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This is the description of the case of a 42-year-old male who presented with a growing, painless lump on his anterior leg. The diagnosis of a rare tumor called hibernoma was suspected after inspection of the radiologic findings. The unusual location of the tumor resulted in superficial peroneal nerve entrapment. The tumor was excised and the diagnosis of hibernoma was confirmed by histopathology. Surgery resulted in foot drop that was successfully treated with a tibialis posterior tendon transfer. Our case illustrates a rare tumor in an unusual location that can be challenging for clinicians to discern and to properly treat.

Purpose Common peroneal nerve (CPN) palsy is quite disabling and every effort should be made to prevent its injury during the treatment. Methods We retrospectively reviewed the prospectively collected data of 7 cases of tibial plateau fractures in association with proximal fibula fracture from January 2019 to September 2019 who presented to emergency room of our hospital. Results In addition to fibular neck fracture, the first case had type 6 tibial plateau displaced fracture and the second case had displaced acetabular fracture with instability of knee with tibial tuberosity avulsion. CPN palsy developed following application of distal tibial skeletal traction in both the cases. Other 6 such cases remained neurologically intact as traction was not applied to them. Conclusion Such iatrogenic complication could have been prevented if the injury pattern of "concomitant medial and lateral columns" of the proximal leg is kept in mind by the treating surgeon before applying skeletal traction.

Foot drop in the absence of limb ischemia is a chronic complication in peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) survivors; however, there is little published regarding the incidence and functional outcomes of this condition. Common peroneal nerve is the most common cause of foot drop, a condition that leads to significant debility and requires extensive physical therapy and rehabilitation, thereby affecting the patient's quality of life. We completed a retrospective review of 153 patients who received femoral cannulation for V-A ECMO support for greater than 1 hour. The incidence of foot drop in our V-A ECMO population was 7.8% (12/153). Importantly, only two patients with foot drop were discharged home. The majority (10/12) of patients with foot drop required in-patient rehabilitation; five patients were nonambulatory, and five patients required an ankle foot orthosis assistive device. This study identifies foot drop as a relevant complication in peripherally cannulated V-A ECMO survivors and provides an initial incidence rate. By raising awareness of this complication in the V-A ECMO population, an early diagnosis is possible, which can enable appropriate rehabilitation. Prospective trials are needed to identify possible risk factors of foot drop and methods to reduce this complication of V-A ECMO.

Acute correction of rigid drop foot deformity can be problematic due to the skin defect that may occur in the medial part of the ankle. The purpose of this study is to present an innovative solution for this problem. We hypothesized that acute correction for rigid ankle contractures without arthrosis might be possible if the medial skin defect could be closed. Therefore, we described a surgical technique for acute functional correction of rigid drop foot deformities. The closure of the medial defect was performed by applying a flap and partial-thickness skin graft. We have retrospectively evaluated the results of 18 patients who were treated between 2010-2016 with this technique. The mean age of the patients was 37±9.5 ( 22 to 56) years. Foot drop etiology was firearm-related nerve injury. Corrections were performed after 14.6±7.9 ( 8 to 38) months following the injury. At the end of an average follow-up period of 44.4 ± 6.2 (37 to 60) months, 14 of 18 patients (78%) recovered without complications, three patients experienced partial loss in the medial skin graft region, and one patient developed a superficial infection. None of the patients have developed pes planus. We observed that the ankle flexion contracture, which was 34°±9.2° (20° to 50°) preoperatively, could reach an average of 2.2°±2.5° (0° to 6°) dorsiflexion after surgery. We suggest that acute correction and tibialis posterior tendon transfer in the treatment of rigid foot drop deformity can be performed with an effective skin closure with low soft tissue complications.

Dysfunction of the common peroneal nerve is the most common mononeuropathy in the lower limb and a source of significant disability for patients. The nerve can be damaged at various levels for various reasons (direct or indirect trauma, extrinsic compression, anatomical variant, endocrine, rheumatological, or neurological disease). Clinical evidence of foot drop with steppage gait is very typical. Conservative treatment should be considered as a first step (avoidance of the contributing factors, functional rehabilitation, foot drop brace ± injection). If properly conducted conservative treatment is not successful, palliative surgery is indicated: either tendon transfer using the posterior tibial tendon or ankle arthrodesis.

We present a 71-year-old man who developed left calf pain after an elective laparoscopic assisted anterior resection. A clinical picture with a raised creatine kinase and negative Doppler ultrasound was suggestive of compartment syndrome. Successful surgical management was performed with two incisional fasciotomies to release all four compartments of the left leg. The patient recovered well postoperatively. The lateral incision was closed primarily while the medial incision required vacuum-assisted closure dressings and healed by secondary intention. Neither wound required skin grafts. The patient recovered well but had an extended hospital stay due to extensive physiotherapy requirements and mild foot drop. This report is intended as a guide for clinicians when considering differentials in calf pain following surgery and to keep in mind the small risk of developing compartment syndrome after pelvic surgery.

Foot drop due to lumbar disc herniation (LDH) is a relatively common finding in spinal practice. Bilateral foot drop (BFD) due to LDH is an extremely rare condition with only a few reported cases. We describe the case of a middle-aged man presenting with a rapid onset BFD with back and leg pain. Urgent MRI revealed an L4-L5 centrally located LDH with bilateral compression of the L5 nerve roots and the cauda equina centrally. About 4 h after presentation surgery was performed adopting a bilateral L4-L5 interlaminar approach and the prolapsed disc was removed. Nine months after surgery, the patient showed a complete recovery of his deficit. We discuss the advantages of this approach in this urgent situation and we compare it with other techniques.

We present a case of indolent neurolymphomatosis in a 55-year-old male patient with worsening pain and weakness in his right leg over the past few months. The patient has a past medical history of type II diabetes mellitus, four-year history of worsening left foot drop, left lower limb pain and weakness attributed to diabetic amyotrophy, and back pain. The new right-sided symptoms prompted further imaging which revealed a left sciatic nerve mass which was biopsied. Initial biopsy results were inconclusive. 18F-FDG PET/CT revealed the full extent of this patient's disease and helped plan for a more representative biopsy site, which finally established a diagnosis of diffuse large B-cell lymphoma involving the lumbosacral nerve roots. The patient underwent a course of chemotherapy. 18F-FDG PET/CT was ordered again at the end of treatment showing partial response to therapy. He underwent radiation therapy to the site of residual disease, with complete metabolic response of lesions on follow up PET CT.

