A Rare Atypical Case of Asymptomatic and Spontaneous Intraneural Hematoma of Sural Nerve: A Case Report and Literature Review.

Intraneural hematoma is a rare disease that results in an impaired nerve function because of bleeding around the peripheral nerve, with only 20 cases reported. Trauma, neoplasm, and bleeding disorders are known factors for intraneural hematoma. However, here we report atypical features of asymptomatic and spontaneous intraneural hematoma which are difficult to diagnose. A 60-year-old woman visited our clinic with the complaint of a palpable mass on the right calf. She reported no medical history or trauma to the right calf and laboratory findings showed normal coagulopathy. Ultrasonography was performed, which indicated hematoma near saphenous vein and sural nerve or neurogenic tumor. We performed surgical exploration and intraneural hematoma was confirmed on sural nerve. Meticulous paraneuriotomy and evacuation was performed without nerve injury. Histological examination revealed intraneural hematoma with a vascular wall. No neurologic symptoms were observed. In literature review, we acknowledge that understanding anatomy of nerve, using ultrasonography as a diagnostic tool and surgical decompression is key for intraneural hematoma. Our case report may help establish the implications of diagnosis and treatment. Also, we suggested surgical treatment is necessary even in cases that do not present symptoms because neurological symptoms and associated symptoms may occur later.

A Bilateral Symmetrical Variant Formation of the Sural Nerve.

Typically, the sural nerve is formatted by the connection of the lateral sural cutaneous nerve (branch of the common fibular nerve) and the medial sural cutaneous nerve (branch of the tibial nerve). The current cadaveric report aims to describe a quite unusual symmetrical variant of the sural nerve. Classical dissection was performed on an 84-year-old donated male cadaver. On both sides, the sural nerve was formatted directly by the sciatic nerve. After its emanation, it continued its typical course between the gastrocnemius muscle heads. Sural nerve formation has been extensively studied due to its great clinical significance. The identified variant corresponds to one of the rarest types of sural nerve formation. Knowledge of sural nerve variants may play a crucial role in lower limb surgery and nerve harvest for reconstruction.

Anatomical considerations of the sural nerve in the distal leg: Side branch patterns and significance in nerve harvesting procedures.

BACKGROUND: The sural nerve is a somatosensory nerve that provides sensation to the posterolateral aspect of the lower leg and the lateral part of the ankle and foot. Due to its location and anatomical properties, it is often used as an autologous nerve graft. However, the nerve harvest can be complicated by the presence of side branches. The objective of this study was to investigate the anatomy of the sural nerve and to map its side branches. This information can be used to predict the localization of separate incisions during the stair-step incisions technique for nerve harvest, thereby reducing the risk of complications. METHODS: The study involved the dissection of 50 adult cadaveric legs (25 left and 25 right) obtained from 27 Central European cadavers. The focus of the dissection was to identify the sural nerve, small saphenous vein, and surrounding anatomical structures. Detailed measurements were taken on the side branches of the sural nerve, tributaries of the small saphenous vein, and their interrelationship. RESULTS: The average number of sural nerve side branches in a single leg was 4.2±1.9. These side branches were categorized into six groups based on their location and course: mediodistal, medioproximal, lateroproximal, laterodistal, medial perpendicular, and lateral perpendicular. Specific patterns of combination of these side branches were also identified and described. The branching point of the sural nerve was found to be 5.8±2.7 cm proximal to the lateral malleolus, whereas the small saphenous vein branching point was located more distally, 4.5 ± 2.8 cm proximal to the lateral malleolus. The highest density of sural nerve side branches was found 2.1-6.0 cm above the lateral malleolus. CONCLUSION: This study presents valuable data about the relationship between the sural nerve and the surrounding anatomical structures in the distal part of the leg, including the identification of its side branches and their relevance during nerve harvest procedures. On the basis of the most frequent locations of side branches, a three-incision-technique for nerve harvest is proposed.

Ultrahigh-frequency ultrasound of fascicles in the common fibular, superficial fibular, and sural nerves.

