Neurological

Question 1

What is Poliomyelitis?

Answer 1

• VIRAL DESTRUCTION OF THE ANTERIOR HORN CELLS IN THE SPINAL CORD AND BRAIN STEM MOTOR NUCLEI

​

• Hallmark
  
  • MOTOR WEAKNESS with NORMAL SENSATION

Question 2

What is polio’s clinical features ?

Answer 2

• MOTOR WEAKNESS NORMAL SENSATION
• Flaccid, Asymmetrical Muscle weakness
• Flexion, abduction contracture hip
• Flexure contracture knee, valgus deformity and genorecurvatum
• ankle -equinus, foot- valgus/varus

Question 3

What is the epidemiology of polio?

Answer 3

• Present in developing countries- WHO tried to erradicate it in 2006 endemic in 6 countried
• Eliminated in US and UK due to vaccination

Question 4

What is its treatment of polio foot deformities?

Answer 4

non operative

• lightweight orthosis
  
  • first line
  • Help pt maintain functional independence

Surgery

• Contracture release, Tendon transfer, Arthrodesis
  
  • if orthosis not achieving satifiactory ADL’s

Question 5

Name associated conditions of Polio? What is it?

Answer 5

• Post Polio Syndrome
• AN aging phenomenon when more nerve cells become inactive with time.
• Characterised by Muscle weakness, myalgia & fatigue
• Doesn’t represent reactivation of virus
• Occurs in middle age (20-40 yrs after inital infection)
• Occurs in up to 50% cases of polio
• Leads to difficulties of ADL
• Patients should exercise at sub-exhaustion levels to tone affected muscles groups without causing muscle breakdown

Question 6

What is post polio syndrome tx?

Answer 6

Non operative

• Limited exercise with periods of rest and lightweight orthosis
  
  • first line of tx
  • Maintain but not overuse muscles

Operative

• Tendon transfers, contracture releases & arthrodesis
• To optimise funcitonal capacity

Question 7

Define Tarsal Tunnel syndrome?

Answer 7

• Compression neuropathy caused by compression of TIBIAL nerve

Question 8

What is the aetiology of tarsal tunnel syndrome?

Answer 8

• Intrinsic
  
  • Ganglionic cyst
  • Tendonopathy
  • Tenosynovitis
  • Lipoma/tumour
  • Peri-neural fibrosis
  • Osteophytes
• Extrinsic
  
  • Shoes
  • Trauma
  • Anatomical deformity- tarsal coalition/valgus hindfoot
  • Systemic inflammatory disease
  • Oedema of the lower extremity
• IN 80% cases no cause for compression is found

Question 9

Describe the prognosis of tarsal tunnel syndrome?

Answer 9

• Result vary between 50-90%
• Worse results with ‘Double crush injury’ and post operative scarring
• Revision surgery less successful than index operation

Question 10

Define the anatomy of the tarsal tunnel?

Answer 10

Anatomy defined by

• Flexor retinaculum- Lacinate ligament
• Calcaneus - medial
• Talus- medial
• Adbuctor hallucis- inferior

Question 11

What is in the tarsal tunnel?

Answer 11

• Tibial Nerve- posterior
• Posterior tibial artery
• FHL tendon
• FDL tendon
• tibialis posterior tendon

Question 12

What does the tibial nerve divide into?

Answer 12

• Medial plantar
• Lateral Plantar
• Medical Calcaneal
• The medial and lateral plantar nerves can be compressed in their own sheaths, distal to tarsal tunnel
• Bifurcation of tibial nerve in 5% cases occurs proximal to tarsal tunnel

Question 13

Describe the signs and symptoms of tarsal tunnel syndrome?

Answer 13

Hx of previous trauma/ surgery

Symptoms

• Pain with prolonged standing/walking
• Often vague medial foot pain
• Sharp burning pains in foot
• Intermittent numbness in plantar of foot

Signs

• Tenderness of tibial n- Tinel’s sign
• Pes planus
• Muscle wasting of foot instrinsics- abductor digit quntini, or abductor hallucis
• Pain with dorsiflexion & eversion of ankle
• Compression test
  
  • compression over tarsal tunnel= pain - sensitive and specific
  • Compression with plantarflexion & inversion

Question 14

What investigations are helpful to aid diagnosis of tarsal tunnel syndrome?

Answer 14

• Weight bearing radiographs- osseoud
• MRI
  
  • exclude accessoty muscle/ soft tissue tumour
• EMG
  
  • positive finding
  • distal motor latencies of >7.0ms
  • prolonged sensory latencies of >2.3msec
  • Sensory more likely abnormal cf motor
  • Decreased amplitude of motor action potentials of abductor hallucis or abductor digiti minimi

Question 15

What is the treatment of tarsal tunnel syndrome?

Answer 15

• Non operative
  
  • Lifestyle modifications. medications
    
    • usually ineffective
    • NSAIDS/ SSRIs
    • Bracing
      
      • orthosis/ foot wear changes to adress aligment of hindfoot
      • try a period of short leg cast
• Operative
  
  • Surgical Release of Tarsal Tunnel
    
    • 3-6 months after failed consx
    • compressive mass identified
    • reproducible findings
    • best outcomes- where a compressing anatomic stricture ganglionic cyst is identified and removed

Question 16

Describe how would you release the tarsal tunnel?

Answer 16

• 2 inicsion - medial ankle and medical foot
• Identify the nerve proximally
• Release these layers-
  
  • Flexor retinaculum
  • Deep investig fascia of lower leg
  • Superficial and deep fascia of abductor hallucis
  • http://www.orthobullets.com/video/view?id=812

Question 17

What is the aetiology of deep peroneal nerve entrapment?

