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Peroneal nerve compression resulting from fibular head osteophyte-like lesions
Surgical Neurology 64 (2005) 249 – 252 www.surgicalneurology-online.com
Peripheral Nerves
Peroneal nerve compression resulting from fibular head osteophyte-like lesions Leandro P. Flores, MDa,b, Andrei Koerbel, MDa, Marcos Tatagiba, MD, PhDa,* a
Department of Neurosurgery, University Hospital Tu¨bingen, Tu¨bingen, Germany b Unit of Neurosurgery, Hospital de Base do Distrito Federal, Brası´lia, Brazil Received 20 July 2004; accepted 30 November 2004
Abstract
Background: The anatomical relationship of the fibular head with the fibular nerve is a critical point in regard to injuries of peripheral nerves in the lower extremities. In this location, the peroneal nerve may be injured due to several mechanisms, and osteophyte-like lesions can be considered as a differential diagnosis. Methods: The suitable literature concerning this association is reviewed and a case is presented. A 15-year-old adolescent boy presented with right peroneal nerve palsy on admission. The radiological examinations (computed tomography and magnetic resonance imaging) demonstrated an osteophytic lesion in the head of the right fibula. The patient underwent surgical decompression of the nerve and resection of the lesion. Postoperatively, there was a complete recovery of the deficits. Conclusions: The association of osteophyte-like bone changes and peroneal nerve palsy is rare. The differential diagnoses of these lesions include cartilaginous exostoses and osteochondromas, which may be related to hereditary multiple exostoses syndrome. The timing of the treatment plays an important role in the neurological recovery. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Peroneal nerve; Compression; Benign tumor; Osteophytes; Peripheral nerve surgery
1. Introduction
2. Case report
The fibular nerve is frequently involved in cases of lesions or entrapment in the lower limb [2]. The nerve can be damaged because of several mechanisms: direct trauma, pressure injuries, fibular fractures, ischemic neuropathies, spontaneous hematomas, cysts from the tibiofibular joint, entrapments, and neoplasms [16]. One of the most vulnerable points of injury to the peroneal nerve is the head of the fibular bone [9]. However, only few cases have been reported on peroneal nerve compression by a benign bone growth in this area [1,3,5,7,9,12,19-21,29,33]. A case of nerve compression caused by a benign osteophyte-like lesion is presented. Its mechanism, diagnostic investigation, and respective suitable treatment are presented and discussed.
A 15-year-old adolescent boy presented with right peroneal nerve palsy at admission. The patient reported right foot and toe extension weakness, which had begun 4 months before. There were no complaints about sensory loss or pain in the referred leg. There was no history of trauma or any previous neurological disease. The physical examination revealed a marked weakness to dorsiflexion of the right ankle and toes, and ankle dorsoeversion, both grade 1 according to the Medical Research Council scale. There was no sensory loss in the affected leg. A bony prominence was noted in the right lateral head of the fibula, and a Tinel’s sign proved positive with percussion to this area. Electrophysiological studies confirmed denervation of the muscles supplied by the right peroneal nerve, which suggested impairment of this nerve at the level of the fibular head. A computed tomography (CT) with a 3-D reconstruction and a magnetic resonance imaging (MRI) of the knee region demonstrated an osteophytic protuberance in the
* Corresponding author. Klinik fu¨r Neurochirurgie, Universita¨tsklinikum Tu¨bingen, Hoppe-Seyler-Str 3, 72076 Tu¨bingen, Germany. Tel.: +49 7071 29 8 03 25; fax: +49 7071 29 8 55 54. E-mail address: [email protected] (M. Tatagiba). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2004.11.031
250
L.P. Flores et al. / Surgical Neurology 64 (2005) 249–252
