Anatomical study of the facial nerve canal in comparison to the site of the lesion in Bell's palsy

The term Bell's palsy is used for the peripheral paresis of the facial nerve and is of unknown origin. Many studies have been performed to find the cause of the disease, but none has given certain evidence of the etiology. However, the majority of investigators agree that the pathophysiology of the palsy starts with the edema of the facial nerve and consequent entrapment of the nerve in the narrow facial canal in the temporal bone. In this study the authors wanted to find why the majority of the paresis are suprastapedial, i.e. why the entrapment of the nerve mainly occurs in the proximal part of the canal. For this reason they carried out anatomical measurements of the facial canal diameter in 12 temporal bones. By use of a computer program which measures the cross-sectional area from the diameter, they proved that the width of the canal is smaller at its proximal part. Since the nerve is thicker at that point because it contains more nerve fibers, the authors conclude that the discrepancy between the nerve diameter and the surrounding bony walls in the suprastapedial part of the of the canal would, in cases of a swollen nerve after inflammation, cause the facial palsy.     

A Guyon's canal ganglion presenting as occupational overuse syndrome: A case report

We report a case of severe weight loss secondary to anorexia nervosa causing bilateral superficial peroneal nerve entrapment in a young female patient who was treated successfully by bilateral surgical decompression.     

A new surgical technique for the treatment of high common peroneal nerve palsy

In this article, the authors introduce a new procedure for the treatment of high common peroneal nerve palsy. The principle of this technique consists of the neurotization of the anterior tibial nerve (deep peroneal nerve) with the bundle composed of the nerves to the soleus and lateral head of gastrocnemius muscles. The authors used this procedure for eight children who had permanent common peroneal nerve palsy caused by the injection of diclofenac in the gluteal region and for a 25-year-old male patient whose common peroneal nerve was transected near the gluteal region by a stab wound. For the cases in which paralysis was less than 8 months in duration, the results are satisfactory.     

Blowout fracture of the medial orbital wall, with entrapment of the medial rectus muscle.

A case of fracture of the orbital wall, with entrapment of the medial rectus muscle and paresis of the 6th nerve in association with a large fracture of the orbital floor, is presented. The diagnosis was made primarily by the forced duction test.     

The harvest and clinical application of the superficial peroneal sensory nerve for grafting motor and sensory nerve defects.

Potential donor nerves for autografting are finite and usually limited to cutaneous nerves of the extremities. The superficial peroneal nerve is the major lateral branch of the common peroneal nerve that innervates the peroneus longus and brevis muscles and provides sensation to the lateral aspect of the lower leg and the dorsal foot. It has generally been overlooked as a potential donor of nerve autografts. Cadaver dissections were performed on 10 fresh lower extremity specimens to investigate the anatomic characteristics of the superficial peroneal nerve and to refine a harvesting technique for the nerve. Thirty-one patients underwent nerve grafting of 39 upper and lower extremity nerves using the superficial peroneal donor. There were nine median nerves, four ulnar nerves, two radial nerves, two brachial plexus lesions, 16 digital nerves, and six lower extremity nerves grafted. The superficial peroneal nerve provided a consistently long donor, comparable in length to the sural nerve. The anatomic pattern is consistent, the patient positioning is simple, the surgical harvesting technique is straightforward, and the donor defect is acceptable. The superficial peroneal nerve provides a safe and valuable donor nerve, particularly in cases where multiple or very long nerve grafts are required.     

Aberrant cutaneous nerve of the thigh arising from the sciatic nerve in the human

An aberrant cutaneous nerve of the thigh arising from the peroneal portion of the human sciatic nerve or common peroneal nerve was observed in 9 cases (4.6% of sides). After giving a branch to the short head of the biceps femoris muscle and a branch to the knee joint, this cutaneous nerve reaches the subcutaneous tissue by passing between the short head of the biceps femoris and the vastus lateralis or by piercing through the biceps femoris. The authors presume that the cutaneous nerve shows the presence of the potential cutaneous nerve routes from the common peroneal nerve to the skin of the lateral aspect of the thigh.     