INTRODUCTION/AIMS: While ultrasound assessment of cross-sectional area and echogenicity has gained popularity as a biomarker for various neuropathies, there is a scarcity of data regarding fascicle count and density in neuropathies or even healthy controls. The aim of this study was to determine whether fascicles within select lower limb nerves (common fibular, superficial fibular, and sural nerves) can be counted in healthy individuals using ultrahigh-frequency ultrasound (UHFUS). METHODS: Twenty healthy volunteers underwent sonographic examination of the common fibular, superficial fibular, and sural nerves on each lower limb using UHFUS with a 48 MHz linear transducer. Fascicle counts and density in each examined nerve were determined by a single rater. RESULTS: The mean fascicle number for each of the measured nerves included the following: common fibular nerve 9.85 (SD 2.29), superficial fibular nerve 5.35 (SD 1.59), and sural nerve 6.73 (SD 1.91). Multivariate linear regression analysis revealed a significant association between cross-sectional area and fascicle count for all three nerves. In addition, there was a significant association seen in the common fibular nerve between fascicle density and height, weight, and body mass index. Age and sex did not predict fascicle count or density (all p > .13). DISCUSSION: UHFUS enabled the identification and counting of fascicles and fascicle density in the common fibular, superficial fibular, and sural nerves. Knowledge about normal values and normal peripheral nerve architecture is needed in order to further understand and identify pathological changes that may occur within each nerve in different disease states.

Automated whole slide morphometry of sural nerve biopsy using machine learning.

AIM: The morphometry of sural nerve biopsies, such as fibre diameter and myelin thickness, helps us understand the underlying mechanism of peripheral neuropathies. However, in current clinical practice, only a portion of the specimen is measured manually because of its labour-intensive nature. In this study, we aimed to develop a machine learning-based application that inputs a whole slide image (WSI) of the biopsied sural nerve and automatically performs morphometric analyses. METHODS: Our application consists of three supervised learning models: (1) nerve fascicle instance segmentation, (2) myelinated fibre detection and (3) myelin sheath segmentation. We fine-tuned these models using 86 toluidine blue-stained slides from various neuropathies and developed an open-source Python library. RESULTS: Performance evaluation showed (1) a mask average precision (AP) of 0.861 for fascicle segmentation, (2) box AP of 0.711 for fibre detection and (3) a mean intersection over union (mIoU) of 0.817 for myelin segmentation. Our software identified 323,298 nerve fibres and 782 fascicles in 70 WSIs. Small and large fibre populations were objectively determined based on clustering analysis. The demyelination group had large fibres with thinner myelin sheaths and higher g-ratios than the vasculitis group. The slope of the regression line from the scatter plots of the diameters and g-ratios was higher in the demyelination group than in the vasculitis group. CONCLUSION: We developed an application that performs whole slide morphometry of human biopsy samples. Our open-source software can be used by clinicians and pathologists without specific machine learning skills, which we expect will facilitate data-driven analysis of sural nerve biopsies for a more detailed understanding of these diseases.

Morphometry of the sural nerve in diabetic neuropathy: a systematic review.

PURPOSE: The aim of this systematic review is to evaluate the usefulness of sural nerve ultrasonography in diagnosing diabetes mellitus (DM) and diabetic polyneuropathy (DPN), the latter of which is a common long-term complication for diabetic patients that frequently involves the sural nerve. METHODOLOGY: A meta-analysis of the cross-sectional areas (CSAs) of sural nerves in healthy individuals and patients with diabetes mellitus based on a total of 32 ultrasonographic-based studies from 2015 to 2023 was performed. Sub-analyses were performed for factors such as geographical location and measurement site. RESULTS: The meta-analysis showed that the mean CSA of the sural nerve was significantly larger in DM patients with DPN only compared to healthy individuals across all regions and when pooled together. An age-dependent increase in the CSA of healthy sural nerves is apparent when comparing the paediatric population with adults. CONCLUSION: Sural nerve ultrasonography can distinguish diabetic adults with DPN from healthy adults based on cross-sectional area measurement. Future studies are needed to clarify the relationships between other parameters, such as body metrics and age, with sural nerve CSAs. Cut-offs for DPN likely need to be specific for different geographical regions.