Objective To investigate the efficacy of modified percutaneous Achilles tendon lengthening for severe ankle joint deformity. Methods This retrospective case series study included 33 patients with an average age of 25.2 years who underwent surgery in our hospital from April 1, 2010 to March 1, 2018. Triple hemisection percutaneous Achilles tendon lengthening was performed. One stage surgery, other soft tissue surgery or bone correction surgery could be performed. After surgery, a plaster cast was used to fix the functional position, and rehabilitation training was carried out as planned. Complications during the perioperative period were recorded. Statistical analysis of the patients' visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score before and at the last follow‐up was performed. The recurrence rate of Achilles tendon contracture at the last follow‐up and the patients' satisfaction rate were investigated. Results All patients were followed up, with an average follow‐up period of 56.31 months (8–104 months). All achieved good ankle joint function and appearance improvement And there were no infection or skin necrosis complications. In two cases, the incision was poorly healed at non‐Achilles tendon site and was cured by change of dressing. The average VAS score at the last follow‐up was reduced from (2 ± 1.48) points before surgery to (0.26 ± 0.51) points (P = 0.001), and the average AOFAS score was increased from (64.97 ± 13.56) points before surgery to (90.06 ± 10.06) points (P = 0.001). During the follow‐up period, there was no chronic rupture of Achilles tendon. There were two cases of recurrence of foot drop (5.7%), and the patients' satisfaction rate was 93.9%. Conclusion In the surgical treatment of severe ankle joint deformity, the application of triple hemisection percutaneous Achilles tendon lengthening for Achilles tendon contracture has the advantages of less trauma, beautiful incision, and reliable efficacy. The satisfaction rate of patients with this treatment is high, and it is worth promoting in the clinic., This study reported a minimally invasive modified percutaneous lengthening that was applied to complex cases and achieved good short‐term results. The core surgical details of this technique are different from the widely used percutaneous lengthening by triple hemisection and can reduce surgical complications without reducing the surgical efficacy.

Objective. To study the changes in gait characteristics of stroke patients with foot drop after the combination treatment of foot drop stimulator and moving treadmill training and thus provide a basis for the improvement in a foot drop gait after stroke. Methods. Sixty patients with hemiplegia and foot drop caused by stroke were randomly divided into two groups of 30: the test group and the control group. Both groups received basic rehabilitation training. On this basis, the test group received the combination treatment of foot drop stimulator and moving treadmill training. The control group received foot drop stimulator training. Both groups received consecutive treatment for 3 weeks, five times a week, and every single time lasted for 30 minutes. Before and after the treatment, a gait watch three-dimensional gait analysis system was used to measure and record the maximum angles of flexion of the affected side’s hip, knee, and ankle; the pace; the step length asymmetry; the iEMG of the tibialis anterior muscle; the functional ambulation category; and Ashworth’s modified spasticity classification of the gastrocnemius. Results. After treatment, in the two groups, the maximum angles of flexion of the affected side’s hip, knee, and ankle improved, the pace increased, the step length asymmetry decreased, the iEMG of the tibialis anterior muscle increased, the functional ambulation category improved, and Ashworth’s modified spasticity classification of the gastrocnemius decreased, but the above changes in the test group were better than those in the control group. The difference is statistically significant ( p < 0.05 ). Conclusions. The combination treatment of the foot drop stimulator and moving treadmill can significantly improve stroke patients’ foot gait and promote the normalization of hip flexion, knee flexion, and ankle flexion. It can increase the pace, significantly reduce the step length asymmetry, reduce the muscle tone of the gastrocnemius, and improve walking function.

Objective. This present study aimed to explore the clinical effects of a novel capsule lumbar interbody fusion (CLIF) on foot drop due to lumbar degenerative diseases. Methods. Between June 2018 and January 2019, a total of 27 patients admitted to our department with lumbar degenerative diseases with associated foot drop were prospectively enrolled. Given the selection of surgical technique, patients were divided into traditional TLIF group and CLIF group. We assessed patients’ neurological status using JOA and VAS score, tibialis anterior muscle strength using MMT score, diameter and hemodynamic parameters of the L5 nerve root using intraoperative ultrasonography (IoUS), and related radiological parameters of the lumbar spine. Operation time, blood loss, and surgery-associated complications were also recorded. Results. The median duration of follow-up was 150 (6–1460) months. At the final follow-up, all patients acquired satisfactory improvement of neurological function. However, patients in the CLIF group showed better early recovery of foot drop three months after operation than those in the TLIF group, with 75% excellent rate. In addition, IoUS suggested that the diameter and hemodynamic parameters of the L5 nerve root were improved better in the CLIF group, which may suggest the correlation between the recovery of foot drop and the status of L5 nerve root. No severe complications were encountered with CLIF. Conclusions. Our preliminary study revealed that the axial tension of L5 nerve root may be involved in the pathological mechanism of foot drop. The novel technique of CLIF can shorten the lumbar spine and can be effective and safe for the treatment of foot drop due to lumbar degeneration-related diseases.

Background and purpose Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established. Methods We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome. Results Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%-≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%-100% after conservative treatment and 40%-100% after neurolysis. No study compared both treatments. Conclusions Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.

Introduction: Foot drop is defined by the inability to elevate the foot due to diminished strength of the dorsiflexor muscles. To elaborate a treatment plan, it is necessary to determine its etiology. Thus, the family doctor must recognize the situations in which the management of foot drop can be done exclusively in primary health care, differentiating from those that may require observation and assessment in-hospital care. Case description: 71-year-old man with arterial hypertension and dyslipidemia, medicated with indapamide. An appointment with the family doctor referred that, two days ago, had remained seated for two hours with the right leg crossed over the contralateral lower limb. By getting up, the patient noticed right foot numbness and inability to elevate the same foot. At the physical examination, he presented a steppage gait, with right foot drop and decreased sensitivity of the back of the foot. It was requested electromyography, which documented severe axonal damage of the right common peroneal nerve below the fibular neck, compatible with prolonged compression. The patient was submitted to physiotherapy sessions, demonstrating complete clinical resolution of foot drop after three months. Comment: The neuropathy of the common peroneal nerve is the main cause of foot drop and the third most frequent focal neuropathy, after the median nerve and cubital nerve. Compression remains the most frequent etiology. The most affected site is at the level of the fibular neck, manifested by steppage gait, consequent to decreased strength of the dorsiflexor muscles of the foot. Even though the diagnosis is usually clinical, most of the patients require electromyography. The initial treatment tends to be conservative, with a frequent resolution of the complaints in three months. This is a condition that may be uncommon in family medicine’s clinical practice, but its approach could be, many times, managed in primary health care. It is important to know how to reassure the patients about the semiology, therapeutic approach, and prognosis.

Bortezomib-induced peripheral neuropathy (BIPN) has a profound impact on quality of life, which is an important issue considering the growing number of survivors of multiple myeloma and amyloidosis. BIPN is typically symmetric, distal, "stocking and glove" distribution and predominantly consists of sensory rather than motor symptoms. In this case series, we report an acute neurotoxicity syndrome induced by bortezomib, which is clinically distinct from BIPN by not being peripheral and distal. We describe six patients that developed unilateral or bilateral foot drop attributed to bortezomib. With bortezomib discontinuation symptoms improved gradually over months to years.