前列地尔联合丹红注射液治疗糖尿病周围神经病变的疗效分析

目的：探讨前列地尔联合丹红注射液治疗糖尿病周围神经病变的效果,为治疗糖尿病周围神经病变提供临床依据。方法：采用回顾性调查的方法,选取我院2011年1月-2012年12月收治的糖尿病周围神经病变150例,分为前列地尔联合丹红注射液组（联合治疗组）,前列地尔组和丹红组,每组各50例。结果：联合治疗组总有效率为94．00％（47／50）,高于丹红组86．00％（43／50）和前列地尔组88．00％（44／50）（P〈0．05）;联合治疗组显效率为68．00％（34／50）,高于丹红组60．00％（30／50）和前列地尔组60．00％（30／50）;联合治疗组无效率为9．00％（3／50）,低于丹红组14．00％（7／50）和前列地尔组12．00％（6／50）（P〈0．05）;三组治疗后正中神经和腓总神经MNCV和SNCV均高于治疗前,差异有统计学意义（P〈0．05）;联合治疗组治疗后均高于丹红组和前列地尔组治疗后,差异有统计学意义（P〈0．05）。结论：前列地尔联合丹红注射液可有效提高正中神经和腓总神经MNCV和SNCV,对改善糖尿病周围神经病变效果较好。     

Post-tetanic potentiation of reciprocal Ia inhibition in human lower limb.

The purpose of this study was to investigate how reciprocal Ia inhibition is changed during muscle fatigue of lower limb muscle, induced with a voluntary contraction or height frequency electrical stimulation. Reciprocal Ia inhibition from ankle flexors to extensors has been investigated in 12 healthy subjects. Hoffmann reflex (H-reflex) in the soleus muscle was used to monitor changes in the amount of reciprocal Ia inhibition from common peroneal nerve as demonstrated during voluntary dorsi or planterflexion and 50 Hz electrical stimulation induced dorsi or planterflexion. The test soleus H-reflex was kept at 20-25% of maximum directly evoked motor response (M response) and the strength of the conditioning common peroneal nerve stimulation was kept at 1.0 x motor threshold. At rest, weak la inhibition was demonstrated in 12 subjects, maximal inhibition from the common peroneal nerve was 28.8%. During voluntary dorsiflexion and 50 Hz electrical stimulation induced dorsiflexion, there absolute amounts of inhibition increased as compared to at rest, and decreased or disappeared during voluntary planterflexion and 50 Hz electrical stimulation induced planterflexion as compared to at rest. During voluntary or electrical stimulation induced agonist muscle fatigue, the inhibition of the soleus H-reflex from the common peroneal nerve was greater during voluntary dorsiflexion (maximal, 11.1%) and 50 Hz (maximal, 6.7%) electrical stimulation induced dorsiflexion than at rest. The inhibition was decreased or disappeared during voluntary planterflexion 50 Hz electrical stimulation induced planterflexion. It was concluded that the results were considered to support the hypothesis that alpha-motoneurones and la inhibitory intemeurones link to antagonist motoneurones in reciprocal inhibition. The diminished reciprocal Ia inhibition of voluntary contraction during muscle fatigue as compared to electrical stimulation, is discussed in relation to its possible contribution to ankle stability.     

Decompression of the common peroneal nerve: experience with 20 consecutive cases

A retrospective review of 20 patients with common peroneal nerve palsy treated with decompression between 1986 and 1997 was undertaken. Subjects were evaluated preoperatively and postoperatively by electromyography, nerve conduction, and clinical measures. The mean interval between the onset of symptoms to surgery (operative delay) was 15.9 months. The mean postoperative follow-up was 32.2 months with a minimum follow-up of 1 year. Decompression was performed at the level of the fibular neck and slightly distally at the tendinous origin of the peroneus longus using a standard approach to release tight fascial structures or scar tissue. External neurolysis was performed using the operating microscope in two cases for which scarring of the nerve was identified intraoperatively. Postoperatively, 19 of 20 patients showed improvement in ankle dorsiflexion as assessed by the Medical Research Council scale. Electromyographic examination was useful in the preoperative evaluation and selection of patients for decompression surgery. In conclusion, decompression even after a 1-year delay may offer benefit and suggest early intervention in patients with a severe lesion.     

