rate <br />
  80. 80. Complications of:Supervised Neglect<br />Decreased Activity Level<br />Decreased metabolism<br />Increased Weight (obesity)<br />Diabetes<br />Hypertension<br />Arterial Disease<br />Increased Nerve Pain<br />Loss of Sensation<br />Ulceration<br />Bone infection<br />Amputation<br />Charcot’s Foot<br />
  81. 81. Current Forms of Treatment<br />Biannual testing<br />Extra depth shoes<br />NSAIDS<br />Pain pills<br />Nerve Pills<br />Psychiatry<br />Wheelchair/walker<br />Shows increased nerve damage<br />Prevent ulceration<br />Do nothing<br />Barely take off the edge<br />See next slide<br />Loosing battle<br />Syndrome X- further decrease in activity<br />
  82. 82. Nerve Pills: Neurontin, Lyrica, Cymbalta<br />Mask the symptoms<br />Do not help nerve repair<br />Expensive<br />Increased symptoms, increased dosage<br />Side-effects<br />Swelling/edema<br />Blurred vision<br />Drowsiness<br />Fatigue/muscle weakness<br />Muscle cramps<br />Vomiting<br />Constipation/Diarrhea<br />Sexual dysfunction<br />
  83. 83. Autonomic Neuropathy<br />Manifests after years of peripheral nerve symptoms<br />We really don’t know<br />Why<br />Who<br />when<br />Only get worse<br />Really no help<br />Orthostatic hypotension<br />Bladder dysfunction<br />GI Problems<br />Blurred vision<br />Muscle weakness<br />Sexual dysfunction<br />
  84. 84. Comparison of Symptoms of Side effects from Nerve Pills and Autonomic Neuropathy.<br />Orthostatic hypotension<br />Bladder dysfunction<br />GI Problems<br />Blurred vision<br />Muscle weakness<br />Sexual dysfunction<br />Orthostatic hypotension<br />Bladder dysfunction<br />GI Problems<br />Blurred vision<br />Muscle weakness<br />Sexual dysfunction<br />
  85. 85. My Results<br />Claim 80% effective within a year<br />20% will either just take > 1 year are the nerves are just too severely damaged.<br />
  86. 86. Conclusion<br />Doing nothing leads to progression<br />Complications of proposed surgical treatment options have a better outcome than supervised neglect<br />I hope that I have open some eyes so that we can change our thinking on this extremely serious condition<br />
  87. 87. For Further Information/Training<br />www.grahamiii.com<br />
  88. 88. “Changing Lives, One Step at a Time”<br />www.hyprocure.com<br />View our on-line training<br />www.hyprocuredoctors.com<br />

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