head of the fibula on the right side (Fig. 1). Further radiological examination disclosed a similar bone prominence at the left distal femur. The patient underwent surgical decompression of the right peroneal nerve. A large exostosis of the fibular head, compressing and displacing the common peroneal nerve, was observed during surgery. The bone lesion was removed and an external epineurolysis was performed. Postoperatively, there was a progressive improvement of the nerve function. One month after surgery, the patient presented almost full recovery of the preoperative deficit. The pathologic lesion was that of a cartilaginous exostosis. 3. Discussion The most frequent area of peroneal nerve injury is the point where it encircles the head of the fibula [9,10,28]. Some factors may contribute to explain this frequency: some tethering of the nerve at this point, the increased number of fascicles in this area, the epineural enlargement, and the superficial location of the nerve on the lateral knee location [13]. The fibular head bone may be a source of
some lesions, such as fractures, benign cysts from the tibiofibular joint, tumors, and osteophytes [22]. Osteophytic formation in tubular bones has the potential to compress surrounding peripheral nerves [11]. There are 2 main categories of benign osteophyte-like lesions that originate from the head of the fibula: cartilaginous exostoses or osteochondromas [8,18]. A simple exostosis is a benign bony growth projecting outward from the surface of a bone, whereas an osteochondroma consists of a proliferative bone, capped by cartilage [18,25,30]. Both lesions causing peroneal nerve compression are very infrequent, and only the histological examination can provide the definitive diagnosis [8,18,19]. Although osteoid osteomas may also mimic exostosis, there are no reports of the association of this lesion with fibular nerve compression [4,6,14,24]. Cartilaginous exostoses are usually asymptomatic [5,8,18]. Nerve compression caused by this lesion is usually linked to the hereditary multiple exostoses syndrome (HMES) [5,17,18,32]. HMES is considered the most frequent benign bone alteration of the skeleton [26,34]. It is an autosomic dominant disorder characterized by the formation of multiple bone prominences, developing from the epiphysis. The exostosis begins to develop in childhood
Fig. 1. Coronal CT (A) and MRI (B) of the right knee region, demonstrating an osteophytic lesion in the lateral head of the fibula (arrow), with compression and displacement of the peroneal nerve. 3-D reconstruction CT of the same region in 2 different angles: anterior (C) and posterior (D), demonstrating the exostosis in the head of the fibula (arrow).
L.P. Flores et al. / Surgical Neurology 64 (2005) 249–252
and continues to grow until puberty. The most common complication is skeletal deformity, as ulnar wrist deviation, ankle valgus, genu valgus [15], scoliosis, radial head dislocation, bony synostosis, and short stature [18,26,32]. These deformities are a consequence of an abnormal remodeling of the bones by a disrupting epiphyseal plate growth [23]. It has the potential to malignant transformation to chondrosarcomas in 0.9% to 25% of the cases [18,34]. Nonskeletal complications, such as nerve compressions, are extremely rare, present in less than 1% of all cases [18]. In a study of Vanhoenacker et al [32], a serial evaluation of 489 exostoses in HMES did not demonstrate any nerve compression. This study estimated that the fibular bone can be involved in 8.2% of the exostoses cases. Kim and Kline [9] reported 302 cases of peroneal nerve injuries and described only one patient who presented with bilateral peroneal compression by exostosis of the head of the fibula. Only a few cases of compressions of the peroneal nerve by cartilaginous exostosis have been reported so far [5,9,20,21,29]. Motor deficits are more frequently and severely involved than the sensory ones. This finding may be explained by the arrangement of the fascicles inside of the common peroneal nerve. The motor fascicles run more medially, whereas the sensorial fascicles are located laterally [27,31]. The exostosis grows from inside to outside direction, thus compressing the motor fibers earlier. The general surgical indications for benign bony growths are cosmetic defect, exostosis in a location at risk to repetitive trauma, increased risk of the exostosis fracture [29], neurological involvement, impairment of the articular range of motion, and suspicion of malignancy [1,5]. In the fibular head region, the peroneal nerve is at risk for repetitive trauma, and motor weakness is the result of compression. In conclusion, osteophyte-like lesions arising from the head of the fibula constitute rare mechanisms of peroneal nerve injury. These affections should be remembered as a possible differential diagnosis. Surgical treatment should not be delayed because neurological improvement may be achieved if surgery is carried out before severe neurological deficits become irreversible.