Answer 17

• Impingement of DPN by distal margin of INFERIOR EXTENSOR mechanism
• Also
• Dorsal osteophytes over apex of medial longitudinal arch
• Ganglionic cyst
• Tight laces or ski boots
• aka anterior TARSAL TUNNEL syndrome

Question 18

What does the anterior tarsal tunnel contain?

Answer 18

• Extensor digitorium Longus
• Extensor hallucis longus
• Tibialis anterior
• deep peroneal nerve
• Dorsalis pedis artery

Question 19

What are the signs and symtpoms of anterior tarsal tunnel?

Answer 19

Symptoms

• Dysesthesia & parathesias of dorsum of foot & 1st web space
• Vague foot pain

Signs

• Tinel sign with symptoms in first web space

Question 20

What are the tx for Anterior tarsal tunnel?

Answer 20

• Non operative
  
  • Shoe Modification
  • First line
  • Well padded tongue of shoe
  • Full length rocker -sole steel shank
• Operative
  
  • Surgical release of DPN by releasing retinaculum & ostephyte/ ganglion resection
    
    • failure of non op tx
  • symptoms of RSD are CI to release
  • Start distal, idenify nerve and release Proximally- nerve lateral to EHB
  • warn pt recovery is prolonged

Question 21

What is the cause of Ilioinguinal nerve entrapment?

What signs and symptoms of ilioinguinal entrapment?

Answer 21

• Hypertophied abdominal muscles- result of intensive training
• Symptoms
  • Hyperesthesia is common
  • Pain worse with hip hyperextension

Question 22

What is the tx of Ilioinguinal nerve entrapment?

Answer 22

• Non operative
  
  • lifestyle modification
• Operative
  
  • failed consx
  • Surgical release

Question 23

What is the epidemiology and symptoms of Obturator nerve entrapment?

Answer 23

• Common in skaters with well developed adductors
• Chronic medial thigh pain

Question 24

What investigations are useful in Ilioinguinal nerve entrapment?

What is the tx of Ilioinguinal nerve entrapment?

Answer 24

• Nerve conduction studies
• Tx
• Conservative= Supportive

Question 25

What are the symptoms of lateral femoral cutaneous nerve of the thigh entrapment?

Answer 25

* **Pain on lateral aspect of thigh** * **MERALGIA PAESTHETICA**

Question 26

What is exacerbates the pain in lateral femoral cutaneous nerve of the thigh entrapment?

Answer 26

* **Tight belts and prolonged hip flexion**

Question 27

Describe the tx in lateral femoral cutaneous nerve of the thigh entrapment?

Answer 27

* Non operative * **PT, NSAIDS** * postural excercises * release of compressive devices

Question 28

Where is the sciatic nerve often entraped?

Answer 28

* Any where along its length * Common= Level of **ischial tuberosity** * **At piriformis muscle**= pirifomis syndrome

Question 29

What is Saphenous neuritis?

Answer 29

* **Compression of saphenous nerve** * Usually at **Hunter's canal** * aka Surfer's neuropathy Hunter's canal- aponeurotic canal extending from femoral triangle to addcuctor hiatus ( adductor magnus) Anteriorly - Sartorius Psoterior Medial - Adductor longus & adductor magnus Laterally- vastus medialis Superior- Inguinal ligament

Question 30

What is and define the anatomy of Hunter's canal?

Answer 30

* Hunter's canal- aponeurotic canal extending from femoral triangle to addcuctor hiatus ( adductor magnus) Boundaries * Anteriorly - Sartorius * Posterior Medial - Adductor longus & adductor magnus * Laterally- vastus medialis * Superior- Inguinal ligament

Question 31

What are the symptoms of saphenous neuritis? How is it treated?

Answer 31

* **Pain inferior & medial to knee** Tx * Non operative * **Knee pads- f**orst line of tx

Question 32

Wher can the common peroneal nerve be compressed?

Answer 32

* Behind fibula by ganglionic cyst or directed by trauma * fusion of proximal tibiofibulr joint may be required to prevent recurrence * PC- foot drop- inability to dorsiflex & evert foot * loss of sensation dorsum foot

Question 33

What is the cause of superifical peroneal nerve compression?

Answer 33

* **Fascia defect**- usually 12cm proximal to lateral malleolus where it exits the fascia of the anterolateral leg * Mechanisms include * Inversion injuty * Fascial defect

Question 34

What are the symptoms of patient with superfical peroneal nerve compression? What is the tx?

Answer 34

* Sensation= **Numbness & tingling over dorsum of foot,** SPARING of 1st web space * This worsens with **Plantar flexion** and **Inversion of foot** **TX** * Non operative * **Observe** * Operative * **Fascial release** * May be indicated in refractory cases

Question 35

What is the cause of Lateral planar nerve compression? How is it treated?

Answer 35

* Compression of **First branch of lateral plantar nerve** - BAXTER's nerve - branch to _abductor digiti quinti_ * Common nerve compression in runners * **Medial heel pain-** nerve travels across heel anterior to medial tuberosity of calcaneus * **Chronic heel pain** -similar to _plantar fascitis_ * compression between fascia of **ABDUCTOR HALLUCIS LONGUS and medial side of QUADRATUS PLANTAE** **Tx** * Operative * **​Surgical release of _Abductor hallucis fascia_**

Question 36

Where does the medial plantar nerve get compressed? What is the TX?

Answer 36

* At the **knot of Henry** * where **FDL and FHL cross** * Most common cause of compression is **foot orthotics** **Tx** Non operative * **Discontinue orthotics**

Question 37

Where does the sural nerve get entraped? What does tx involve?

Answer 37

* Anywhere along course * Most vunerable 12-15mm distal to tip of fibula as foot rests in equius position * Tx * **Surgical release**