A second gene for autosomal dominant Möbius syndrome is localized to chromosome 10q, in a Dutch family.

Möbius syndrome (MIM 157900) consists of a congenital paresis or paralysis of the VIIth (facial) cranial nerve, frequently accompanied by dysfunction of other cranial nerves. The abducens nerve is typically affected, and often, also, the hypoglossal nerve. In addition, orofacial and limb malformations, defects of the musculoskeletal system, and mental retardation are seen in patients with Möbius syndrome. Most cases are sporadic, but familial recurrence can occur. Different modes of inheritance are suggested by different pedigrees. Genetic heterogeneity of Möbius syndrome has been suggested by cytogenetic studies and linkage analysis. Previously, we identified a locus on chromosome 3q21-22, in a large Dutch family with Möbius syndrome consisting essentially of autosomal dominant asymmetric bilateral facial paresis. Here we report linkage analysis in a second large Dutch family with autosomal dominant inherited facial paresis. After exclusion of >90% of the genome, we identified the locus on the long arm of chromosome 10 in this family, demonstrating genetic heterogeneity of this condition. The reduced penetrance suggests that at least some of the sporadic cases might be familial.     

Lumbar spinal stenosis.

Lumbar spinal stenosis, the results of congenital and degenerative constriction of the neural canal and foramina leading to lumbosacral nerve root or cauda equina compression, is a common cause of disability in middle-aged and elderly patients. Advanced neuroradiologic imaging techniques have improved our ability to localize the site of nerve root entrapment in patients presenting with neurogenic claudication or painful radiculopathy. Although conservative medical management may be successful initially, surgical decompression by wide laminectomy or an intralaminar approach should be done in patients with serious or progressive pain or neurologic dysfunction. Because the early diagnosis and treatment of lumbar spinal stenosis may prevent intractable pain and the permanent neurologic sequelae of chronic nerve root entrapment, all physicians should be aware of the different neurologic presentations and the treatment options for patients with spinal stenosis.     

A possible coordinating role for presynaptic inhibition

Conditioning stimuli were applied to the common peroneal or superficial peroneal nerve in acute experiments on anesthetized cats. Changes in the N₁-component of the dorsal cord potential evoked by stimulation of one of these nerves or of other nerves (tibial, deep peroneal) and changes in the amplitude of antidromic action potentials in the afferent fibers of these nerves were investigated. The degree of reinforcement of antidromic action potentials, reflecting the degree of depolarization of the afferent terminals, was found to be greater for the passive nerve than for the active to which the conditioning stimulus was applied. Inhibition of the N₁-component of the dorsal cord potential was deeper when a pair of stimuli was applied to two different nerves (under these conditions only the mechanism of presynaptic inhibition was activated) than when they were applied to the same nerve. It is concluded that presynaptic inhibition, by selectively controlling afferent volleys, can evidently play a coordinating role.     

Permanent alterations of spinal cord reflexes following nerve lesion in newborn rats