Adrenomyeloneuropathy (AMN) is a rare inherited condition where affected individuals develop slowly progressive spastic paraparesis with a gradual decline in walking ability. There is no cure for AMN and treatment focuses on supportive measures and aids. One treatment option is functional electrical stimulation (FES), a treatment, approved by The National Institute for Health and Care Excellence (NICE), for managing foot drop in upper motor neuron disorders. Limited evidence exists for its use in AMN patients. We describe the effects of FES in an individual case and more broadly within a cohort of 21 patients successfully treated with FES. Patients with AMN referred for FES typically report frequent falls (71%) and foot drop (57%) as the most common barriers to walking. When using FES, walking speed at baseline (0.70 m/s [SD = 0.2]) was maintained at the 2‐year review (0.68 m/s [SD = 0.2]) with a persistent orthotic effect (improvement in walking speed when device on vs. off) seen from wearing FES over the same 2‐year period (11%–19%). Patient walking satisfaction (visual analogue scale: 0 – very dissatisfied; 10 – very satisfied) was also greater when comparing no‐FES versus FES over the same period (Year 1: 2.5 vs. 7.7; Year 2: 2.1 vs. 6.1). FES is not effective in all patients. Twelve patients referred found no benefit from the device; although there was no clear evidence, this was related to the degree of AMN associated peripheral neuropathy. However, FES is a safe, cost‐effective treatment option and should be considered, along with assessment in a multidisciplinary clinic, for all AMN patients with walking difficulties.

Objective: the authors presented a extremely rare case of severe foraminal stenosis combined with huge lateral lumbar disc herniation Case presentation: The authors presented a 74 – year old, male with type II chronic diabetes, had severe pain of the dermatomal distribution of L5, S1 nerve roots, and foot-drop of the right lower limb. When we evaluated the patient’s MRI, the huge paramedian disc herniation of the right L5-S1 level was seen and the right L5-S1 laminotomy and discetomy were planned for the treatment of the patient. However, the clinical symptoms were not completely correlated with that MRI findings so that, we re-checked the MRI, particularly at the lumbosacral region, and the right severe foraminal stenosis of L5-S1 level was found. The patient underwent surgery with facetectomy, transforaminal interbody fusion, and pedicle screw fixation. After the operation, the patient has quickly reduced radiating pain of the right lower extremity, although the foot-drop was not improved. Because of the huge lateral lumbar disc herniation impression, that could affect the assessing the patient’s injury correctly, leaded consequences of a missing diagnosis of foraminal stenosis and inadequate surgery method. Conclusion: It is essential to detail examination of the clinical manifestations and thorough assessment of MRI for evaluation of the correlation between the physical examination and MRI findings before making the decision of surgical method.

Supplementary motor area (SMA) syndrome refers to varying degrees of transient hemiparesis and mutism following insult to the medial posterior frontal lobe. We describe a rare case of an isolated lower limb SMA deficit with associated pre- and post-operative multimodality neurophysiological monitoring data. We review the literature on SMA somatotopy and the prognostic abilities of intraoperative motor evoked potentials in suspected SMA dysfunction. A 45-year-old male underwent staged resection of a complex parasagittal WHO grade II meningioma involving the posterior superior frontal gyrus bilaterally. Intraoperative neurophysiological monitoring with transcranial motor evoked potentials (TCMEP) and direct cortical motor evoked potentials (DCMEP) were used during both stages of resection. The patient developed an isolated left foot drop despite unchanged DCMEP and TCMEP data obtained during the first stage of the procedure. During the second stage of resection 3 days later, repeat neurophysiological monitoring confirmed intact corticospinal tracts. Deep peroneal somatosensory evoked potentials (SSEPs) revealed good morphology, appropriate latency and amplitudes during the second stage of resection. These results suggested a diagnosis of focal SMA dysfunction. Left foot drop persisted 7 days post-operatively. At one month follow up, the patient was neurologically intact with full strength noted in all muscle groups of the left lower extremity. An improved understanding of the somatotopic organization of the SMA with additional neuromonitoring data can allow neurosurgeons to better predict and understand perioperative SMA dysfunctions.

Objectives: Limited data support the use of fasciotomies in acute limb ischemia (ALI) in patients with isolated arterial occlusion. This study describes an experience in which fasciotomies are not regularly performed post-revascularization. Methods: Using International Classification of Diseases, Ninth and Tenth Edition codes, patients presenting to the University of California Davis Medical Center between January 2003 and July 2018 with ALI, excluding those with traumatic injuries were identified. The primary outcome was major amputation, and the secondary outcome was foot drop. Additionally, the characteristics of those patients in each category of ischemic severity excluding those with grade 3 ischemia were summarized. Results: Of the 253 patients identified, revascularization was successful in 230 patients with 11 total fasciotomies performed. One hundred thirty-five patients were Rutherford Class 1/2A and 95 were 2B. In those with 1/2A ischemia, 134 (102 had >6 hours of symptoms) did not undergo fasciotomy with only one amputation occurring in this group. In those with 2B ischemia, 65 had >6 hours of symptoms; 58 did not undergo fasciotomy with 4 major amputations. In the 30 patients with ≤6 hours of ischemic symptoms, 27 did not undergo fasciotomy with 1 major amputation occurring in this group. There were no amputations in those patients who underwent fasciotomies. Additionally, there were 14 patients with a foot drop, of which 11 were in patients with 2B ischemia without fasciotomy. Conclusions: The data suggest that regardless of ischemic duration, 1/2A patients may not need fasciotomies, while those patients with 2B ischemia may benefit.

Functional Electrical Stimulation is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract & create a moment about a joint. In recent years, FES is relatively used as a new therapeutic tool in rehabilitation program of different neurological conditions. Although FES has been used for long time for treating foot drop, there are many studies which supports the beneficiary effect to improve upper and lower extremity’s function, spasticity, subluxation, respiration, balance, gait training, activities of daily living, quality of life. Multiple databases were searched for relevant articles. The purpose of this study is to evaluate the effectiveness of FES in different neurological condition and to collect the existing literature dealing with FES in a single article to analyze the result & to finally reach the overall conclusion. Keywords: FES, Stroke, Spinal Cord Injury, Multiple Sclerosis, Parkinsonism, etc.

