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1.
World Neurosurg ; 2020 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-32407922

RESUMO

BACKGROUND: Adipose lesions of nerve are generally distinguished as either extraneural or intraneural lipomas or, alternatively, lipomatosis of nerve. We present a patient with an unusual circumferential lipoma that completely encircles the right sciatic nerve and discuss a possible pathogenesis. CASE REPORT: A 44-year-old woman presented with progressive symptoms and signs of sciatic neuropathy for 1 year. MR imaging revealed a large lipomatous mass extending from the level of the lesser trochanter to the distal third of the femur. The sciatic nerve was completely enveloped by the lipoma in the proximal segment, partially enveloped in the mid-segment and was separate from the nerve in the distal segment. The lipoma was not covered by epineurium. The tumor was completely resected and the patient's neurologic symptoms improved. CONCLUSION: The pathogenetic mechanism of the reported circumferential lipoma is not known. Two possible mechanisms considered included 1) envelopment by an extraneural lipoma over time, and 2) occurrence of a lipoma in the paraneurial compartment (and in this case, extension into an extraneural one). Based on the available literature, lipomas that circumferentially envelop the entire nerve seem to be underrecognized and poorly understood. Analogous cases of lipomas enveloping nerves or other structures than nerves have been reported in the literature. Our reported case highlights the complexity of adipose lesions affecting nerve.

3.
Invest Radiol ; 54(12): 781-791, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31503079

RESUMO

OBJECTIVES: The aim of this work was to devise mitigation strategies for addressing a range of image artifacts on a clinical 7 T magnetic resonance imaging scanner using the regulatory-approved single-channel radiofrequency transmit mode and vendor-supplied radiofrequency coils to facilitate clinical scanning within reasonable scan times. MATERIALS AND METHODS: Optimized imaging sequence protocols were developed for routine musculoskeletal knee and neurological imaging. Sources of severe image nonuniformities were identified, and mitigation strategies were devised. A range of custom-made high permittivity dielectric pads were used to compensate for B1 and B1 inhomogeneities, and also for magnetic susceptibility-induced signal dropouts particularly in the basal regions of the temporal lobes and in the cerebellum. RESULTS: Significant improvements in image uniformity were obtained using dielectric pads in the knee and brain. A combination of small voxels, reduced field of view B0 shimming, and high in-plane parallel imaging factors helped to minimize signal loss in areas of high susceptibility-induced field distortions. The high inherent signal-to-noise ratio at 7 T allowed for high receiver bandwidths and thin slices to minimize chemical shift artifacts. Intermittent artifacts due to radiofrequency inversion pulse limitations (power, bandwidth) were minimized with dielectric pads. A patient with 2 implanted metallic cranial fixation devices located within the radiofrequency transmit field was successfully imaged, with minimal image geometric distortions. CONCLUSIONS: Challenges relating to severe image artifacts at 7 T using single-channel radiofrequency transmit functionality in the knee and brain were overcome using the approaches described in this article. The resultant high diagnostic image quality paves the way for incorporation of this technology into the routine clinical workflow. Further developmental efforts are required to expand the range of applications to other anatomical areas, and to expand the evidence- and knowledge-base relating to the safety of scanning patients with implanted metallic devices.

5.
Hand Clin ; 35(3): 241-257, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31178083

RESUMO

The scaphoid is the most commonly fractured bone in the wrist but 20% to 40% of scaphoid fractures are radiographically occult. Delayed or misdiagnosis can have significant consequences with late complications such as nonunion, malunion, or the development of avascular necrosis in the proximal pole. After initial negative radiographs, advanced cross-sectional imaging, including CT and MRI, ultimately may provide more accurate and rapid diagnosis than conventional radiography. With chronic fractures, the preferred modality depends on the clinical question. New techniques are evolving that will further advance imaging for diagnosis and treatment of scaphoid fractures.


