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8 Tarsal Tunnel Syndrome
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The tibial nerve, the other branch of the sciatic, supplies several muscles in the lower extremity, gives origin to the sural nerve, and then continues as the posterior tibial nerve to supply the plantar flexors of the foot and toes It passes through the tarsal tunnel behind and below the medial malleolus, giving off calcaneal branches and the medial and lateral plantar nerves that supply small muscles of the foot and the skin on the plantar aspect of the foot and toes Compression of the posterior tibial nerve or its branches between the bony floor and ligamentous roof of the tarsal tunnel leads to pain, paresthesias, and numbness over the bottom of the foot, especially at night, with sparing of the heel Muscle weakness may be hard to recognize clinically Compressive lesions of the individual plantar nerves may also occur more distally, with clinical features similar to those of the tarsal tunnel syndrome Treatment is surgical decompression
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5 Femoral Neuropathy
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The clinical features of femoral nerve palsy consist of weakness and wasting of the quadriceps muscle, with sensory impairment over the anteromedian aspect of the thigh and sometimes also of the leg to the medial malleolus, and a depressed or absent knee jerk Isolated femoral neuropathy may occur in diabetics or from compression by retroperitoneal neoplasms or hematomas (eg, expanding aortic aneurysm) Femoral neuropathy may also result from pressure from the inguinal ligament when the thighs are markedly flexed and abducted, as in the lithotomy position
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The lateral femoral cutaneous nerve, a sensory nerve arising from the L2 and L3 roots, may be compressed or stretched in obese or diabetic patients and during pregnancy The nerve usually runs under the outer portion of the inguinal ligament to reach the thigh, but the ligament sometimes splits to enclose it Hyperextension of the hip or increased lumbar lordosis such as occurs during pregnancy leads to nerve compression by the posterior fascicle of the ligament However, entrapment of the nerve at any point along its course may cause similar symptoms, and several other anatomic variations predispose the nerve to damage when it is stretched Pain, paresthesia, or numbness occurs about the outer aspect of the thigh, usually unilaterally, and is sometimes relieved by sitting Examination shows no abnormalities except in severe cases when cutaneous sensation is impaired in the affected area Symptoms are usually mild and commonly settle spontaneously Hydrocortisone injections medial to the anterosuperior iliac spine often relieve symptoms temporarily, while nerve decompression by transposition may provide more lasting relief
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9 Facial Neuropathy
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An isolated facial palsy may occur in patients with HIV seropositivity, sarcoidosis, or Lyme disease (see 34), but most often it is idiopathic (Bell s palsy)
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ESSENTIALS OF DIAGNOSIS
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Sudden onset of lower motor neuron facial palsy Hyperacusis or impaired taste may occur No other neurologic abnormalities
General Considerations
Bell s palsy is an idiopathic facial paresis of lower motor neuron type that has been attributed to an inflammatory
Nervous System Disorders
reaction involving the facial nerve near the stylomastoid foramen or in the bony facial canal Increasing evidence incriminates reactivation of herpes simplex virus infection in the geniculate ganglion at least in some instances The disorder is more common in pregnant women or in persons with diabetes
CMDT 2008
DISCOGENIC NECK PAIN
ESSENTIALS OF DIAGNOSIS
Neck pain, sometimes radiating to arms Restricted neck movements Motor, sensory, or reflex changes in arms with root involvement Neurologic deficit in legs, gait disorder, or sphincter disturbance with cord involvement
Clinical Findings
The facial paresis generally comes on abruptly, but it may worsen over the following day or so Pain about the ear precedes or accompanies the weakness in many cases but usually lasts for only a few days The face itself feels stiff and pulled to one side There may be ipsilateral restriction of eye closure and difficulty with eating and fine facial movements A disturbance of taste is common, owing to involvement of chorda tympani fibers, and hyperacusis due to involvement of fibers to the stapedius occurs occasionally
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