Hendra Gunawan,1– 3 Atika Kamilia,1,2 Sri Linuwih Menaldi,2– 4 Melani Marissa,2,4 Cita Rosita Sigit Prakoeswa,2,3,5 Medhi Denisa Alinda,2,5 Dhelya Widasmara,2,6 Santosa Basuki,2,6 Qaira Anum,2,7 Tutty Ariani,2,7 Enricco H Mamuaja,2,8 Luh Made Mas Rusyati2,9 1Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia; 2Indonesian Leprosy Study Group – Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia; 3Indonesian College of Dermatology and Venereology, Jakarta, Indonesia; 4Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 5Department of Dermatology and Venereology, Faculty of Medicine, Universitas Airlangga, Soetomo Hospital, Surabaya, Indonesia; 6Department of Dermatology and Venereology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia; 7Department of Dermatology and Venereology, Faculty of Medicine, Universitas Andalas, Padang, Indonesia; 8Department of Dermatology and Venereology, Faculty of Medicine, Universitas Sam Ratulangi, Prof. R. D. Kandou Hospital, Manado, Indonesia; 9Department of Dermatology and Venereology, Faculty of Medicine, Universitas Udayana, Bali, IndonesiaCorrespondence: Hendra GunawanDepartment of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Hasan Sadikin Hospital, Jl. Pasteur 38, Bandung, West Java, 40161, IndonesiaTel +62 812 2111 1215Email h.gunawan2016@unpad.ac.idBackground: One of the indicators of achieved leprosy control is lower new cases of leprosy with grade 2 disability (G2D), while zero new pediatric case with G2D is one of the targets of The Global Leprosy Strategy. This study aimed to describe the characteristics of leprosy in children with G2D from seven provincial hospitals in Indonesia, spanning a period of five years.Methods: This was a descriptive and retrospective study with cross-sectional design. Data were obtained from the medical records of leprosy-affected children in seven provincial hospitals in Indonesia between January 2014 and December 2019 using a total sampling method. Data obtained include characteristics of patients, clinical manifestations, and profile of leprosy in children with G2D.Results: From the 132 data of childhood leprosy retrieved, male (58.33%), age group of 13– 14 years (47.73%), and borderline tuberculoid leprosy (34.09%) comprised the majority of patients. Most of the patients had anesthetic macules as the initial manifestation. The results showed 20 (15.15%) children had G2D. Hands were the most common site affected (50.00%), manifested as claw hands, contractures, atrophy of thenar and hypothenar muscles, and pseudomutilation. Foot drop was seen in five (62.50%) children, and lagophthalmos was seen in one child with leprosy.Conclusion: This study shows that G2D is observed in 15.15% Indonesian children with leprosy at the time of diagnosis, which mostly occurs on the hands in the form of claw hands. Foot disabilities were also observed, most commonly as foot drop, while lagophthalmos was present with disabilities in the eyes. Disability due to leprosy in children really exists. The commitment of all health care services and related institutions is needed in order to reduce the incidence of disability due to leprosy in children.Keywords: children, grade 2 disability, leprosy

BACKGROUND: Paresthesia with intrathecal anesthesia occurs when the entry of the needle causes an uncomfortable pain, burning, or electric sensation that usually radiates to the buttocks or legs. The importance of avoiding paresthesia is to lower the risk of postoperative neurological problems, in addition to reducing the incidence of that unpleasant sensation. The majority of reported occurrences of nerve injury caused by spinal anesthesia were preceded by paresthesia during the spinal anesthesia needle insertion. To the best of our knowledge, no studies have been done to compare the incidence of paresthesia in cesarean sections using median and paramedian routes to provide spinal anesthetic. AIM: Our study aimed to compare the incidence of paresthesia in the median and paramedian approaches of intrathecal anesthesia to predict its association with nerve injury. METHODOLOGY: Two hundred-ninety-six parturients scheduled for elective cesarean sections under spinal anesthesia were in the study from November 2020 to January 2021. They were divided into two groups. The median group (n = 157) and the paramedian group (n = 135) according to the approach used for providing spinal anesthesia. The incidence of paresthesia was compared between both groups. The number of trials in each approach and the occurrence of postoperative neurological complications (for example: nerve injury, paraplegia, or foot drop) were also documented. RESULTS: The sample size was calculated based on a pilot study that was conducted before the original study. The calculated sample size was based on an alpha error of 0.05 and 90% power. The incidence of paresthesia was higher in the median group (10.7%) than the paramedian (3.7) group with statistical significance (p = 0.039). In both groups, no postoperative neurological problems were noted in any groups. CONCLUSION: The median group has significantly more incidence of paresthesia than the paramedian group. The significance of this finding is that the paramedian approach is expected to be less likely to cause neurologic problems during spinal anesthesia.

Foot drop is a relatively uncommon presentation of lumbar degenerative disease and there is currently a paucity of evidence on management and outcomes which is reflective of the lack of standardised treatment provided to patients. The purpose of this systematic review and meta-analysis is to determine the effectiveness of surgical management and the factors that predict surgical outcome. A systematic database search of Cochrane Library, Ovid Medline, Pubmed, Embase and Google Scholar was undertaken from inception through August 2018. Only studies reporting on surgical outcome in adult patients who had a painful foot drop and underwent decompression were included. Case reports and studies with surgical fixation were excluded. Study quality was assessed using the Newcastle–Ottawa Scale. Data were pooled using a random-effects model. 797 studies were screened and 9 observational studies met the inclusion criteria. This resulted in a total of 431 patients who underwent decompression for foot drop. Pooled rates of outcome for improvement in foot drop MRC grade were 84.5% (range 67.9–96%). Sub-group meta-analyses of studies revealed a statistically significant association between duration of foot drop (pooled 4.95 [95% CI 1.13–21.74]), severity of preoperative weakness (pooled 0.38 [95% CI 0.15–0.93]) on post-operative outcome and age (pooled 6.28 [1.33–29.72]). This is the first systematic review and meta-analysis to explore the outcome and prognostic indicators of lumbar decompression for foot drop. Findings indicate that age, duration of foot drop weakness and MRC grade of foot drop prior to intervention were strong predictors of surgical outcome.

Chiari malformation (CM) type 1 is characterized by descent of the cerebellar tonsils resulting from crowding of the posterior fossa. In 30% of cases, it is associated with syringomyelia. When symptomatic, it may result in a classic constellation of symptoms. Here we describe a case of a 16-year-old male who presented with isolated, unilateral foot drop due to CM type 1 and holosyrinx. This unique presentation is extremely rare, and we additionally present a review of all other reported cases in the literature. After undergoing posterior fossa decompression with C1 laminectomy and duraplasty, our patient made a complete neurological recovery within 2 weeks postoperatively and his MRI entire spine at 3 months postoperatively demonstrated a nearly complete resolution of the holosyrinx with significant decompression of the foramen magnum. This rare presentation highlights the importance of maintaining a broad differential, particularly in pediatric patients, and expediting the workup in order to offer a surgical decompression within 1–2 months of foot weakness to maximize the probability of a full neurological recovery.