Utilization of the Rat Tibial Nerve Transection Model to Evaluate Cellular and Molecular Mechanisms Underpinning Denervation-Mediated Muscle Injury.

Peripheral nerve injury denervates muscle, resulting in muscle paralysis and atrophy. This is reversible if timely muscle reinnervation occurs. With delayed reinnervation, the muscle's reparative ability declines, and muscle-resident fibro-adipogenic progenitor cells (FAPs) proliferate and differentiate, inducing fibro-fatty muscle degradation and thereby physical disability. The mechanisms by which the peripheral nerve regulates FAPs expansion and differentiation are incompletely understood. Using the rat tibial neve transection model, we demonstrated an increased FAPs content and a changing FAPs phenotype, with an increased capacity for adipocyte and fibroblast differentiation, in gastrocnemius muscle post-denervation. The FAPs response was inhibited by immediate tibial nerve repair with muscle reinnervation via neuromuscular junctions (NMJs) and sensory organs (e.g., muscle spindles) or the sensory protection of muscle (where a pure sensory nerve is sutured to the distal tibial nerve stump) with reinnervation by muscle spindles alone. We found that both procedures reduced denervation-mediated increases in glial-cell-line-derived neurotrophic factor (GDNF) in muscle and that GDNF promoted FAPs adipogenic and fibrogenic differentiation in vitro. These results suggest that the peripheral nerve controls FAPs recruitment and differentiation via the modulation of muscle GDNF expression through NMJs and muscle spindles. GDNF can serve as a therapeutic target in the management of denervation-induced muscle injury.

Heel Pain Management in Haglund's Deformity Targeting Sural Nerve Branches under Ultrasound Guidance: Case Report.

Introduction: Haglund's deformity is an abnormality of the bone and soft tissue of the foot, also known as retrocalcaneal exostosis, Mulholland deformity, and "pump bump". The etiology is not well known. Probable causes include a tight Achilles tendon, a high arch of the foot, and hereditary. The clinical features consist of pain at the posterior aspect of the heel which is predominantly present when the patient begins to walk after a period of rest or inactivity. Case Report: We report a case of a 60-year-old teacher with left heel pain for 3 years, unable to stand or walk for more than 15 min due to pain. We diagnosed him as a case of Haglund's deformity and treated him with ultrasound-guided injections targeting the superficial branches of the sural nerve. This case report illustrates a rarely described modality for the management of heel pain due to Haglund's deformity. Targeting superficial branches of the Sural nerve under ultrasound guidance can act as a superior treatment modality for the management of heel pain due to Haglund's deformity. Conclusion: Haglund's deformity is a cause of pain in the hindfoot that should be taken into account in the differential diagnosis of any patient presenting with heel pain. Ultrasonography has proved to be an important cost-effective tool in the diagnosis and management of various ankle pathologies like Haglund's deformity, thereby reducing the sole dependence on surgical management. Targeting the superficial (cutaneous) branches of the sural nerve can give satisfactory long-term relief of heel pain in patients with Haglund deformity.

Selective neural inhibition via photobiomodulation alleviates behavioral hypersensitivity associated with small sensory fiber activation.