Assuntos
Fraturas Ósseas/diagnóstico por imagem , Osso Escafoide/diagnóstico por imagem , Reabsorção Óssea/diagnóstico por imagem , Simulação por Computador , Diagnóstico por Imagem/métodos , Fixação Interna de Fraturas , Consolidação da Fratura , Fraturas Ósseas/cirurgia , Humanos , Imageamento Tridimensional , Impressão Tridimensional , Osso Escafoide/lesões , Osso Escafoide/cirurgia
6.
World Neurosurg ; 129: e555-e560, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31154102

RESUMO

BACKGROUND: Diverse adipose lesions can affect peripheral nerves, including an intrinsic disorder known as lipomatosis of nerve (LN). This condition leads to massive nerve enlargement and has often been associated with nerve territory overgrowth. Although LN has been well documented as a peripheral lesion, it is uncertain whether LN can occur or extend intradurally. METHODS: In the present 2-part study, we searched our institutional database and the world literature to identify any case of LN occurring or extending intradurally. Strict pathognomonic imaging and histopathologic features of LN were required to be present. RESULTS: We did not identify any case of LN that had occurred or extended intradurally in our institution. Specifically, in our database, we found no case of intradural LN, and an evaluation of the imaging studies of proximal examples of LN did not show any extension proximal to the spinal foramen. Our literature search identified 208 reports of potential interest, of which only 3 had reported on spinal LN. Although 2 of the 3 cases showed some similarities to LN, none had demonstrated features diagnostic for LN and none had demonstrated nerve territory overgrowth. A review of 16 cases of LN in proximal locations summarized in a recently reported systematic review did not reveal any cases with LN proximal to the foramen or in an intradural location. CONCLUSION: A review of our institutional cases and reported cases did not show any example of LN extending or occurring intradurally. It appears that LN is a benign tumor-like nerve lesion that is without a central location, unlike more well-known tumors such as schwannomas.


Assuntos
Lipomatose/patologia , Nervos Periféricos/patologia , Adulto , Idoso , Feminino , Humanos , Lipomatose/diagnóstico por imagem , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Nervos Periféricos/diagnóstico por imagem , Estudos Retrospectivos , Adulto Jovem
9.
J Magn Reson Imaging ; 50(5): 1534-1544, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30779475

RESUMO

BACKGROUND: MR image intensity nonuniformity is often observed at 7T. Reference scans from the body coil used for uniformity correction at lower field strengths are typically not available at 7T. PURPOSE: To evaluate the efficacy of a novel algorithm, Uniform Combined Reconstruction (UNICORN), to correct receive coil-induced nonuniformity in musculoskeletal 7T MRI without the use of a reference scan. STUDY TYPE: Retrospective image analysis study. SUBJECTS: MRI data of 20 subjects was retrospectively processed offline. Field Strength/Sequence: Knees of 20 subjects were imaged at 7T with a single-channel transmit, 28-channel phased-array receive knee coil. A turbo-spin-echo sequence was used to acquire 33 series of images. ASSESSMENT: Three fellowship-trained musculoskeletal radiologists with cumulative experience of 42 years reviewed the images. The uniformity, contrast, signal-to-noise ratio (SNR), and overall image quality were evaluated for images with no postprocessing, images processed with N4 bias field correction algorithm, and the UNICORN algorithm. STATISTICAL TESTS: Intraclass correlation coefficient (ICC) was used for measuring the interrater reliability. ICC and 95% confidence intervals (CIs) were calculated using the R statistical package employing a two-way mixed-effects model based on a mean rating (k = 3) for absolute agreement. The Wilcoxon signed-rank test with continuity correction was used for analyzing the overall image quality scores. RESULTS: UNICORN was preferred among the three methods evaluated for uniformity in 97.9% of the pooled ratings, with excellent interrater agreement (ICC of 0.98, CI 0.97-0.99). UNICORN was also rated better than N4 for contrast and equivalent to N4 in SNR with ICCs of 0.80 (CI 0.72-0.86) and 0.67 (CI 0.54-0.77), respectively. The overall image quality scores for UNICORN were significantly higher than N4 (P < 6 × 10-13 ), with good to excellent interrater agreement (ICC 0.90, CI 0.86-0.93). DATA CONCLUSION: Without the use of a reference scan, UNICORN provides better image uniformity, contrast, and overall image quality at 7T compared with the N4 bias field-correction algorithm. LEVEL OF EVIDENCE: 4 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;50:1534-1544.