Ankle dysfunction in patients with stroke is a common but serious cause of balance and gait impairments. However, comprehensive paretic ankle training seldom exists. Thus, we investigated the effects of a bi-axial ankle muscle training program using visual feedback as a means to improve ankle strength and performance of functional activities in patients with stroke.This study was a randomized controlled pilot trial with concealed allocation and assessor blinding and intention-to-treat analysis. Twenty-five patients with stroke and difficulty in walking (e.g., foot drop) or ankle muscle weakness receiving inpatient rehabilitation were included. The experimental group underwent ankle muscle training consisting of passive stretching, control of ankle muscles, and active-resistive strengthening using visual feedback for 40 min per day, 5 times per week for 4 weeks. The control group underwent ankle-related physical therapy, including ankle range-of-motion exercises. The amount of time for training was equal between the two groups. The outcome measurements were isometric ankle contraction force to assess the strength of ankle muscles, ankle proprioception, Fugl-Meyer lower extremity score, Berg balance scale score, walking speed, and ankle co-contraction index to assess muscle efficiency during gait.The analysis revealed significant between-group differences in the ankle muscle strength in each direction (P0.05), Fugl-Meyer score (P0.01), and stance-phase co-contraction index (P0.05). After training, the experimental group displayed significant within-group differences in the strength of the ankle muscles in each direction (P0.01), ankle proprioception (P0.05), and walking speed (P0.05).Our findings demonstrate the significant short-term effects of ankle muscle training on strength, walking speed, and muscle efficiency in patients with chronic stroke.

Foot drop is defined as an impaired ability or inability of dorsiflexion. Peripheral nervous system injuries are commonly considered as the cause of this condition. The central causes including parasagittal meningioma are also described in the literature but very rarely and commonly not recognized early. In this article, we report 2 patients with isolated unilateral foot drop as the first symptom of a parasagittal meningioma and discuss several reasons for delayed diagnosis. Two patients were treated with decompressive craniotomy. The histopathological findings demonstrated a fibroblastic meningioma and a meningothelial meningioma. During postoperative follow-up, the woman patient showed nearly complete recovery and the second case regained total muscle power over a period of 12 months. The rarity of the disease, the absence of upper motor neuron signs, the occurrence of peripheral pathologies and misinterpretation of F wave on nerve conduction study, and motor unit recruitment on electromyography lead to delay in diagnosis and treatment of the central foot drop due to parasagittal meningioma.

A 42-year-old businessman had a 27-year history of multiple complaints. He had been born of a non-consanguineous marriage, but his siblings had young-onset hypertension. When aged 15 years, he developed an ulcerated skin lesion on the medial right thigh with right foot drop. This was presumptively treated as tuberculosis with corticosteroids and antituberculous therapy; the skin lesion resolved in 1–2 weeks and the foot drop recovered within 6–8 weeks. He stopped antituberculous therapy after 1 month. When aged 24 years, he developed a left foot drop that improved with oral corticosteroids in 3–4 weeks. However, on corticosteroid withdrawal he developed fever, left foot ulceration and abdominal pain. Biopsy of the skin ulcer was reported as ‘systemic lupus erythematosus-like’. His symptoms resolved with tapering corticosteroids over 4–6 months. He was also diagnosed and treated for hypertension at this time. When aged 30 years, he developed similar complaints. A rheumatologist prescribed monthly cyclophosphamide for 6 months with symptom resolution. He was then lost to follow-up for 6 years. When aged 36 years he presented with fever, abdominal and testicular pain, with skin ulcerations in the lower limbs. His viral markers for HIV, hepatitis B, hepatitis C were negative and a CT aortogram was normal. His condition responded well to pulsed corticosteroids and mycophenolate mofetil. He had further recurrent relapses every 1–2 years and tried a combination of multiple immunosuppressants: mycophenolate, azathioprine and cyclophosphamide. When aged 40 years, he had another relapse (fever, abdominal pain, left foot drop and weight loss) with significant (22 kg) unintentional weight loss over 2 months. CT scan of abdomen showed a left perirenal haematoma, with splenic and bilateral renal cortical infarcts. CT aortic angiogram showed multiple aneurysms in medium-sized abdominal aortic visceral branches. Chest X-ray and two-dimensional echocardiography were unremarkable. Upper gastrointestinal endoscopy identified oesophageal candidiasis, whereas colonoscopy showed multiple …

Purpose: Microsurgical anatomy of the corticospinal tract, its functional role and crucial points in differential diagnosis were evaluated. There is no consensus about its differences and cerebral origin of the corticospinal tract. Tractography and cadaver dissection can help to investigate the characteristics of the corticospinal tract. Also, amyotrophic lateral sclerosis is hard to diagnose as it has common symptoms and signs with other disorders. Methods: Three formalin-fixed human brains (six sides) were dissected by the Klingler technique in a stepwise manner from the lateral to medial and superior to inferior under 6x–40x magnification using a surgical microscope. All stages of the dissection were photographed using three-dimensional method. Lastly, we present a patient with the sign of drop foot who underwent electromyographical and radiological examination, diagnosed as atypic amyotrophic lateral sclerosis. Results: The connections of the corticospinal tract, in particular the travel in the in trajectories of stepwise in manner cerebral origin. We demonstrated a case report with anatomic correlation to define the damage of corticospinal tract in variable levels. Crucial landmarks, connections, eloquent brain areas that related to the corticospinal tract were emphasized. Conclusion: So that pointing the importance of such disorders to keep in mind as not to move forward with incorrect operation decision. Trajectory of one of the largest desending pathway, corticospinal tract and the relationship with different diagnosis should be considered.

Clear cell sarcoma is a rare tumor with a predilection to involve tendon and aponeuroses, predominantly around the foot and ankle region. It is clinically, genetically as well as biologically distinct from malignant melanoma, however share some histological and immunohistochemical similarities with it. Clear cell sarcoma usually arise from the deep soft tissue of lower extremities and carries a balanced translocation t(12;22) (q13;q12). The fusion protein activates MiTF, a melanocytic transcription factor which leads to tumor growth and melanin production. The head & neck and trunk are distinctly unusual sites for occurrence of CCS. We herewith describe a CCS in the pelvis of the 26 years-old male patient presented with the chief complaints of paraesthesia, weakness, muscle wasting in right lower limb with foot drop since one year with review of literature. Keywords: Clear cell sarcoma, Melanoma of soft part, Pelvic region.

BackgroundThe infiltration between the popliteal artery and the capsule of the knee (IPACK) block has been described as an alternative analgesic strategy for knee pain.ObjectiveOur aim was to perform a narrative review to examine the place and value that the IPACK block has in comparison to and in conjunction with other regional anesthesia modalities.Evidence reviewFollowing an extensive search of electronic databases, we included anatomical studies, letters, comparative observational studies, and non-randomized and randomized controlled trials that examined the IPACK block in relation to surgery on the knee under general or neuraxial anesthesia.FindingsIn all, 35 articles were included. Cadaveric studies demonstrated the potential for injected dye to spread to the nerves responsible for the innervation of the posterior as well as anteromedial and anterolateral aspects of the knee. Of the comparative observational studies (n=15) and non-randomized (n=1) and randomized controlled trials (n=13), 2 and 27 were conducted in the context of anterior cruciate ligament reconstruction and knee replacement surgery, respectively. The role of the IPACK block with each different permutation of regional anesthesia techniques was investigated by a small number of studies. Clinical studies, in the setting of knee replacement surgery, revealed variation in the manner in which the IPACK block was performed, and indicated the possible superiority of distal injection at the level of the femoral condyles for the management of posterior knee pain. Evidence suggested the following: the IPACK block in combination with single shot adductor canal block (ACB) may be beneficial for analgesic and functional outcomes; in conjunction with single shot or continuous ACB, the IPACK block might be superior to local infiltration analgesia (LIA); and functional outcomes may be improved with the supplementation of continuous ACB and LIA with the IPACK block. The IPACK block did not commonly result in the occurrence of foot drop. Relative to tibial nerve block (TNB), the IPACK block reduced the occurrence of foot drop and increased the proportion of patients who were able to be discharged on the third postoperative day.ConclusionsThe IPACK block was potentially complementary to the ACB and might be preferable to the TNB as a motor-sparing regional anesthesia technique in knee surgery. Definitive recommendations were not reached in the presence of the heterogeneous and limited evidence base.