OBJECTIVE: Photobiomodulation at higher irradiances has great potential as a pain-alleviating method that selectively inhibits small diameter nerve fibers and corresponding sensory experiences, such as nociception and heat sensation. The longevity and magnitude of these effects as a function of laser irradiation parameters at the nerve was explored. METHODS: In a rodent chronic pain model (spared nerve injury-SNI), light was applied directly at the sural nerve with four delivery schemes: two irradiance levels (7.64 and 2.55 W/cm2 ) for two durations each, corresponding to either 4.8 or 14.4 J total energy, and the effect on sensory hypersensitivities was evaluated. RESULTS: At emitter irradiances of 7.64 W/cm2 (for 240 s), 2.55 W/cm2 (for 720 s), and 7.64 W/cm2 (for 80 s) the heat hypersensitivity was relieved the day following photobiomodulation (PBM) treatment by 37 ± 8.1% (statistically significant, p < 0.001), 26% ± 6% (p = 0.072), and 28 ± 6.1% (statistically significant, p = 0.032), respectively, and all three treatments reduced the hypersensitivity over the course of the experiment (13 days) at a statistically significant level (mixed-design analysis of variance, p < 0.05). The increases in tissue temperature (5.3 ± 1.0 and 1.3 ± 0.4°C from 33.3°C for the higher and lower power densities, respectively) at the neural target were well below those typically associated with permanent action potential disruption. CONCLUSIONS: The data from this study support the use of direct PBM on nerves of interest to reduce sensitivities associated with small-diameter fiber activity.

Effects of exosomes from mesenchymal stem cells on functional recovery of a patient with total radial nerve injury: A pilot study.

BACKGROUND: Peripheral nerve injury can result in significant clinical complications that have uncertain prognoses. Currently, there is a lack of effective pharmacological interventions for nerve damage, despite the existence of several small compounds, peptides, hormones, and growth factors that have been suggested as potential enhancers of neuron regeneration. Despite the objective of achieving full functional restoration by surgical intervention, the persistent challenge of inadequate functional recovery remains a significant concern in the context of peripheral nerve injuries. AIM: To examine the impact of exosomes on the process of functional recovery following a complete radial nerve damage. METHODS: A male individual, aged 24, who is right-hand dominant and an immigrant, arrived with an injury caused by a knife assault. The cut is located on the left arm, specifically below the elbow. The neurological examination and electrodiagnostic testing reveal evidence of left radial nerve damage. The sural autograft was utilized for repair, followed by the application of 1 mL of mesenchymal stem cell-derived exosome, comprising 5 billion microvesicles. This exosome was split into four equal volumes of 0.25 mL each and delivered microsurgically to both the proximal and distal stumps using the subepineural pathway. The patient was subjected to a period of 180 d during which they had neurological examination and electrodiagnostic testing. RESULTS: The duration of the patient's follow-up period was 180 d. An increasing Tinel's sign and sensory-motor recovery were detected even at the 10th wk following nerve grafting. Upon the conclusion of the 6-mo post-treatment period, an evaluation was conducted to measure the extent of improvement in motor and sensory functions of the nerve. This assessment was based on the British Medical Research Council scale and the Mackinnon-Dellon scale. The results indicated that the level of improvement in motor function was classified as M5, denoting an excellent outcome. Additionally, the level of improvement in sensory function was classified as S3+, indicating a good outcome. It is noteworthy that these assessments were conducted in the absence of physical therapy. At the 10th wk post-injury, despite the persistence of substantial axonal damage, the nerve exhibited indications of nerve re-innervation as evidenced by control electromyography (EMG). In contrast to the preceding. EMG analysis revealed a significant electrophysiological enhancement in the EMG conducted at the 6th-mo follow-up, indicating ongoing regeneration. CONCLUSION: Enhanced comprehension of the neurobiological ramifications associated with peripheral nerve damage, as well as the experimental and therapy approaches delineated in this investigation, holds the potential to catalyze future clinical progress.

Vascularized Sural Nerve Graft, Fascial Free Flap, and Regenerative Peripheral Nerve Interface in the Setting of Recurrent Thigh Liposarcoma: A Case Report.