[6] [7] [8]
[9] [10]
[11]
[12] [13]
[14]
[15] [16] [17]
[18]
[19] [20]
[21] [22] [23]
[24] [25]
References [1] Cardelia JM, Dormans MD, Drummond DS, Davidson RS, Duhaime C, Sutton L. Proximal fibular osteochondroma with associated peroneal nerve palsy: a review of six cases. J Pediatr Orthop 1995;15:574 - 7. [2] Dowson D. Entrapment neuropathies. 2nd ed. Boston7 Little, Brown and Company; 1990. [3] Gallagher-Oxner K, Bagley L, Dalinka MK, Kneeland JB. Case report 822: osteochondroma causing peroneal palsy—imaging evaluation. Skeletal Radiol 1994;23:71 - 2. [4] Giustra PE, Freiberg RH. Severe growth disturbance with osteoid osteoma: a report of two cases involving the femoral neck. Radiology 1970;96:285 - 8. [5] Goudarzi YM, Khodadadyan C, Leuenberger D. Bilateral L7sion des Nervus Peronaeus mit L7sion der linksseitigen Nervi Medianus und
[26] [27] [28]
[29]
[30]
251
Ulnaris bei Multiplen Osteocartilagin7ren Exostosen. Chirurgia 1995;66:1158 - 61 [German]. Haskel L, Pogrund H, Rosenmann E. Osteoid osteoma presenting as an osteocartilaginous exostosis. Isr J Med Sci 1981;17:380 - 2. Hazmy W. Peroneal nerve palsy secondary to proximal fibular osteochondroma—case report. Med J Malaysia 2001;56:89 - 90. Hudson TM, Chew FS, Manaster BJ. Scintigraphy of benign exostosis and exostotic chondrosarcomas. AJR Am J Roentgenol 1983;140:581 - 6. Kim DH, Kline DG. Management and results of peroneal nerve lesions. Neurosurgery 1996;39:312 - 9. Kline D, Hudson A. Nerve tumors. In: Kline D, Hudson A, editors. Nerve injuries: operative results of major nerves injuries, entrapments and tumors. Philadelphia7 WB Saunders; 1995. p. 345 - 60. Lange RH, Lange TA, Rao BK. Correlative radiographic, scintigraphic and histological evaluation of exostoses. J Bone Joint Surg Am 1984;66:1454 - 9. Levin KH, Wilbourn AJ, Jones Jr HR. Childhood peroneal neuropathy from bone tumors. Pediatr Neurol 1991;7:308 - 9. Mackinnom S, Dellon AL. Other lower extremity entrapments. In: Mackninnom S, Dellon A, editors. Surgery of peripheral nerves. Stuttgart7 Thieme Med.; 1988. p. 378 - 410. Marinelli A, Giacomini S, Bianchi G, Pellacani A, Bertoni F, Mercuri M. Osteoid osteoma simulating an osteocartilaginous exostosis. Skeletal Radiol 2004;33:181 - 5. McCornack EB. Bilateral genu recurvatum after skeletal traction. J Bone Joint Surg Am 1980;62:1388. Mumenthaler M, Schliack H. Peripheral nerves lesions—diagnosis and therapy. Stuttgart7 Thieme Med.; 1991. Nunez DA, Grahan HK, Fixsen JA. Cervical cord compression and femoral neuropathy in hereditary multiple exostoses. J Neurol Neurosurg Psychiatry 1990;53:439. Paik NJ, Han TR, Lim SJ. Multiple peripheral nerve compressions related to malignantly transformed hereditary multiple exostoses. Muscle Nerve 2000;23:1290 - 4. Peterson HA. Multiple hereditary osteochondromata. Clin Orthop 1989;239:222 - 30. Piton C, Fabre T, Lasseur E, Andre D, Geneste M, Durandeau A. Common fibular nerve lesions. Etiology and treatment. Apropos of 146 cases with surgical treatment. Rev Chir Orthop Reparatrice Appar Mot 1997;83:515 - 21. Rinaldi E. Peroneal paralysis due exostosis of the fibula. Report of two cases. Ital J Orthop Traumatol 1983;9:259 - 62. Salter RB. Textbook of disorders and injuries of the musculoskeletal system. 2nd ed. Baltimore7 William & Wilkins; 1983. Shapiro F, Simom S, Glimcher MJ. Hereditary multiple exostoses. Anthropometric, roentgenographic and clinical aspects. J Bone Joint Surg Am 1979;61:815 - 24. Sherman MS, Caldwell GA. Osteoid osteoma. Clin Orthop 1953;2: 203 - 10. Slepian A, Hamby WB. Neurological complication associated with hereditary deforming chondrodysplasia: review of literature and report on two cases occurring in the same family. J Neurosurg 1951;8: 529 - 35. Solomon L. Hereditary multiple exostoses. Am J Hum Genet 1964;16:351 - 63. Suterland S, Braley KC. The cross sectional area of peripheral nerves trunks devoted to nerve fibers. Brain 1949;72:428 - 49. Tatagiba M, Leitao F, Samii M. Peripheral nerve tumors. In: Tatagiba M, Mazzer N, editors. Peripheral nerves. Rio de Janeiro7 Ed. Revinter; 2003. p. 254 - 78. Theodorou SD, Karamitsos S, Tsouparopoulos D, Hatzipavlou AG. Rare complications of exostosis. Fractures and injury to the common peroneal nerve. Acta Orthop Belg 1978;44:496 - 505. Tsuchiya H, Morikawa S, Tomita K. Osteochondroma arising from multiple cartilaginous exostoses: a case report. Jpn J Clin Oncol 1990;20:296 - 8.
