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J Reconstr Microsurg 2024; 40(07): 566-570
DOI: 10.1055/a-2253-6360
Invited Review

Differential Diagnosis of “Foot Drop”: Implications for Peripheral Nerve Surgery

Mitchel Seruya
1   Division of Plastic and Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Abstract

Background At least 128,000 patients in the United States each year suffer from foot drop. This is a debilitating condition, marked by the inability to dorsiflex and/or evert the affected ankle. Such patients are rendered to a lifetime of relying on an ankle-foot orthosis (AFO) for walking and nighttime to prevent an equinovarus contracture.

Methods This narrative review explores the differential diagnosis of foot drop, with a particular focus on clinical presentation and recovery, whether spontaneously or through surgery.

Results Contrary to popular belief, foot drop can be caused by more than just insult to the common peroneal nerve at the fibular head (fibular tunnel). It is a common endpoint for a diverse spectrum of nerve injuries, which may explain its relatively high prevalence. From proximal to distal, these conditions include lumbar spine nerve root damage, sciatic nerve palsy at the sciatic notch, and common peroneal nerve injury at the fibular head. Each nerve condition is marked by a unique clinical presentation, frequency, likelihood for spontaneous recovery, and cadre of peripheral nerve techniques.

Conclusion The ideal surgical technique for treating foot drop, other than neurolysis for compression, remains elusive as traditional peripheral nerve procedures have been marred by a wide spectrum of functional results. Based on a careful understanding of why past techniques have achieved limited success, we can formulate a working set of principles to help guide surgical innovation moving forward, such as fascicular nerve transfer.

Keywords

foot drop - L5 nerve injury - sciatic nerve palsy - common peroneal nerve palsy - nerve transfer