Background Neurolysis techniques have been adapted for decompression of peripheral nerves in multiple locations, including the common peroneal nerve (CPN) at the fibular neck. The aim of this study was to conduct a systematic review and meta-analysis to summarize the clinical outcomes of neurolysis for the management of peroneal nerve palsy (PNP). Methods Preferred Reporting Systems for Systematic Reviews and Meta-Analyses guidelines were followed for this meta-analysis. Four databases were queried, and randomized clinical trials, cohort studies, case-control studies, and case series with n > 10 published in English that evaluated clinical outcomes of neurolysis for the treatment of PNP and foot drop were included. Two reviewers completed screening and data extraction. Methodological quality was evaluated using the Newcastle-Ottawa Scale. Results A total of 493 articles were identified through literature search. Title and abstract screening identified 39 studies for full-text screening. Ten articles met the inclusion criteria for qualitative analysis, and 8 had complete data for meta-analysis.Overall, there were 368 patients (370 nerves) who had neurolysis of the CPN for PNP, of which 59.2% (n = 218) were men and 40.8% (n = 150) were women. The mean age of the patients was 47.1 years (SD, 10.0 years), mean time to surgery was 9.65 months (SD, 6.3 months), and mean follow-up time was 28 months (SD, 14.0 months). The median preoperative Medical Research Council (MRC) score was 1 (IQR 0, 3), with 42.2% (n = 156) having MRC score of 0. The median postoperative MRC score was 5 (IQR 4, 5), with 53.9% (n = 199) having MRC score of 5. Complications of neurolysis of the peroneal nerve for treatment of PNP included postoperative infection (0.54%, n = 2), wound dehiscence (0.27%, n = 1), hematoma (0.54%, n = 2), bleeding (0.27%, n = 1), relapse of PNP (0.27%, n = 1), and 1 case of mortality due to sepsis. Conclusions Our meta-analysis shows that neurolysis of the CPN is safe and improves ankle dorsiflexion strength in patients with PNP. Future studies should use a standardized method of measuring sensory outcomes, and studies of higher levels of evidence are needed to better assess the clinical outcomes of neurolysis for treatment of PNP.

Background: Acetabular fractures remain one of the most difficult Orthopaedic injuries to treat successfully. 80% of the acetabular fractures result from high-energy trauma like motor vehicle accidents and 10% falls from a significant height. Posterior wall fracture with or without dislocation are the most common type acetabular fracture accounting for a quarter to a third of all acetabular fractures. Unsatisfactory clinical results occur in more than 80% of patients treated non-surgically. Recently it has become obvious that accurate reduction of fracture is an important factor in achieving satisfactory outcome and open reduction is better than closed reduction Operative management usually offers the best chance of preserving long-term joint function and early mobilization but only if an anatomically reconstructed acetabulum is achieved. Results: The mean follow up period ranged from 6 weeks to 18 months. All the fractures were united at an average of 16 weeks and mean Harris hip score at the end of 1 year was 85.8. There was 1 superficial wound infections which was treated with intravenous antibiotic and wound healed with secondary intention and 1 case had foot drop post-operatively treated with foot drop splint recovery occurred after 6 month postoperatively. Conclusion: Good to excellent results were achieved in 75% of total cases. Hence we conclude that management of posterior wall or posterior column of Acetabular fracture is best achieved by means surgical approach by open reduction internal fixation with plates and screws.

Common peroneal nerve injury is present in 40% of knee dislocations, and foot drop is the principal complication. Posterior tibial tendon transfer is a viable solution to replace the function of the anterior tibial tendon (ATT) in the mid-foot. Several techniques for posterior tibial tendon transfer exist today, with variable results reported. However, adding augmentation with side-to-side tenorrhaphy of ATT to the transferred posterior tibial tendon (PTT) enhances anterior tissue balance and load sharing stress between native ATT enthesis and PTT tenodesis, allowing early rehabilitation and improving functional outcomes. Side-to-side tenorrhaphy is performed after PTT tenodesis in the lateral cuneiform to improve reliability in foot drop. This technique allows shorter immobilization time (from 6 to 2 weeks), earlier rehabilitation, sooner weight-bearing, and decreased risk of arthrofibrosis, scar formation, and muscle atrophy., Technique Video Video 1 Anterior tibial tendon side-to-side tenorrhaphy after posterior tibial tendon transfer: a technique to improve reliability in drop foot after common peroneal nerve injury.

Introduction/aims We aimed to describe the clinical phenotype, histopathological findings and overall survival (OS) of the immune-mediated neuromuscular complications of graft-versus-host disease (GVHD). Methods We conducted a retrospective chart review of adult patients presenting with immune-mediated neuromuscular complications of GVHD to Mayo Clinic, between April 2013 and July 2018.We collected clinical and laboratory characteristics, histopathological findings, response to treatment and survival data. Results We identified 20 patients with a mean age at presentation of 55 y. Mean time from transplant to neurological presentation was 14 mo. Myositis was the most common complication seen in 17 patients, manifesting with predominantly axial and/or proximal weakness. Eleven patients had a muscle biopsy showing diffuse perimysial, predominantly macrophagic infiltration in 10, 3 of them with perimysial perivascular lymphocytic collections, and endomysial and perimysial lymphocytic infiltration in 1. Only two patients had a neuropathic complication: one each with acute inflammatory demyelinating polyradiculoneuropathy and neuralgic amyotrophy. A single patient had a myasthenic syndrome presenting with fluctuating foot drop. Nineteen patients were treated and all responded to immunosuppressive agents; however, 11 had further GVHD flares requiring escalation of therapy. After a median follow-up of 83 mo, seven (35%) patients died: five from progressive GVHD and two from infections. The 5-y OS from time of transplant was 68%. Discussion Myositis is the most common immune-mediated neuromuscular complication of GVHD while peripheral neuropathy and myasthenic syndromes appear less common. The macrophage-predominant infiltration on muscle biopsy deserves further study to better clarify the role of macrophages in GVHD pathogenesis.