252
L.P. Flores et al. / Surgical Neurology 64 (2005) 249–252
[31] Urushidani H. The funicular pattern of sciatic nerve in Japanese adults. Nippon Geka Hokan 1974;43:254 - 75 [Japanese]. [32] Vanhoenacker FM, Hul WV, Wuyts W, Willems PJ, De Schepeprr AM. Hereditary multiple exostoses: from genetics to clinical syndrome and complications. Eur J Radiol 2001;40:208 - 17. [33] Watson LW, Torch MA. Peroneal nerve palsy secondary to compression from an osteochondroma. Orthopedics 1993;16:707 - 10. [34] Wicklund CL, Pauli RM, Johnston D, Hecht JT. Natural history study of hereditary multiple exostoses. Am J Med Genet 1995;55:43 - 6.
problem in this location. The authors present a case of a 15-year-old adolescent boy who developed a peroneal nerve entrapment caused by an apparent osteophyte. The relevant literature is also discussed. There are relatively few neurosurgeons who perform peripheral nerve surgery, and the lower extremity nerves appear to me to be particularly poorly represented in the average neurosurgical practice. Publications such at the article by Flores et al help raise the awareness of our colleagues to these conditions.
Commentary Peroneal nerve entrapment at the fibular head is probably the most common entrapment injury in the lower extremities. In a minority of these cases, a clear lesion can be identified. One of those is an osteophyte, an uncommon
Ben Roitberg, MD Department of Neurosurgery University of Illinois at Chicago Chicago, Illinois 60612, USA
The U.S. Pharmacopeia (USP) reported that the technologic panacea for safety is involved in 20% of reported hospital medication errors. Computer entry errors, which are steadily increasing, are the fourth leading cause of such errors. — AAPS News, February 2005 www.aaps.online.org
Peripheral Nerves
Peroneal nerve compression resulting from fibular head osteophyte-like lesions Leandro P. Flores, MDa,b, Andrei Koerbel, MDa, Marcos Tatagiba, MD, PhDa,* a
Department of Neurosurgery, University Hospital Tu¨bingen, Tu¨bingen, Germany b Unit of Neurosurgery, Hospital de Base do Distrito Federal, Brası´lia, Brazil Received 20 July 2004; accepted 30 November 2004
Abstract
Background: The anatomical relationship of the fibular head with the fibular nerve is a critical point in regard to injuries of peripheral nerves in the lower extremities. In this location, the peroneal nerve may be injured due to several mechanisms, and osteophyte-like lesions can be considered as a differential diagnosis. Methods: The suitable literature concerning this association is reviewed and a case is presented. A 15-year-old adolescent boy presented with right peroneal nerve palsy on admission. The radiological examinations (computed tomography and magnetic resonance imaging) demonstrated an osteophytic lesion in the head of the right fibula. The patient underwent surgical decompression of the nerve and resection of the lesion. Postoperatively, there was a complete recovery of the deficits. Conclusions: The association of osteophyte-like bone changes and peroneal nerve palsy is rare. The differential diagnoses of these lesions include cartilaginous exostoses and osteochondromas, which may be related to hereditary multiple exostoses syndrome. The timing of the treatment plays an important role in the neurological recovery. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Peroneal nerve; Compression; Benign tumor; Osteophytes; Peripheral nerve surgery
1. Introduction
2. Case report
The fibular nerve is frequently involved in cases of lesions or entrapment in the lower limb [2]. The nerve can be damaged because of several mechanisms: direct trauma, pressure injuries, fibular fractures, ischemic neuropathies, spontaneous hematomas, cysts from the tibiofibular joint, entrapments, and neoplasms [16]. One of the most vulnerable points of injury to the peroneal nerve is the head of the fibular bone [9]. However, only few cases have been reported on peroneal nerve compression by a benign bone growth in this area [1,3,5,7,9,12,19-21,29,33]. A case of nerve compression caused by a benign osteophyte-like lesion is presented. Its mechanism, diagnostic investigation, and respective suitable treatment are presented and discussed.