Publication History

Received: 20 October 2023

Accepted: 08 January 2024

Accepted Manuscript online:
24 January 2024

Article published online:
29 February 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Total Physician Commercial Claims with a Primary Diagnosis of Drop Foot. Definitive Healthcare, LLC; 2023
    PubMed
  • 2 Choo YJ, Chang MC. Commonly used types and recent development of ankle-foot orthosis: a narrative review. Healthcare (Basel) 2021; 9 (08) 1046
    CrossrefPubMedGoogle Scholar
  • 3 Rogati G, Caravaggi P, Leardini A. Design principles, manufacturing and evaluation techniques of custom dynamic ankle-foot orthoses: a review study. J Foot Ankle Res 2022; 15 (01) 38
    CrossrefPubMedGoogle Scholar
  • 4 Van Langenhove M, Pollefliet A, Vanderstraeten G. A retrospective electrodiagnostic evaluation of footdrop in 303 patients. Electromyogr Clin Neurophysiol 1989; 29 (03) 145-152
    PubMedGoogle Scholar
  • 5 Pateder DB, Kostuik JP. Lumbar nerve root palsy after adult spinal deformity surgery. Spine 2005; 30 (14) 1632-1636
    CrossrefPubMedGoogle Scholar
  • 6 Ghobrial GM, Williams Jr KA, Arnold P, Fehlings M, Harrop JS. Iatrogenic neurologic deficit after lumbar spine surgery: a review. Clin Neurol Neurosurg 2015; 139: 76-80
    CrossrefPubMedGoogle Scholar
  • 7 Shriver MF, Xie JJ, Tye EY. et al. Lumbar microdiscectomy complication rates: a systematic review and meta-analysis. Neurosurg Focus 2015; 39 (04) E6
    CrossrefPubMedGoogle Scholar
  • 8 Kim HJ, Iyer S, Zebala LP. et al; International Spine Study Group (ISSG). Perioperative neurologic complications in adult spinal deformity surgery: incidence and risk factors in 564 patients. Spine 2017; 42 (06) 420-427
    CrossrefPubMedGoogle Scholar
  • 9 Kato S, Fehlings MG, Lewis SJ. et al. An analysis of the incidence and outcomes of major versus minor neurological decline after complex adult spinal deformity surgery: a subanalysis of Scoli-RISK-1 Study. Spine 2018; 43 (13) 905-912
    CrossrefPubMedGoogle Scholar
  • 10 Barrett KK, Fukunaga D, Rolfe KW. Perioperative major neurologic deficits as a complication of spine surgery. Spinal Cord Ser Cases 2021; 7 (01) 81
    CrossrefPubMedGoogle Scholar
  • 11 Dowlati E, Alexander H, Voyadzis JM. Vulnerability of the L5 nerve root during anterior lumbar interbody fusion at L5-S1: case series and review of the literature. Neurosurg Focus 2020; 49 (03) E7
    CrossrefPubMedGoogle Scholar
  • 12 Berger A, Mangel L, Basal S. et al. Predictors of functional recovery following surgery for foot drop due to degenerative lumbar disease. J Neurosurg Spine 2021; 36 (03) 408-413
    CrossrefPubMedGoogle Scholar
  • 13 Macki M, Lim S, Elmenini J, Fakih M, Chang V. Clinching the cause: a review of foot drop secondary to lumbar degenerative diseases. J Neurol Sci 2018; 395: 126-130
    CrossrefPubMedGoogle Scholar
  • 14 Macki M, Syeda S, Kerezoudis P, Gokaslan ZL, Bydon A, Bydon M. Preoperative motor strength and time to surgery are the most important predictors of improvement in foot drop due to degenerative lumbar disease. J Neurol Sci 2016; 361: 133-136
    CrossrefPubMedGoogle Scholar
  • 15 Spangfort EV. The lumbar disc herniation. A computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl 1972; 142: 1-95
    CrossrefPubMedGoogle Scholar
  • 16 Liu K, Zhu W, Shi J. et al. Foot drop caused by lumbar degenerative disease: clinical features, prognostic factors of surgical outcome and clinical stage. PLoS One 2013; 8 (11) e80375
    CrossrefPubMedGoogle Scholar
  • 17 Liguori R, Krarup C, Trojaborg W. Determination of the segmental sensory and motor innervation of the lumbosacral spinal nerves. An electrophysiological study. Brain 1992; 115 (Pt 3): 915-934
    CrossrefPubMedGoogle Scholar
  • 18 Matsui H, Kitagawa H, Kawaguchi Y, Tsuji H. Physiologic changes of nerve root during posterior lumbar discectomy. Spine 1995; 20 (06) 654-659
    CrossrefPubMedGoogle Scholar
  • 19 Ohyama S, Takahashi S, Tamai K. et al. Prevention of nerve root thermal injury caused by bipolar cauterization near the nerve roots. Spine 2019; 44 (06) E321-E328
    CrossrefPubMedGoogle Scholar
  • 20 Pekkarinen J, Alho A, Puusa A, Paavilainen T. Recovery of sciatic nerve injuries in association with total hip arthroplasty in 27 patients. J Arthroplasty 1999; 14 (03) 305-311
    CrossrefPubMedGoogle Scholar
  • 21 McQuarrie HG, Harris JW, Ellsworth HS, Stone RA, Anderson III AE. Sciatic neuropathy complicating vaginal hysterectomy. Am J Obstet Gynecol 1972; 113 (02) 223-232