Lesions of peripheral nerve with cysts filled with mucoid material has been termed as peripheral nerve mucoid degeneration/intra-neural ganglion cyst. There is lack of awareness of the condition, and the pathogenesis still remains elusive to clinicians and radiologists, leading to high rates of misdiagnosis and mistreatment. Although no clinical symptoms or signs are diagnostic, it must be included into the differential diagnosis of lesions arising adjacent to nerves and presenting with compressive neuropathy. Characteristic signs and intra-articular connection can be located on radiological investigations, clinching the diagnosis. Wrong diagnosis and mistreatment of this condition can lead to a more aggressive approach with devastating consequences. Two cases affecting the common peroneal nerve presenting with insidious onset of foot drop were operated. Presentation, diagnosis, and management of these cases are discussed along with the current understanding of the lesion. Both the cases were diagnosed as intra-neural ganglion cyst of common peroneal nerve. MRI was done in these cases, and intra-articular connection was established in one case. The lesion was decompressed along with excision of intra-articular connection in one of the cases. Post-operatively patients had a good recovery with improvement in sensations and power of dorsiflexors. MRI is the investigation of choice for diagnosis of intra-neural ganglion cyst. Connection to the adjacent joint can be visualized in majority of cases. Various methods have been reported for management but cyst incision and ligation or excision of intra-articular branch is currently the best modality of treatment in these cases. Level of evidence: Level V: therapeutic; diagnostic; risk/prognostic study.

Highlights • The CMAPshin measurement is a convenient and safe method with good intra-observer reliability. • The right-left difference in the CMAPshin amplitude/area is likely pathological where a difference is more then 25%. • This method can be used to estimate the axonal loss in lesions involving these muscles., Objective The normal limits of symmetry for the compound muscle action potential of the shin muscles (CMAPshin) have not been determined yet. The goal of this study is to provide extensive data on the limits of symmetry and the reliability of CMAPshin. Methods The study was conducted in normal healthy males and females. All subjects underwent CMAPshin measurements bilaterally. The median percent differences of right/left amplitude/area, with range of these measurements, were calculated. In addition, the intra- and interobserver reliability was examined in a separate population. Results The study group consisted of 58 healthy individuals. The median percent right/left difference for amplitude and area were respectively 7.2% (range 0–23.6%) and 5.4% (range 0.7–25.6%). Right/left difference of the amplitude/area of the CMAPshin greater than 24%/26% respectively can be considered as pathological. The Pearson correlation coefficients (r) for the intra-observer reliability amplitude/area are 0.905/0.882 and for the inter-observer reliability are 0.968/0.981. Conclusions The results confirm symmetry and good intra- and interobserver reliability in CMAPshin measurements. Significance CMAPshin can be used in practice to estimate axonal loss in case of a foot drop. Data studies examining symmetry of CMAPshin can facilitate in the clinical interpretation of these nerve conduction studies.

Introduction Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded. Methods Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery. Results Seven patients are presented. The mean age at presentation was 52.1 years (range 41–66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other. Conclusion When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.

To compare functional outcomes of single versus double tendon transfer for foot drop correction and toe drop prevention in posttraumatic common fibular nerve palsy. A retrospective study was conducted on data from patients with posttraumatic common fibular nerve palsy treated by tendon transfer between 2001 and 2018. In cases of single tendon transfer (STT) the tibialis posterior (TP) tendon was transferred anteriorly through the interosseous membrane to a new insertion on the lateral cuneiform. In cases of double tendon transfer (DTT), the same TP tendon transfer was combined with a transfer of the flexor digitorum longus to the extensor digitorum longus and extensor hallucis longus tendons. Functional assessment was based on the Carayon score to evaluate foot drop correction and on the Yeganeh score to evaluate toe drop prevention. A total of 27 patients were included: 13 in the STT group and 14 in the DTT group. Functional results were comparable between groups in terms of reduction of foot drop, active range of ankle motion and Carayon score. Prevention of toe drop, active toe extension and Yeganeh score were significantly greater in the DTT group, however, active toe extension of was only restored in only 8 cases in the DTT group. Double transfer of TP and FDL tendons is a reliable method to restore balanced ankle dorsiflexion and prevent toe drop. However, recovery of active toe extension was inconsistent and Carayon scores were not superior to those obtained with a single TP tendon transfer.

The application of the 3D printing and additive manufacturing in making medical devices have become widespread in the last decades as the opportunity of the technology is rapidly growing. Notably, the Fused Deposition Modeling (FDM) in 3D printing technique has been applied to develop the ankle-foot orthosis (AFO) with different materials and composites. This paper presents a new design and simulation results of a novel orthosis using Carbon Fiber Reinforced Polymer (CFRP). The orthosis for ankle-foot is designed for rehabilitation of the patient from the foot drop disease. The orthosis’ shape is modelled to support the backside of the calf. It contributes to the maintenance of the gait cycle. In this paper, two different models of the AFO are compared, namely articulated and non-articulated. The finite-element analysis is done using the ANSYS software, and the results for equivalent Von-Mises stress as well as total deformation are observed and analyzed. Various materials are applied during the numerical analysis, as well as their combinations are tested.

Functional electrical stimulation (FES) provides an effective way for foot drop (FD) correction. To overcome the redundant and blind stimulation problems in the state-of-the-art methods, this study proposes a closed-loop scheme for an adaptive electromyography (EMG)-modulated stimulation profile. The developed method detects real-time angular velocity during walking. It provides feedbacks to a long short-term memory (LSTM) neural network for predicting synchronous tibialis anterior (TA) EMG. Based on the prediction, it modulates the stimulation intensity, taking into account of the subject-specific dead zone and saturation of the electrically evoked activation. The proposed method is tested on ten able-bodied participants and six FD subjects as proof of concept. The experimental results show that the proposed method can successfully induce the dorsiflexion of the ankle joint, and generate an activation pattern similar to a natural gait, with the mean Correlation Coefficient of 0.9021. Thus, the proposed method has the potential to help patients to retrieve normal gait.

We present a 69-year-old male with osteoarthritis of a varus mechanically aligned left knee that developed delayed arterial thrombosis after primary total knee arthroplasty (TKA) requiring stenting and subsequent trans-metatarsal amputation. This case is unique since initial presentation involved neurologic instead of ischemic changes. We also performed a literature review of arterial injuries in primary TKA. This case highlights the importance of maintaining a high clinical suspicion for vascular insult in patients undergoing correction of varus malalignment with initial complaints of neurologic dysfunction.

Sciatica due to a lumbar disc herniation is a frequent symptom, between 13% and 40% of the general population will experience an episode of sciatica during their lives. Different techniques exist to treat this condition. Among them the percutaneous intradiscal Discogel®. In all the series of patients reviewed treated with Discogel®, so far, there is not any case reported with disc extrusion and significant neurological damage. We present a case of a foot drop, caused by a disc herniation after percutaneous treatment with Discogel®. We hypothesize that the pathogenic mechanism would be the increased intradiscal volume and pressure post-puncture and annulus fibrosus damage, which could produce the disc extrusion. The extrusion of Discogel® material is possible. To the best of our knowledge, this is the first reported case of this complication with this product.