Sciatic nerve lesion in newborn rats is known to cause degeneration of a large number of axotomized motoneurones and spinal ganglion cells. Some of the surviving motoneurones exhibit abnormal firing properties and the projection pattern of central terminals of sensory neurones is altered. We report here on long-term changes in spinal cord reflexes in adult rats following neonatal nerve crush. In acutely spinalized and anaesthetized adult rats 4-6 months old in which the sciatic nerve had been crushed on one side at birth, the tibial nerve, common peroneal nerve or sural nerve were stimulated on the reinnervated and control side and reflex responses were recorded from the L5 ventral spinal roots. Ventral root responses (VRRs) to tibial and peroneal nerve stimulation on the side of the nerve lesion were significantly smaller in amplitude representing only about 15% of the mean amplitude of VRRs on the control side. The calculated central delay of the first, presumably monosynaptic component of the VRR potential was 1.6 ms on the control side while the earliest VRR wave on the side of the nerve lesion appeared after a mean central latency of 4.0 ms that seems too long to be of monosynaptic origin. These results suggest that neonatal sciatic nerve injury markedly alters the physiological properties and synaptic connectivity in spinal cord neurones and causes a marked depression of spinal cord responses to peripheral nerve stimulation.     

The toe-spreading reflex of the rabbit revisited--functional evaluation of complete peroneal nerve lesions.

Although a variety of electrophysiological and morphological tests are available for studying nerve regeneration in animals, these endpoints do not necessarily correlate with the return of muscle function. Recent efforts have focused on the assessment of function as the endpoint of nerve regeneration. One of the best known of these tests is the sciatic function index in rats. For rabbits, the toe-spreading reflex has been suggested as a valuable index of peroneal function. We examined the reliability and sensitivity of the toe-spreading reflex in a study of nerve regeneration of the peroneal nerve in 10 New Zealand White rabbits. Eleven weeks after the transection and immediate suturing of the peroneal nerve in both hind legs (at two slightly different sites), a toe-spreading reflex could always be elicited on that side where the level of the severed nerve was closer to the dependent muscles. Also on this hind leg the muscle weight of the peroneal target muscles was significantly higher (P = 0.031) than on the contralateral side, which corresponds well to the results of the toe-spreading reflex. The toe-spreading reflex is an excellent and sensitive indicator of the onset of motor recovery in the peroneal nerve-dependent muscles of rabbits. Even small differences in the localization of lesions in both hind legs can be differentiated with this test.     

Age-related changes of elements with their relationships in human cranial and spinal nerves

To elucidate compositional changes of peripheral nerves with aging, the authors investigated age-related changes of elements and their relationships in the optic, trigeminal, vagus, median, radial, ulnar, femoral, sciatic, tibial, and common peroneal nerves by inductively coupled plasma-atomic emission spectrometry. The subjects consisted of 10 men and 12 women, ranging in age from 65 to 91 yr. It was found that although accumulations of Ca and P occurred only in the trigeminal nerve at old age, it hardly occurred in the optic, vagus, median, radial, ulnar, femoral, sciatic, tibial, and common peroneal nerves at old age. The average contents of Ca and P were three and two times higher in the trigeminal nerve than in the other nine kinds of nerve, respectively. Likewise, the average content of Mg was a little higher in the trigeminal nerve compared with the other nerves. With regard to the relationships among elements, significant direct correlations were found among the contents of Ca, P, S, and Mg in most, but not all, 10 kinds of nerve. In the trigeminal nerve, a significant inverse correlation was found between the contents of S and the other elements, such as Ca, P, and Mg. Regarding the relationships between the contents of S and other elements, the nerves, except for the trigeminal nerve, differed from those found in the arteries previously reported.     

Human group I excitatory projections from ankle dorsiflexors to quadriceps muscle

A short latency projection of group I afferent fibers from ankle dorsiflexors to knee extensor muscles has been categorized as species specific to humans. However, the effects of the pathway have only been inferred from conditioning homonymous reflexes in relaxed muscle. This study focused directly on the responses evoked in the electromyogram of the heteronymous muscles when active, in two experiments. In the first, preferential activation of group I afferents of ankle dorsiflexors, by electrical stimulation of the common peroneal nerve, excited both vastus medialis (mean latency, 26.3 ms) and rectus femoris (mean latency, 33.5 ms). No excitation or inhibition in either muscle was associated with stimulation of the tibial nerve. The second experiment compared vastus medialis responses with common peroneal nerve stimulation during three different movement conditions in which the muscle was equally contracted: rhythmic isotonic (pedalling); episodic isotonic; isometric contraction. Responses were identified in all three active states, with no significant differences in amplitude or latency. No responses were seen in the relaxed muscle.     