    CrossrefPubMedGoogle Scholar
  • 22 Batres F, Barclay DL. Sciatic nerve injury during gynecologic procedures using the lithotomy position. Obstet Gynecol 1983; 62 (3 Suppl) 92s-94s
    PubMedGoogle Scholar
  • 23 Romfh JH, Currier RD. Sciatic neuropathy induced by the lithotomy position. Arch Neurol 1983; 40 (02) 127
    CrossrefPubMedGoogle Scholar
  • 24 Kubiak R, Wilcox DT, Spitz L, Kiely EM. Neurovascular morbidity from the lithotomy position. J Pediatr Surg 1998; 33 (12) 1808-1810
    CrossrefPubMedGoogle Scholar
  • 25 Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM. Lower extremity neuropathies associated with lithotomy positions. Anesthesiology 2000; 93 (04) 938-942
    CrossrefPubMedGoogle Scholar
  • 26 Babadjouni R, Azadgoli B, Werner JM, Vrahas MS, Seruya M. Poor ankle eversion and dorsiflexion at 6 months predicts incomplete sciatic nerve recovery in closed, high sciatic nerve injuries. 2023
    PubMedGoogle Scholar
  • 27 Chughtai M, Khlopas A, Gwam CU. et al. Nerve decompression surgery after total hip arthroplasty: what are the outcomes?. J Arthroplasty 2017; 32 (04) 1335-1339
    CrossrefPubMedGoogle Scholar
  • 28 Regev GJ, Drexler M, Sever R. et al. Neurolysis for the treatment of sciatic nerve palsy associated with total hip arthroplasty. Bone Joint J 2015; 97-B (10) 1345-1349
    CrossrefPubMedGoogle Scholar
  • 29 Wilson TJ, Kleiber GM, Nunley RM, Mackinnon SE, Spinner RJ. Distal peroneal nerve decompression after sciatic nerve injury secondary to total hip arthroplasty. J Neurosurg 2018; 130 (01) 179-183
    CrossrefPubMedGoogle Scholar
  • 30 Woodmass JM, Romatowski NP, Esposito JG, Mohtadi NG, Longino PD. A systematic review of peroneal nerve palsy and recovery following traumatic knee dislocation. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2992-3002
    CrossrefPubMedGoogle Scholar
  • 31 Kahan JB, Li D, Schneble CA. et al. The pathoanatomy of posterolateral corner ligamentous disruption in multiligament knee injuries is predictive of peroneal nerve injury. Am J Sports Med 2020; 48 (14) 3541-3548
    CrossrefPubMedGoogle Scholar
  • 32 Dellon AL, Ebmer J, Swier P. Anatomic variations related to decompression of the common peroneal nerve at the fibular head. Ann Plast Surg 2002; 48 (01) 30-34
    CrossrefPubMedGoogle Scholar
  • 33 Lenartowicz KA, Amrami KK, Spinner RJ. Peroneal intraneural ganglion cyst with a nearly invisible joint connection (even to advocates of the articular theory): illustrative case. J Neurosurg Case Lessons 2023; 5 (07) CASE22572
    CrossrefPubMedGoogle Scholar
  • 34 Campbell WW. Diagnosis and management of common compression and entrapment neuropathies. Neurol Clin 1997; 15 (03) 549-567
    CrossrefPubMedGoogle Scholar
  • 35 Ogata K, Naito M. Blood flow of peripheral nerve effects of dissection, stretching and compression. J Hand Surg [Br] 1986; 11 (01) 10-14
    PubMedGoogle Scholar
  • 36 Bsteh G, Wanschitz JV, Gruber H, Seppi K, Löscher WN. Prognosis and prognostic factors in non-traumatic acute-onset compressive mononeuropathies–radial and peroneal mononeuropathies. Eur J Neurol 2013; 20 (06) 981-985
    CrossrefPubMedGoogle Scholar
  • 37 Mackay MJ, Ayres JM, Harmon IP, Tarakemeh A, Brubacher J, Vopat BG. Traumatic peroneal nerve injuries: a systematic review. JBJS Rev 2022;10(01):
    PubMedGoogle Scholar
  • 38 Head LK, Hicks K, Wolff G, Boyd KU. Clinical outcomes of nerve transfers in peroneal nerve palsy: a systematic review and meta-analysis. J Reconstr Microsurg 2019; 35 (01) 57-65
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Gutmann E, Young JZ. The re-innervation of muscle after various periods of atrophy. J Anat 1944; 78 (Pt 1-2): 15-43
    PubMedGoogle Scholar
  • 40 Hoffmann P, Buck-Gramcko D, Lubahn JD. The Hoffmann-Tinel sign. 1915. J Hand Surg [Br] 1993; 18 (06) 800-805
    CrossrefPubMedGoogle Scholar
  • 41 Woodhall B. Peripheral nerve injuries; basic data from the peripheral nerve registry concerning 7,050 nerve sutures and 67 nerve grafts. J Neurosurg 1947; 4 (02) 146-163
    CrossrefPubMedGoogle Scholar
  • 42 White J. The results of traction injuries to the common peroneal nerve. J Bone Joint Surg Br 1968; 50 (02) 346-350
    CrossrefPubMedGoogle Scholar
  • 43 Prasad AR, Steck JK, Dellon AL. Zone of traction injury of the common peroneal nerve. Ann Plast Surg 2007; 59 (03) 302-306
    CrossrefPubMedGoogle Scholar