Background: There is no clear consensus in the literature regarding clinical indications for vascularized nerve grafts. Most studies indicate that vascularized nerve grafting, rather than non-vascularized nerve grafting, is indicated for nerve gaps of greater than 7 cm. Vascularized nerve grafts are superior to non-vascularized nerve grafts because they possess an independent blood supply. However, not all nerve injuries can be repaired via vascularized nerve grafts. Methods: A 32-year-old female received a fascial free flap and vascularized sural nerve graft after having multiple reresections of a recurrent thigh liposarcoma. Results: A 25-cm segment of the sural nerve was isolated alongside the lesser saphenous vein and intervening fascia. The free fascial flap was subsequently reversed and placed into the thigh. Vascular anastomoses were created, and the sural nerve was anastomosed to the peroneal nerve. A small portion of muscle from the thigh was wrapped around tibial nerve fascicles of the sciatic nerve to create a regenerative nerve interface. Conclusions: Benefits of vascularized sural nerve graft compared with other vascularized nerve grafts include negligible sensory loss at the donor site and a nerve graft that can be designed on itself due to its vast length. Additionally, vascularized sural nerve grafts provided a better rate of axonal regeneration, rate of electromyographic return, and motor and sensory outcome compared with non-vascularized sural nerve grafts.

Diagnostic Approach to Lower Limb Entrapment Neuropathies: A Narrative Literature Review.

Entrapment neuropathies of the lower limb are a misunderstood and underdiagnosed group of disorders, characterized by pain and dysesthesia, muscular weakness, and specific provoking movements on physical examination. The most frequent of these syndromes encountered in clinical practice are fibular nerve entrapment, proximal tibial neuropathy, sural nerve neuropathy, deep gluteal syndrome or sciatic nerve entrapment, and lateral femoral cutaneous nerve entrapment, also known as meralgia paresthetica. These are commonly mistaken for lumbar plexopathies, radiculopathies, and musculotendinous diseases, which appear even more frequently and have overlapping clinical presentations. A comprehensive anamnesis, physical examination, and electrodiagnostic studies should help clarify the diagnosis. If the diagnosis is still unclear or a secondary cause of entrapment is suspected, magnetic resonance neurography, MRI, or ultrasonography should be conducted to clarify the etiology, rule out other diseases, and confirm the diagnosis. The aim of this narrative review was to help clinicians gain familiarity with this disease, with an increase in diagnostic confidence, leading to early diagnosis of nerve damage and prevention of muscle atrophy. We reviewed the epidemiology, anatomy, pathophysiology, etiology, clinical presentation, and EDX technique and interpretation of the entrapment neuropathies of the lower limb, using articles published from 1970 to 2022 included in the Pubmed, MEDLINE, Cochrane Library, Google Scholar, EMBASE, Web of Science, and Scopus databases.

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study.

INTRODUCTION: Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity. METHODS: Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures. RESULTS: The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity. CONCLUSION: The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise. LEVELS OF EVIDENCE: Level IV.

Long-Term Donor-Site Morbidity Following Entire Sural Nerve Harvest for Grafting.

PURPOSE: The sural nerve is the autologous nerve used most commonly for grafting. However, recent studies indicate a high rate of complications and complaints after sural nerve removal. In this prospective study, we evaluated donor-site morbidity following full-length sural nerve harvesting on long-term follow-up. METHODS: Fifty-one legs from 43 patients who underwent complete sural nerve harvesting for brachial plexus reconstruction were included in the study. After an average of 5 years, with a minimum postoperative follow-up of 12 months, sensory deficits in the leg and foot were analyzed using 2.0-g monofilaments. Regions of sensory deficit were marked with a skin marker and photographed. Over these regions of decreased sensation, we tested nociception using an eyebrow tweezer. Patients were also asked about pain, cold intolerance, pruritis, difficulties walking, and foot swelling. RESULTS: Regions most affected (84% of patients) were over the calcaneus and cuboid. However, in these regions, nociception was preserved. Regions of decreased sensation extended to the calf region in 11 of 51 legs. In 13 patients, we also observed regions of decreased sensation on the proximal leg. In five feet, the sensation was entirely preserved. No patient had any complaints about pain, cold intolerance, itchiness, difficulties walking, or foot swelling. CONCLUSION: Decreased sensation with nociception preserved was most common along the lateral side of the foot over the calcaneus and cuboid. Removing the entire sural nerve produced no long-term complaints of pain. Sural nerve use appears safe. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Hemangioma cavernoso de nervio periférico: presentación de un caso clínico / Cavernous hemangioma of the peripherical nerve: A case report