10.
World Neurosurg ; 126: e259-e269, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30797927

RESUMO

BACKGROUND: Intraneural ganglion cysts of the obturator nerve are rare. Our aim is to review cases of obturator intraneural ganglion cysts at our institution and those reported in the literature. METHODS: We reviewed all cases evaluated by the senior author. A literature search was performed using the PubMed database and Google Scholar with the following terms: "obturator cyst," "obturator intraneural ganglion cyst," and "obturator intraneural ganglia." All cases underwent a retrospective review. Patient demographic data, including age, sex, and presenting signs and symptoms were recorded. Imaging studies were re-evaluated by 2 musculoskeletal radiologists experienced in the diagnosis of intraneural ganglion cysts. RESULTS: We identified 2 cases of obturator intraneural ganglia at our institution; both were connected to the hip joint. We found 4 cases that were clearly diagnosed as intraneural ganglia in the literature, of which only 1 was recognized by the original authors as being joint connected, but based on our reinterpretation, 3 of 4 were joint connected. An additional 9 cases identified in the literature did not definitely report the nerve-cyst relationship, but based on our reinterpretation, were believed to be intraneural; 8 were joint connected. CONCLUSIONS: We believe that obturator intraneural ganglion cysts adhere to the principles of the unifying articular theory. They arise from the anteromedial hip joint and extend into an articular branch and can reach the parent obturator nerve. Surgery should address the hip disease and/or the articular branch connection. Not appreciating the pathoanatomy of these cysts can lead to persistent or recurrent cysts.


Assuntos
Cistos Glanglionares/cirurgia , Adulto , Idoso , Eletromiografia , Feminino , Cistos Glanglionares/diagnóstico por imagem , Cistos Glanglionares/patologia , Articulação do Quadril/diagnóstico por imagem , Articulação do Quadril/patologia , Articulação do Quadril/cirurgia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Debilidade Muscular/etiologia , Nervo Obturador/diagnóstico por imagem , Nervo Obturador/patologia , Nervo Obturador/cirurgia , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/cirurgia , Estudos Retrospectivos , Espondiloartropatias/etiologia , Adulto Jovem
11.
Acta Neurochir (Wien) ; 161(4): 679-684, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30798481

RESUMO

BACKGROUND: Lipomatosis of nerve (LN) is a peripheral nerve disorder characterized by fibroadipose proliferation within the epineurium. It has been associated with nerve-territory overgrowth affecting soft tissue and/or bony structures. We sought to understand if there is an anatomical relationship associated with nerve-territory overgrowth. METHODS: A review of the literature and our institutional LN cases was performed to determine the prevalence of nerve-territory overgrowth. Only cases with sufficient clinical and/or imaging data were selected. The cases were then subdivided into two groups and analyzed: (1) motor (mixed) nerve and (2) predominant sensory nerve, based on the anatomical location of the LN lesion. Subgroup analysis was performed on median nerves affected by LN, for a more homogenous population. RESULTS: We identified 329 LN cases with sufficient information for analysis. Motor (mixed) nerve group (M) consisted of 287 cases (155 with overgrowth and 132 without overgrowth). Sensory nerve group (S) revealed group of 42 cases (4 cases with overgrowth and 38 without overgrowth). Statistical analysis comparing overgrowth status in the M and S nerve groups showed a statistically significant difference in overgrowth, favoring the M group for overgrowth (p < 0.0001). The analysis of median nerve group consisted of 225 cases in the M group (106 with overgrowth and 119 without overgrowth) and 20 cases in the S group (3 with overgrowth and 17 cases without overgrowth). A statistically significant difference in nerve-territory overgrowth status was present in the M vs. the S group, again favoring the M group for overgrowth. (p = 0.0083). Cases from our institution included 44 cases for this analysis. Forty-two cases in the M group (28 with overgrowth and 14 without overgrowth) and 2 cases in the S group (all 2 without overgrowth). CONCLUSION: We believe the association of LN and nerve-territory overgrowth might be explained by involvement of mixed motor nerves; however, the exact underlying mechanism is not known.