A 15-year-old adolescent boy presented with right peroneal nerve palsy at admission. The patient reported right foot and toe extension weakness, which had begun 4 months before. There were no complaints about sensory loss or pain in the referred leg. There was no history of trauma or any previous neurological disease. The physical examination revealed a marked weakness to dorsiflexion of the right ankle and toes, and ankle dorsoeversion, both grade 1 according to the Medical Research Council scale. There was no sensory loss in the affected leg. A bony prominence was noted in the right lateral head of the fibula, and a Tinel’s sign proved positive with percussion to this area. Electrophysiological studies confirmed denervation of the muscles supplied by the right peroneal nerve, which suggested impairment of this nerve at the level of the fibular head. A computed tomography (CT) with a 3-D reconstruction and a magnetic resonance imaging (MRI) of the knee region demonstrated an osteophytic protuberance in the
* Corresponding author. Klinik fu¨r Neurochirurgie, Universita¨tsklinikum Tu¨bingen, Hoppe-Seyler-Str 3, 72076 Tu¨bingen, Germany. Tel.: +49 7071 29 8 03 25; fax: +49 7071 29 8 55 54. E-mail address: [email protected] (M. Tatagiba). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2004.11.031
250
L.P. Flores et al. / Surgical Neurology 64 (2005) 249–252
head of the fibula on the right side (Fig. 1). Further radiological examination disclosed a similar bone prominence at the left distal femur. The patient underwent surgical decompression of the right peroneal nerve. A large exostosis of the fibular head, compressing and displacing the common peroneal nerve, was observed during surgery. The bone lesion was removed and an external epineurolysis was performed. Postoperatively, there was a progressive improvement of the nerve function. One month after surgery, the patient presented almost full recovery of the preoperative deficit. The pathologic lesion was that of a cartilaginous exostosis. 3. Discussion The most frequent area of peroneal nerve injury is the point where it encircles the head of the fibula [9,10,28]. Some factors may contribute to explain this frequency: some tethering of the nerve at this point, the increased number of fascicles in this area, the epineural enlargement, and the superficial location of the nerve on the lateral knee location [13]. The fibular head bone may be a source of
some lesions, such as fractures, benign cysts from the tibiofibular joint, tumors, and osteophytes [22]. Osteophytic formation in tubular bones has the potential to compress surrounding peripheral nerves [11]. There are 2 main categories of benign osteophyte-like lesions that originate from the head of the fibula: cartilaginous exostoses or osteochondromas [8,18]. A simple exostosis is a benign bony growth projecting outward from the surface of a bone, whereas an osteochondroma consists of a proliferative bone, capped by cartilage [18,25,30]. Both lesions causing peroneal nerve compression are very infrequent, and only the histological examination can provide the definitive diagnosis [8,18,19]. Although osteoid osteomas may also mimic exostosis, there are no reports of the association of this lesion with fibular nerve compression [4,6,14,24]. Cartilaginous exostoses are usually asymptomatic [5,8,18]. Nerve compression caused by this lesion is usually linked to the hereditary multiple exostoses syndrome (HMES) [5,17,18,32]. HMES is considered the most frequent benign bone alteration of the skeleton [26,34]. It is an autosomic dominant disorder characterized by the formation of multiple bone prominences, developing from the epiphysis. The exostosis begins to develop in childhood
Fig. 1. Coronal CT (A) and MRI (B) of the right knee region, demonstrating an osteophytic lesion in the lateral head of the fibula (arrow), with compression and displacement of the peroneal nerve. 3-D reconstruction CT of the same region in 2 different angles: anterior (C) and posterior (D), demonstrating the exostosis in the head of the fibula (arrow).
