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Flashcards in 26 - Sciatic Nerve Injury Deck (37):

Case 1

A 55-year-old female presents with a 1-week history of difficulty walking and persistent pain in her left foot. She state that when she lifts her left leg to walk it is like her foot is dead, it just” kind of drops”.


What is the history 2 weeks prior to seeing you?

2 weeks prior, she had received an IM injection of 60 mg ketorolac in her left buttock from her PCP for the treatment of foot pain from a non-displaced cuboid fracture in her right foot due to an inversion injury suffered when she fell in a hole and landed on her back.

She was immobilized in a surgical boot and told to bear weight as tolerated, use ice and elevate the right leg.


What happened for the remainder of the first week?

For the remainder of the first week, she continued to experience pain and swelling of her left ankle and foot and difficulty walking. She has persisted in having tenderness along the first and second metatarsals. Her radiographs one week ago were negative for signs of stress fracture of the left forefoot.

She states that although she is able to feel everything, her left leg and foot feel “dead”.

She still might have a stress fracture, but it would not be evident on a radiograph at this point


What happened one week ago?

One week ago, her PCP told her it is likely overuse due to favoring the right foot, prescribed ibuprofen 800 mgs tid, and referred her to you for a second opinion.


What else is in her past medical history?

Other than this incident her medical history is unremarkable other than for occasional asthma for which she uses an albuterol inhaler prn and the ibuprofen as initially prescribed. She is on no other medications.


What are the findings on the physical exams?

- Mild swelling over right lateral midfoot with pain upon palpation of the cuboid. Mild swelling on the dorsal and plantar aspect of the left forefoot, but no pain with palpation.
- Anterior and peroneal muscle group rated at 3/5, posterior and medial muscle groups 5/5


What does this muscle weakness mean?

- There is a problem with the common peroneal nerve
- This would lead to the muscle weakness we see as well as the drop foot


What is the general rule of thumb for standing on heels/tip toes?

Patient can stand on tip toes but not heel, peripheral neuropathy caused by metabolic problem

If the patient can stand on their heel, but not on the tip toes, it is caused by a CNS tumor


How does this patient present in terms of heel/toe weakness?

She is unable to stand on her left heel yet is able to stand on her toes.


How is the sharp/dull sensation in this patient?

Sharp/dull sensation is reduced on the dorsum of her left foot-other neurological exams WNL


What is on the differential?

- Trauma to L4-L5
- Masses
- Compartment syndrome
- Diabetic mononeuropathy
- Vasculitis


Describe a trauma to L4-L5

- Direct injury to the sciatic nerve (L4, L5, S1, S2, S3), primarily to the peroneal branch, from the needle, itself; chemical irritation from the solution, itself; hematoma leading to ischemic injury to nerve
- L4, L5 disc injury from fall


What does the acute onset suggest?

Trauma, rather than a mass or vasculitis/neuropathy


What studies would you like to do in this case?

- EMG (electromyography)
- NCV (nerve conduction velocity - can do motor or sensory)
- MRI (sciatic nerve)

Would probably want to do a motor NCV due to the muscle weakness


What are the results of the motor nerve conduction velocity?

Left peroneal nerve
- 16.7 m/sec

Right peroneal nerve
- 72.5 m/s

Fibular head to extensor digitorum brevis is the nerve we measure


What is a normal NCV in the leg?

50-60 m/sec


Describe the NCV test

- Distance between the proximal and distal stimulation points (mm)
- Difference in time between the onset of the CAMP (compound action muscle potential) when the proximal electrode stimulated minus the distal electrode stimulation (msec)
- Distinguishes demyelinating from axonal diseases


What is the CMAP (compound muscle action potential) in this patient?


- The CMAP (compound muscle action potential) demonstrated an increased latency and a slightly decreased amplitude with left peroneal stimulation
- Additionally, spontaneous fibrillation of the tibialis anterior and short head of the biceps femoris on the left were observed.

These are NOT normal findings


What do you see in demyelinating diseasing?

- the NCV is slowed to 50% normal
- the amplitude is generally normal
- the distal latency is prolonged


What do you see in axonal diseases?

NCV is only SLIGHTLY slower
- the NCV is slowed only slightly
- the amplitude is lowered
- the distal latency is normal


What happens when myelin is gone?

Without myelin, the nerve impulse is slowed, but speed of impulse not altered with axonal damage in teh presence of normal myelin

NCV normal in myopathies and disorders of the anterior horn


What level of activity will be normal in the muscle at rest?

Normally there is no activity of the muscle at rest, but fibrillations suggest acute denervation, acute metabolic neuropathies or polymyositis


What is the diagnosis in this case?

Sciatic nerve injury

90% of patients have immediate symptoms


How do you treat the sciatic nerve injury?

- Inject 3-5 mls of normal saline into the subgluteal space - DILUTE the area
- Consider early PT with strengthening exercises and use of a flexible dropfoot brace - IMMEDIATELY PT
- Consider neuropathy drugs (gabapentin, pregabalin, duloxetine)


What are the three drugs used to treat neuropathy?

- gabapentin
- pregabalin
- duloxetine


When should you consider a surgical approach to a sciatic nerve injury?

Consider surgical neurolysis if pain persists for longer than 1 to 3 months


What is the exact mechanism of nerve injury?

Wallerian degeneration

This is what has happened here


Do NSAID’s interfere with bone healing?

Remember the patient has fractures in the other foot


Can you administer NSAID’s to an asthmatic?

Need to think about the cyclooxygenase pathway here

You can do a COX-2, but don't give the other ones (any COX-1, including aspirin)

Can cause bronchoconstriction

Shift the pathway to the lukotriene pathway, leading to bronchoconstriction

NSAIDs are contraindicated in an asthmatic *******


What is the mechanism of nerve injury?

- Extrafascicular
- Intrafascicular


Describe extrafascicular nerve injury

No damage


Describe intrafascicular nerve injury

- Axonal degeneration and myelin breakdown with Wallerian degeneration (antegrade degeneration of the axons and their accompanying myelin sheaths following proximal axonal or neuronal cell body injury)
- Connective tissue proliferation and scar formation


Why do you need to wait 3 months?

Since there is Wallerian degeneration (the tube is still in tact but the nerve is cut)

You want to see if the cut nerve in the tube will regrow

Need to give it time, but frequently there will be too much scar tissue to have regrowth


Describe the process of Wallerian degeneration

In less than 24 hours
- Neurofilaments break up
- Axons break up into short lengths

Within 10 days
- Myelin sheath breaks down into lipid droplets around the axon

Within a month
- Myelin gets denatured chemically

Within 3 months
- Macrophages from the endoneurium invade the degenerating myelin sheath and axis cylinder and phagocytose the debris


Can you use NSAIDs in bone injury? Does it interfere with bone healing?

He says no - He doesn't use NSAIDs in bone injury

Although increasing evidence from animal studies suggests that cyclooxygenase-2 (COX-2) inhibition suppresses early fracture-healing, in vivo studies involving human subjects have not provided convincing evidence to substantiate this concern


Can you use NSAIDs in asthmatics?

Can you use with history of asthma?
- By blocking cyclo-oxygenase pathway, NSAIDS shift pathway to production of leukotrienes which can cause bronchospasm
- Safe to administer Cox-2 inhibitors



What is the preferred location of a gluteal IM injection?


Preferred location of a gluteal IM injection is the ventrogluteal area, not the dorsogluteal area