12.
J Foot Ankle Surg ; 58(2): 377-380, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30612871

RESUMO

Soft tissue ganglion cysts are a well-known cause of tibial nerve compression in the tarsal tunnel. We describe a patient who presented with tibial nerve symptoms and was found to have an adventitial cyst of the tibial vein arising from the subtalar joint, with the joint connection confirmed both on imaging and at surgery. Surgical decompression of the cyst with transection of the vascular pedicle arising from the subtalar joint improved her symptoms at 6 months, and postoperative magnetic resonance imaging showed resolution of the cyst. Cystic adventitial disease is a rare, poorly understood condition in which a cyst is identified in the adventitia of a vessel, usually an artery. Only 3 cases of adventitial cysts have been reported in the foot and ankle region, 2 in the lesser and 1 in the greater saphenous vein. None of the previous cases have been recognized to be joint connected. This case provides additional evidence for an articular origin for adventitial cysts and helps guide management strategies for these joint-connected cysts.


Assuntos
Descompressão Cirúrgica/métodos , Cistos Glanglionares/cirurgia , Veia Safena/cirurgia , Articulação Talocalcânea/cirurgia , Adulto , Biópsia por Agulha , Progressão da Doença , Feminino , Cistos Glanglionares/diagnóstico por imagem , Cistos Glanglionares/patologia , Humanos , Imuno-Histoquímica , Imagem por Ressonância Magnética/métodos , Síndromes de Compressão Nervosa/diagnóstico , Síndromes de Compressão Nervosa/etiologia , Medição da Dor , Doenças Raras , Medição de Risco , Veia Safena/patologia , Articulação Talocalcânea/diagnóstico por imagem , Resultado do Tratamento
13.
Neurosurgery ; 85(6): 786-792, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30481319

RESUMO

BACKGROUND: Management of intraneural perineuriomas remains controversial, largely due to the lack of knowledge regarding the natural history of these lesions. OBJECTIVE: To describe the typical radiological growth pattern of intraneural perineuriomas and to determine how the pattern of growth relates to clinical progression. METHODS: We performed a retrospective review of the magnetic resonance imaging (MRI) studies and serial clinical examinations of a cohort of patients with biopsy-proven intraneural perineuriomas who had 2 MRI studies at least 2 yr apart. The outcome of interest was radiological growth in length or width of the intraneural perineurioma. Radiological growth was tested for association with clinical progression. RESULTS: Twenty patients were included in the study. By width, the lesions were on average larger on repeat imaging (P = .009). By absolute length, the lesions were on average longer on repeat imaging (P = .02). By lesion:landmark ratio, there was no difference in length of the lesions between sequential images (P = .09), with 10 (50%) lesions being shorter and 7 (35%) showing no change. No lesions grew to involve a new nerve or division of a nerve on sequential imaging. None of the variables tested were associated with clinical progression. CONCLUSION: We found that intraneural perineuriomas only rarely grow in length, do not grow to involve new nerves or nerve divisions, and growth does not correlate with clinical progression. These findings have significant ramifications for management of these tumors.

14.
Clin Anat ; 32(2): 218-223, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30267439

RESUMO

Ulnar neuropathy at the cubital tunnel is common. However, a rare form of ulnar neuropathy here is due to compression from an accessory muscle, the anconeus epitrochlearis. Reports in the literature regarding the details of this muscle's innervation are vague, so the aim of the present study was to characterize this anatomy more clearly. This was a combined review of magnetic resonance imaging (MRI) from patients with an anconeus epitrochlearis and ulnar neuropathy and cadaveric dissections to characterize the innervation of this variant muscle. A review of 11 patients and three reports of ulnar neuropathy and an anconeus epitrochlearis in the literature revealed no MRI changes consistent with acute denervation of this muscle. However, in two cases, there were signs of chronic denervation of the muscle. Dissection of five cadavers revealed that the nerve supply to the anconeus epitrochlearis originated proximal to the medial epicondyle, traveled parallel to the ulnar nerve, terminated on the deep aspect of this muscle, and had a mean length of 60 mm. This clinicoanatomical study provides evidence that the innervation of the anconeus epitrochlearis is proximal to the muscle and on its deep aspect. Clin. Anat. 32:218-223, 2019. © 2018 Wiley Periodicals, Inc.