L.P. Flores et al. / Surgical Neurology 64 (2005) 249–252
and continues to grow until puberty. The most common complication is skeletal deformity, as ulnar wrist deviation, ankle valgus, genu valgus [15], scoliosis, radial head dislocation, bony synostosis, and short stature [18,26,32]. These deformities are a consequence of an abnormal remodeling of the bones by a disrupting epiphyseal plate growth [23]. It has the potential to malignant transformation to chondrosarcomas in 0.9% to 25% of the cases [18,34]. Nonskeletal complications, such as nerve compressions, are extremely rare, present in less than 1% of all cases [18]. In a study of Vanhoenacker et al [32], a serial evaluation of 489 exostoses in HMES did not demonstrate any nerve compression. This study estimated that the fibular bone can be involved in 8.2% of the exostoses cases. Kim and Kline [9] reported 302 cases of peroneal nerve injuries and described only one patient who presented with bilateral peroneal compression by exostosis of the head of the fibula. Only a few cases of compressions of the peroneal nerve by cartilaginous exostosis have been reported so far [5,9,20,21,29]. Motor deficits are more frequently and severely involved than the sensory ones. This finding may be explained by the arrangement of the fascicles inside of the common peroneal nerve. The motor fascicles run more medially, whereas the sensorial fascicles are located laterally [27,31]. The exostosis grows from inside to outside direction, thus compressing the motor fibers earlier. The general surgical indications for benign bony growths are cosmetic defect, exostosis in a location at risk to repetitive trauma, increased risk of the exostosis fracture [29], neurological involvement, impairment of the articular range of motion, and suspicion of malignancy [1,5]. In the fibular head region, the peroneal nerve is at risk for repetitive trauma, and motor weakness is the result of compression. In conclusion, osteophyte-like lesions arising from the head of the fibula constitute rare mechanisms of peroneal nerve injury. These affections should be remembered as a possible differential diagnosis. Surgical treatment should not be delayed because neurological improvement may be achieved if surgery is carried out before severe neurological deficits become irreversible.
[6] [7] [8]
[9] [10]
[11]
[12] [13]
[14]
[15] [16] [17]
[18]
[19] [20]
[21] [22] [23]
[24] [25]
References [1] Cardelia JM, Dormans MD, Drummond DS, Davidson RS, Duhaime C, Sutton L. Proximal fibular osteochondroma with associated peroneal nerve palsy: a review of six cases. J Pediatr Orthop 1995;15:574 - 7. [2] Dowson D. Entrapment neuropathies. 2nd ed. Boston7 Little, Brown and Company; 1990. [3] Gallagher-Oxner K, Bagley L, Dalinka MK, Kneeland JB. Case report 822: osteochondroma causing peroneal palsy—imaging evaluation. Skeletal Radiol 1994;23:71 - 2. [4] Giustra PE, Freiberg RH. Severe growth disturbance with osteoid osteoma: a report of two cases involving the femoral neck. Radiology 1970;96:285 - 8. [5] Goudarzi YM, Khodadadyan C, Leuenberger D. Bilateral L7sion des Nervus Peronaeus mit L7sion der linksseitigen Nervi Medianus und
[26] [27] [28]
[29]
[30]
251
Ulnaris bei Multiplen Osteocartilagin7ren Exostosen. Chirurgia 1995;66:1158 - 61 [German]. Haskel L, Pogrund H, Rosenmann E. Osteoid osteoma presenting as an osteocartilaginous exostosis. Isr J Med Sci 1981;17:380 - 2. Hazmy W. Peroneal nerve palsy secondary to proximal fibular osteochondroma—case report. Med J Malaysia 2001;56:89 - 90. Hudson TM, Chew FS, Manaster BJ. Scintigraphy of benign exostosis and exostotic chondrosarcomas. AJR Am J Roentgenol 1983;140:581 - 6. Kim DH, Kline DG. Management and results of peroneal nerve lesions. Neurosurgery 1996;39:312 - 9. Kline D, Hudson A. Nerve tumors. In: Kline D, Hudson A, editors. Nerve injuries: operative results of major nerves injuries, entrapments and tumors. Philadelphia7 WB Saunders; 1995. p. 345 - 60. Lange RH, Lange TA, Rao BK. Correlative radiographic, scintigraphic and histological evaluation of exostoses. J Bone Joint Surg Am 1984;66:1454 - 9. Levin KH, Wilbourn AJ, Jones Jr HR. Childhood peroneal neuropathy from bone tumors. Pediatr Neurol 1991;7:308 - 9. Mackinnom S, Dellon AL. Other