El hemangioma cavernoso, conocido también como hemangioma profundo, es una neoplasia benigna de los vasos sanguíneos, que se caracteriza por la presencia de un gran número de vasos normales y anormales sobre la piel u otros órganos internos. Su desarrollo de forma intraneural en nervio periférico es muy raro, con menos de 50 casos informados en la literatura. Presentamos un caso de un hemangioma cavernoso del nervio sural medial en una paciente con clínica de dolor severo y alodinia con resolución completa de la sintomatología tras su tratamiento mediante microcirugía (AU)

Cavernous hemangiomas, also known as deep hemangiomas are benign tumors of blood vessels, including normal and abnormal vascular structures, that develop in skin tissue and sometimes even in deep tissues. Its intraneural development in the peripheral nerve is very rare with less than 50 cases reported in the literature. We present a case of a cavernous hemangioma of the medial sural nerve in a patient with symptoms of severe pain and allodynia with complete resolution of symptoms with microsurgery (AU)

Variations in sural nerve formation and course in fetuses.

To investigate variations regarding the formation and course of the sural nerve (SN). We dissected 60 formalin-fixed Brazilian fetuses (n = 120 lower limbs) aged from the 16th to 34th weeks of gestational age. Three incisions were made in the leg to expose the SN, and the gastrocnemius muscle was retracted to investigate the SN course. Statistical analyses regarding laterality and sex were performed using the Chi-square test. Eight SN formation patterns were classified after analysis. Type 4 (in which the SN is formed by the union of the MSCN with the LSCN) was the most common SN formation pattern. Although there was no statistical association between the formation patterns and the lower limb laterality (p = 0.9725), there was as to sex (p = 0.03973), indicating an association between anatomical variation and sex. The site of branch joining was in the distal leg most time (53.75%). In all lower limbs, the SN or its branches crossed from the medial aspect of the leg to the lateral margin of the calcaneal tendon (CT). Most often, the SN is formed by joining the MSCN and the LSCN in the distal leg. The SN or its branches ran close to the saphenous vein, crossed the CT from medial to lateral, and distributed around the lateral malleolus.

Spared nerve injury causes motor phenotypes unrelated to pain in mice.

Most animal models of neuropathic pain use targeted nerve injuries quantified with motor reflexive measures in response to an applied noxious stimulus. These motor reflexive measures can only accurately represent a pain response if motor function in also intact. The commonly used spared nerve injury (SNI) model, however, damages the tibial and common peroneal nerves that should result in motor phenotypes (i.e., an immobile or "flail" foot) not typically captured in sensory assays. To test the extent of these issues, we used DeepLabCut, a deep learning-based markerless pose estimation tool to quantify spontaneous limb position in C57BL/6J mice during tail suspension following either SNI or sham surgery. Using this granular detail, we identified the expected flail foot-like impairment, but we also found SNI mice hold their injured limb closer to the body midline compared to shams. These phenotypes were not present in the Complete Freunds Adjuvant model of inflammatory pain and were not reversed by multiple analgesics with different mechanisms of action, suggesting these SNI-specific phenotypes are not directly related to pain. Together these results suggest SNI causes previously undescribed phenotypes unrelated to altered sensation that are likely underappreciated while interpreting preclinical pain research outcomes.

A TRPV4 mutation caused Charcot-Marie-Tooth disease type 2C with scapuloperoneal muscular atrophy overlap syndrome and scapuloperoneal spinal muscular atrophy in one family: a case report and literature review.