Assuntos
Músculo Esquelético/inervação , Síndromes de Compressão do Nervo Ulnar/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cadáver , Articulação do Cotovelo , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/diagnóstico por imagem , Músculo Esquelético/patologia , Síndromes de Compressão do Nervo Ulnar/diagnóstico por imagem , Síndromes de Compressão do Nervo Ulnar/fisiopatologia
16.
Clin Anat ; 32(2): 201-205, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30194877

RESUMO

Volar radial wrist masses are common. Adventitial cysts of the radial artery are rarely reported and poorly understood. We describe a case series of adventitial cysts in association with the radial artery and detail their pathophysiology and treatment. We conducted an Institutional Review Board-approved retrospective review of patients treated at our institution from 1997 to 2018. Twelve patients were identified. Presenting symptoms typically included pain and swelling over the volar radial wrist. High-resolution magnetic resonance imaging (MRI) demonstrated tubular, cystic lesions within the adventitia of the radial artery with connections to the wrist joint confirmed on multiplanar imaging: (radiocarpal joint = 10; scaphotrapeziotrapezoidal joint = 1; and intercarpal joint = 1). Seven patients underwent operation, at which time the cyst was resected and the articular branch disconnected. These patients reported resolution of their symptoms without clinical recurrence. The consistent finding of a joint connection in these cases of adventitial cysts associated with the radial artery has important clinical implications. The joint connection needs to be disconnected. Level of evidence: Level IV, case series. Clin. Anat. 32:201-205, 2019. © 2018 Wiley Periodicals, Inc.


Assuntos
Túnica Adventícia/patologia , Cistos/diagnóstico , Doença Arterial Periférica/diagnóstico , Artéria Radial/patologia , Adolescente , Adulto , Túnica Adventícia/diagnóstico por imagem , Idoso , Cistos/patologia , Cistos/cirurgia , Feminino , Força da Mão , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/cirurgia , Artéria Radial/diagnóstico por imagem , Artéria Radial/cirurgia , Estudos Retrospectivos , Articulação do Punho/diagnóstico por imagem , Adulto Jovem
17.
Oper Neurosurg (Hagerstown) ; 16(1): E17, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29800277

RESUMO

Neuromuscular choristoma (NMC) is a rare congenital nerve lesion that is classified by the presence of heterotopic muscle fibers intercalated within nerve fascicles.1 The presence of NMC typically causes progressive neuropathy and bony/soft tissue undergrowth, often leading to a shortened atrophic limb.2,3 The typical appearance of NMC on magnetic resonance imaging is an enlarged fusiform nerve that exhibits minimal gadolinium enhancement.4 While there is increasing documentation of pathognomonic clinical and radiographic features for various diffuse fusiform peripheral nerve lesions, nerve biopsy is still occasionally required for some patients given the rarity of these diseases and progressive neuropathic features.The intraoperative appearance of NMC and its unique electrical stimulation properties are quite interesting. Intrafascicular replacement of nerve by skeletal muscle gives the nerve a red beefy color and causes the fascicles to contract with electrical stimulation.5 In this video, we demonstrate the intraoperative appearance and contractile properties of NMC in a 60-yr-old woman with progressive sciatic neuropathy. Histologic and immunohistochemical studies identified a gradient of intralesional mature skeletal muscle within the NMC, with substantially fewer desmin-positive skeletal muscle fibers in the distal aspect. A gradient of contractility with intraoperative stimulation seemed to correlate with this pathology. These findings suggest that the lesional extent of NMC may not be clinically or grossly evident, reflecting a varying distribution of skeletal muscle within the affected nerve.The Mayo Clinic Institutional Review Board Office for Human Research Protection does not require approval for single participant case studies. The subject involved in this study was not identifiable and the general surgical consent form included permission for intraoperative photos and video.

