Common peroneal nerve ganglion; decompression and neurectomy
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Intraneural ganglia are benigin mucinous cysts that occur within peripheral nerves. They are a rare cause of foot drop when they occur in the common peroneal nerve, causing a local compressive neuropathy as they expand within the epineurium.
Although they have been recognised and treated surgically for many decades, their exact pathogenesis remains unknown. It has become increasingly apparent that they have an intra-articular origin which, due to a defect in the proximal tibiofibular joint capsule, permits communication with the main nerve trunk through an articular nerve branch.
This intra-articular, neural communication between the nerve and the proximal tibiofibular joint is often identifiable on a T2 weighted MRI image and should be carefully identified on surgical exploration.
Early surgical intervention is recommended to decompress the common peroneal nerve in order to allow motor recovery and improve neuropathic pain. Extraneural excision with an decompressive epineurotomy has been described but current evidence suggests that the articular branch should also be ligated to eliminate the potential for recurrence.
Where denervation is acute and the motor end plates are preserved, motor recovery may be expected following decompression. However this is difficult to predict and some groups have combined decompression with a tibial motor fascicle transfer.
Where the tibiofibular joint has undergone degenerative change and is the source of pain one may consider a concomitant joint procedure such as an arthrodesis or excision arthroplasty.
The following technique illustrates the surgical approach, and peripheral nerve surgical techniques required to perform an intraneural decompression of the common peroneal nerve as well as a neurectomy of the articular branch.
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Author:Tahseen Chaudhry FRCS (Tr & Orth), Consultant in hand and peripheral nerve surgery,
Institution: University Hospital, Birmingham, UK.