BACKGROUND: Charcot-Marie-Tooth disease 2C (CMT2C) and scapuloperoneal spinal muscular atrophy (SPSMA) are different clinical phenotypes of TRPV4 mutation. The mutation of p.R316C has been reported to cause CMT2C and SPSMA separately. CASE PRESENTATION: Here, we reported a Chinese family harboring the same p.R316C variant, but with an overlap syndrome and different clinical manifestations. A 58-year-old man presented with severe scapula muscle atrophy, resulting in sloping shoulders. He also exhibited distinct muscle atrophy in his four limbs, particularly in the lower limbs. The sural nerve biopsy revealed severe loss of myelinated nerve fibers with scattered regenerating clusters and pseudo-onion bulbs. Nerve conduction study showed axon damage in both motor and sensory nerves. Sensory nerve action potentials could not be evoked in bilateral sural or superficial peroneal nerves. He was diagnosed with Charcot-Marie-Tooth disease type 2C and scapuloperoneal muscular atrophy overlap syndrome, whereas his 27-year-old son was born with clubfoot and clinodactyly. Electromyogram examination indicated chronic neurogenic changes and anterior horn cells involvement. Although there was no obvious weakness or sensory symptoms, early SPSMA could be considered for him. CONCLUSIONS: A literature review of the clinical characteristics in CMT2C and SPSMA patients with TRPV4 mutation suggested that our case was distinct due to the overlap syndrome and phenotype variation. Altogether, this case broadened the phenotype spectrum and provided the nerve biopsy pathological details of TRPV4-related neuropathies.

Surgical treatment of sural nerve entrapment aided by imaging- and electrography-based diagnosis: illustrative case.

BACKGROUND: The sural nerve (SN) is a cutaneous sensory nerve that innervates the posterolateral side of the distal third of the leg and lateral side of the foot. The SN has wide variation in its course and is fixed to the subcutaneous tissue and superficial fascia. Idiopathic spontaneous SN neuropathy is rarely surgically treated because of the difficulty in detecting SN entrapment. OBSERVATIONS: Herein, the authors present a rare case of surgically treated spontaneous SN neuropathy. A 67-year-old male patient presented with right foot pain for several years. Magnetic resonance imaging and ultrasonography showed SN entrapment slightly proximal and posterior to the lateral malleolus. A nerve conduction study showed SN disturbance. After undergoing neurolysis, the patient's foot pain was alleviated. LESSONS: Idiopathic SN neuropathy can be treated surgically when SN entrapment is detected with comprehensive evaluation methods.

Diagnosis and conservative management of sural neuropathy: a case report.

Nerve entrapments in the lower extremity are rare and can be difficult to diagnose. Here we describe a Canadian Armed Forces veteran with left posterior-lateral calf pain. The patient's condition was previously misdiagnosed as a left-sided mid-substance Achilles tendinosis, which subsequently led to mismanagement, persistent pain and severe functional limitations. After performing a thorough evaluation, we diagnosed the patient with chronic left-sided sural neuropathy secondary to entrapment within the gastrocnemius fascia. The patient's physical symptoms abated completely with chiropractic care, while overall disability improved substantially after taking part in an interdisciplinary pain program. The objectives of this case report are to describe a challenging differential diagnosis of sural neuropathy, and present conservative whole-person management options according to the patient's needs and goals.

La compression des nerfs dans les membres inférieurs est rare et peut être difficile à diagnostiquer. Nous décrivons ici le cas d'un vétéran des Forces armées canadiennes souffrant d'une douleur postéro-latérale gauche au mollet. L'état du patient avait été diagnostiqué à tort comme une tendinite achilléenne moyenne du côté gauche, ce qui a entraîné une mauvaise prise en charge, une douleur persistante et de graves limitations fonctionnelles. Après une évaluation approfondie, nous avons diagnostiqué chez le patient une neuropathie surale chronique du côté gauche, secondaire à une compression du fascia gastrocnémien. Les symptômes physiques du patient ont complètement disparu grâce aux soins chiropratiques, tandis que l'incapacité globale s'est considérablement améliorée après avoir participé à un programme interdisciplinaire de lutte contre la douleur. Les objectifs de ce rapport de cas sont de décrire un diagnostic différentiel difficile de neuropathie surale et de présenter des options de gestion conservatrice de la personne entière en fonction des besoins et des objectifs du patient.