We present the case of a 16-week pregnant 19-year-old female who presented with hemiplegia due to a ruptured right frontal pial arteriovenous fistula (PAVF). She was also found to have an unruptured right temporal PAVF and a family history of brain hemorrhage. The patient was managed with Onyx embolization of the ruptured fistula, followed by surgical excision and hematoma evacuation. At 35 weeks gestation, she underwent cesarean section to prevent rupture of the second fistula in the setting of peripartum hypervolemia and increasing headaches. The child was delivered healthy. Subsequently, the right temporal AV fistula, supplied by a middle cerebral artery and posterior cerebral artery branch, underwent staged embolization resulting in complete occlusion. The patient recovered to a modified Rankin score of two, with a left foot drop as only persistent significant motor deficit.

Background Subungual melanoma (SUM) is a rare form of melanoma confined to the nailbed and is rarely of the desmoplastic subtype. The often subtle nature of SUM, initially starting as a small dark spot or line in the nailbed, means deeper invasion can occur before a patient seeks clinical evaluation for a large, ulcerated lesion. We report the only known case of perineural spread of SUM of the lower extremity and describe its extensive path of perineural spread from the toe. Case Description A 72-year-old man with a distant history of SUM status post second ray amputation, presented for evaluation of ipsilateral foot drop. Imaging revealed nodular involvement of tibial, peroneal, and sciatic nerves. Biopsies revealed desmoplastic melanoma and he was treated with nivolumab. Conclusions We report the only known case of perineural spread of SUM of the lower extremity and describe the pathoanatomy of perineural spread. A high index of suspicion for recurrent disease should be maintained even many years after completion of treatment.

The authors present a rare case report from the time when India was struggling with a huge surge in corona cases and the mortality due to it was touching new peaks day by day. Not only the oxygen, ventilators and ICU beds but also cremation sites were overwhelmed by masses of COVID deaths. We report a rare case of a 30 year old male woodcutter in cremation ground, whose axe accidently slipped while cutting woods and injured his leg. Wound exploration and clinical examination confirmed our diagnosis foot drop due to traumatic rupture of anterior compartment muscle & tendons and radiograph confirming unicortical fracture of the tibia. Patient was taken to emergency OT and operated under spinal anesthesia and tendons repaired using modified Kessler technique. Traumatic rupture of the tibialis anterior (TA) tendon represents a very rare foot injury. A combined injury of the tibialis anterior (TA) and the extensor hallucis longus (EHL) tendons has hardly been reported. The rarity of this case prompted us to report it.

Foot Drop (FD) is a condition, which is very commonly found in post-stoke patients; however it can also be seen in patients with multiple sclerosis, and cerebral palsy. It is a sign of neuromuscular damage caused by the weakness of the muscles. There are various approaches of FD's rehabilitation, such as physiotherapy, surgery, and the use of technological devices. Recently, researchers have worked on developing various technologies to enhance assisting and rehabilitation of FD.This review analyzes different types of technologies available for FD. This include devices that are available commercially or still under researchStudies included showed that both RAFO and FES showed considerable improvement in the gait cycle of the patients. Future trends are inclining towards integrating FES with other neuro-concepts such as muscle-synergies for further developments.

Objective To evaluate conservative treatment of giant lumbar disc herniation in patients with extreme pain and to assess temporal changes in pain levels and radiological findings with short-term follow-up. Methods A total of 15 patients with severe pain (as measured by visual analog scale [VAS]) due to giant lumbar disc herniation and without neurological deficits were included. All patients received conservative treatment and were followed weekly for pain and medication assessment. MRI was performed at baseline, second month and fourth month to calculate disc herniation volume. The changes in disc herniation and pain were evaluated. Results There was no relationship between pain and the regression of disc herniation in these five females and ten males with a mean age of 41.4 years. MRI results showed an average of 20.3% and 20.4% regression of disc herniation from baseline to second month, and second month to fourth month, respectively. Whereas, pain levels had reduced from an average of 90.8-13.53 by the second month, and to 3.13 by the fourth month, indicating significant success with conservative treatment. Conclusions Regardless of the size of the herniation and the severity of the pain, patients with giant lumbar disc herniation should be encouraged to undergo conservative treatment, given that the patient does not have urinary-fecal incontinence, foot drop or progressive neurodeficit.

Background: Neurofibroma is a benign nerve sheath tumor in the peripheral nervous system. In 90% of cases they're found as stand-alone tumors, while the remainder are found with neurofibromatosis type I (NF1). Lumbar neurofibroma often encountered in the surgical practice, presenting with sciatic pain, tingling and numbness, or even foot drop. Aim of Study: The aim of this study is to evaluate the role of surgery and defining the prognostic factors that affect the outcome of microscopic resection and how to avoid the possible complications especially those related to spinal instability and CSF leak. Patients and Methods: This is a retrospective study of sixteen cases of lumbar neurofibroma operated in the depart-ments of the authors by gross total resection, the surgery was microscopic assisted to secure the lumbar roots, and improve the outcome. Results: In this study, the male-to-female ratio of patients was 3 to 1 (75% to 25%). The mean age at the time of operation was 29 years. The initial symptoms were pain whether back or leg pain, gait disturbance resulting from leg motor weakness in 12% of our patients, tingling and numbness was found in 10 patients. Total removal of the tumor was achieved in 14 cases. Post-operative complications included CSFpseudo meningocele in onecase (6%), wound infection (including superficial and deep) in 3 cases (19%). One patient did not experience an improvement of the presenting motor power deficit. Conclusion: Excision of the lumbar neurofibroma totally can be achieved safely without complication if proper micro-scopic surgery principles were followed with special concerns directed towards the dissection of the tumor from adherent nerve roots especially the hidden ones. Midline posterior approach is a convenient approach that can guarantee spinal stability. Extreme attention should be applied towards closure steps of the surgery especially those related to the dural seal.

Closed brachial plexus lesions (BPLs) are generally associated with a traumatic mechanism of forced traction between the neck and the shoulder-arm complex. For brachial plexus reconstruction different techniques have been proposed with donor motor nerves like intercostal nerves, or the ipsilateral cervical plexus, the phrenic nerve, the contralateral C7 root, and many others. Despite all these surgical possibilities, the overall recovery is generally poor and not satisfactory. The principal drawback is linked to the loss of upper limb proprioception, in a way that dramatically influences even a good motor recovery, so in complete BPLs the sensory loss still represents a debilitating problem. In this anatomical feasibility study, the possibility to transfer the peroneal component of the sciatic nerve as a donor for complete BPLs has been evaluated. This technique would conceptually bring an important motor and sensory contribution to the upper limb using pure motor and sensory branches of the sciatic nerve. Performing immediate tendon transfer for foot drop palsy could significantly decrease the morbidity of the surgical procedure.