Abnormalities of mutual influences of the upper and lower limbs after a stroke

The common pattern of muscle activation and specifics of interlimb neuronal connections during the performance of rhythmic separate and simultaneous arm and leg movements in the lying position in healthy subjects, which reflected functionally significant interlimb neuronal interactions, were shown. The study was designed to investigate these mutual influences of the upper and lower limbs during the performance of similar motor tasks by stroke patients. Sixteen poststroke patients with different degrees of hemiparesis performed active and passive arm movements simultaneously with stepping leg movements or without them while lying supine. It was demonstrated that the patients had a disordered common pattern of distribution of muscle activity when they performed voluntary cyclic movements with both arms. Passive movements of both paretic and nonparetic arms led to different degrees of activation of their muscles, depending on the degree of paresis: in patients with mild paresis, muscle activation was similar to that in healthy subjects; in patients with severe paresis, it was insignificant. The loading of the nonparetic arm resulted in an increase in the activity in the paretic arm shoulder flexor muscles in patients with mild paresis (which was typical of healthy subjects), while loading did not influence significantly patients with severe paresis. The combination of cyclic arm movements and stepping leg movements in diagonal synergy decreased the activity in the proximal muscles of both arms, irrespective of the degree of paresis, as it was observed in healthy subjects. Simultaneous arm and leg movements did not change the muscle activity in nonparetic legs in either groups of patients, but the activity in the paretic leg muscles even decreased. The results obtained revealed important features of poststroke motor disturbances, which caused changes in interlimb interactions and largely depended on the degree of paresis. The data could be useful for developing new methods for the performance of rehabilitative procedures in poststroke patients.     

Target-specific nerve regeneration through a nerve guide in the rat

Nerve regeneration across a gap in peripheral nerve has been achieved through various nonneural nerve guides in both lower and primate species. This technique can only be useful if the regenerated nerve cable grows specifically to and reinnervates the appropriate distal target. In this study, the proximal peroneal fascicle of rat sciatic nerve was inserted into the proximal limb of a Y-shaped nerve guide. Distal peroneal and tibial fascicles were placed within the two distal limbs of the same Y. The proximal peroneal nerve grew preferentially by a 2:1 ratio to the appropriate distal peroneal fascicle suggesting that target-specific reinnervation is possible through a nerve guide.     

Nonacceptance of innervation by innervated neonatal rat muscle

Denervated adult muscle accepts innervation and has high levels of extrajunctional acetylcholine (ACh) receptor, compared to innervated adult muscle. If the high receptor density or any externally oriented part of the receptor molecule permitted or triggered functional synaptogenesis, then innervated neonatal muscle, with its known high extrajunctional sensitivity, should also accept extra synapses from implanted motor nerves. This prediction was tested by implanting the common peroneal nerve into innervated lateral gastrocnemius muscle in 25 neonatal rats and studying the innervation achieved 1–8 weeks later. With one exception, zero or negligible twitch tensions were obtained when the implanted nerve was stimulated. Intracellular recording in two cases showed no evidence of subthresholdevoked potentials in surface muscle fibers. In contrast, when the original motor nerve was cut at the time of common peroneal nerve implantation, reinnervation occurred as soon as 4 days later, and substantial indirect twitches (most observed qualitatively) were invariably found 6–7 days after operation. Four to eight weeks after nerve implantation into denervated muscle, substantial twitch tensions were obtained upon stimulation of the implanted nerve. α-Bungarotoxin binding to extrajunctional ACh receptors per unit surface area was similar in innervated neonatal and denervated adult muscle. Therefore, nonacceptance of additional functional innervation in neonatal muscle implies that a high average density of extrajunctional ACh receptor is not sufficient to permit or trigger functional neuromuscular junction formation.