lower extremity entrapments. In: Mackninnom S, Dellon A, editors. Surgery of peripheral nerves. Stuttgart7 Thieme Med.; 1988. p. 378 - 410. Marinelli A, Giacomini S, Bianchi G, Pellacani A, Bertoni F, Mercuri M. Osteoid osteoma simulating an osteocartilaginous exostosis. Skeletal Radiol 2004;33:181 - 5. McCornack EB. Bilateral genu recurvatum after skeletal traction. J Bone Joint Surg Am 1980;62:1388. Mumenthaler M, Schliack H. Peripheral nerves lesions—diagnosis and therapy. Stuttgart7 Thieme Med.; 1991. Nunez DA, Grahan HK, Fixsen JA. Cervical cord compression and femoral neuropathy in hereditary multiple exostoses. J Neurol Neurosurg Psychiatry 1990;53:439. Paik NJ, Han TR, Lim SJ. Multiple peripheral nerve compressions related to malignantly transformed hereditary multiple exostoses. Muscle Nerve 2000;23:1290 - 4. Peterson HA. Multiple hereditary osteochondromata. Clin Orthop 1989;239:222 - 30. Piton C, Fabre T, Lasseur E, Andre D, Geneste M, Durandeau A. Common fibular nerve lesions. Etiology and treatment. Apropos of 146 cases with surgical treatment. Rev Chir Orthop Reparatrice Appar Mot 1997;83:515 - 21. Rinaldi E. Peroneal paralysis due exostosis of the fibula. Report of two cases. Ital J Orthop Traumatol 1983;9:259 - 62. Salter RB. Textbook of disorders and injuries of the musculoskeletal system. 2nd ed. Baltimore7 William & Wilkins; 1983. Shapiro F, Simom S, Glimcher MJ. Hereditary multiple exostoses. Anthropometric, roentgenographic and clinical aspects. J Bone Joint Surg Am 1979;61:815 - 24. Sherman MS, Caldwell GA. Osteoid osteoma. Clin Orthop 1953;2: 203 - 10. Slepian A, Hamby WB. Neurological complication associated with hereditary deforming chondrodysplasia: review of literature and report on two cases occurring in the same family. J Neurosurg 1951;8: 529 - 35. Solomon L. Hereditary multiple exostoses. Am J Hum Genet 1964;16:351 - 63. Suterland S, Braley KC. The cross sectional area of peripheral nerves trunks devoted to nerve fibers. Brain 1949;72:428 - 49. Tatagiba M, Leitao F, Samii M. Peripheral nerve tumors. In: Tatagiba M, Mazzer N, editors. Peripheral nerves. Rio de Janeiro7 Ed. Revinter; 2003. p. 254 - 78. Theodorou SD, Karamitsos S, Tsouparopoulos D, Hatzipavlou AG. Rare complications of exostosis. Fractures and injury to the common peroneal nerve. Acta Orthop Belg 1978;44:496 - 505. Tsuchiya H, Morikawa S, Tomita K. Osteochondroma arising from multiple cartilaginous exostoses: a case report. Jpn J Clin Oncol 1990;20:296 - 8.
252
L.P. Flores et al. / Surgical Neurology 64 (2005) 249–252
[31] Urushidani H. The funicular pattern of sciatic nerve in Japanese adults. Nippon Geka Hokan 1974;43:254 - 75 [Japanese]. [32] Vanhoenacker FM, Hul WV, Wuyts W, Willems PJ, De Schepeprr AM. Hereditary multiple exostoses: from genetics to clinical syndrome and complications. Eur J Radiol 2001;40:208 - 17. [33] Watson LW, Torch MA. Peroneal nerve palsy secondary to compression from an osteochondroma. Orthopedics 1993;16:707 - 10. [34] Wicklund CL, Pauli RM, Johnston D, Hecht JT. Natural history study of hereditary multiple exostoses. Am J Med Genet 1995;55:43 - 6.
problem in this location. The authors present a case of a 15-year-old adolescent boy who developed a peroneal nerve entrapment caused by an apparent osteophyte. The relevant literature is also discussed. There are relatively few neurosurgeons who perform peripheral nerve surgery, and the lower extremity nerves appear to me to be particularly poorly represented in the average neurosurgical practice. Publications such at the article by Flores et al help raise the awareness of our colleagues to these conditions.
Commentary Peroneal nerve entrapment at the fibular head is probably the most common entrapment injury in the lower extremities. In a minority of these cases, a clear lesion can be identified. One of those is an osteophyte, an uncommon
Ben Roitberg, MD Department of Neurosurgery University of Illinois at Chicago Chicago, Illinois 60612, USA
The U.S. Pharmacopeia (USP) reported that the technologic panacea for safety is involved in 20% of reported hospital medication errors. Computer entry errors, which are steadily increasing, are the fourth leading cause of such errors. — AAPS News, February 2005 www.aaps.online.org