18.
J Neurosurg ; 131(6): 1869-1875, 2018 Dec 21.
Artigo em Inglês | MEDLINE | ID: mdl-30579281

RESUMO

The authors present the cases of 3 patients with severe injuries affecting the peroneal nerve combined with loss of tibialis posterior function (inversion) despite preservation of other tibial nerve function. Loss of tibialis posterior function is problematic, since transfer of the tibialis posterior tendon is arguably the best reconstructive option for foot drop, when available. Analysis of preoperative imaging studies correlated with operative findings and showed that the injuries, while predominantly to the common peroneal nerve, also affected the lateral portion of the tibial nerve/division near the sciatic nerve bifurcation. Sunderland's fascicular topographic maps demonstrate the localization of the fascicular bundle subserving the tibialis posterior to the area that corresponds to the injury. This has clinical significance in predicting injury patterns and potentially for treatment of these injuries. The lateral fibers of the tibial division/nerve may be vulnerable with long stretch injuries. Due to the importance of tibialis posterior function, it may be important to perform internal neurolysis of the tibial division/nerve in order to facilitate nerve action potential testing of these fascicles, ultimately performing split nerve graft repair when nerve action potentials are absent in this important portion of the tibial nerve.


Assuntos
Nervo Fibular/lesões , Nervo Fibular/cirurgia , Nervo Isquiático/lesões , Nervo Isquiático/cirurgia , Nervo Tibial/lesões , Nervo Tibial/cirurgia , Adulto , Humanos , Masculino , Músculo Esquelético/diagnóstico por imagem , Músculo Esquelético/inervação , Músculo Esquelético/cirurgia , Nervo Fibular/diagnóstico por imagem , Nervo Isquiático/diagnóstico por imagem , Nervo Tibial/diagnóstico por imagem , Adulto Jovem
19.
Acta Neurochir (Wien) ; 160(12): 2479-2484, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30377830

RESUMO

Superficial radial intraneural ganglion cysts are rare. Only nine previous cases have been described. We provide two examples with a wrist joint connection and review the literature to provide further support for the unifying articular (synovial) theory for the pathogenesis and treatment of intraneural ganglia.


Assuntos
Cistos Glanglionares/cirurgia , Punho/cirurgia , Adulto , Feminino , Cistos Glanglionares/diagnóstico por imagem , Cistos Glanglionares/patologia , Humanos , Imagem por Ressonância Magnética , Masculino , Punho/diagnóstico por imagem , Punho/patologia
20.
J Neurosurg ; 131(1): 175-183, 2018 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-30168738

RESUMO

OBJECTIVE: Desmoid-type fibromatosis (DTF) presents a therapeutic dilemma. While lacking metastatic potential, it is a locally aggressive tumor with a strong propensity for occurrence near nerve(s) and recurrence following resection. In this study, the authors introduce the association of an occult neuromuscular choristoma (NMC) identified in patients with DTF. METHODS: After experiencing a case of DTF found to have an occult NMC, the authors performed a retrospective database review of all other cases of biopsy-proven DTF involving the extremities or limb girdles in patients with available MRI data. Two musculoskeletal radiologists with expertise in peripheral nerve imaging reviewed the MRI studies of the eligible cases for evidence of previously unrecognized NMC. RESULTS: The initial case of a patient with an occult sciatic NMC is described. The database review yielded 40 patients with DTF-18 (45%) in the upper limb and 22 (55%) in the lower limb. Two cases (5%) had MRI findings of NMC associated with the DTF, one in the proximal sciatic nerve and the other in the proximal tibial and sural nerves. CONCLUSIONS: The coexistence of NMC may be under-recognized in a subset of patients with extremity DTF. This finding poses implications for DTF treatment and the likelihood of recurrence after resection or biopsy. Further study may reveal crucial links between the pathogenesis of NMC and DTF and offer novel therapeutic strategies.

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