1. Complete formal peripheral nerve surgery training
2. Use of 3-4x surgical loupes (preferably with headlight)
3. Avoidance of monopolar cautery
4. Immediate mobilization after surgery
5. Use of blunt dissection only once through the skin
6. Use of extreme care when entering and dissecting in the lateral compartment
7. Precise incision placement
8. Patient positioning with a flexed knee position
9. Understand that there is a “learning curve” and that working with an experienced surgical mentor during the initial cases can accelerate competence
Pertinent Insights On Surgical Decompression For Common Peroneal Nerve Entrapment
Entrapment of the common peroneal (fibular) nerve can cause a myriad of symptoms, ranging from low back pain to drop foot. This author provides a guide to diagnosing the nerve entrapment, offers pearls on performing neurolysis/decompression and discusses the potential impact it can have for patients.
Common peroneal (fibular) nerve entrapment is a more common pain generator than we recognize clinically.1,2 This nerve entrapment is easy to diagnose most of the time and surgical neurolysis is highly efficacious.3-5 However, we either frequently miss this diagnosis or we may make the diagnosis and do nothing for the condition. There is a significant prevalence of subclinical entrapment of the common peroneal (fibular) nerve in runners, and with scrutiny and suspicion, the astute practitioner can pick these up very early.6
Entrapment of the common peroneal (fibular) nerve can cause a wide range of symptoms from one patient to another with the same etiology. Most apparent and almost universally recognized is when there is such a degree of nerve damage that a drop foot has occurred. Sadly, when the condition has reached this point, there may be limited success with peripheral nerve decompression.
Mild symptoms can range from continued pain after a knee replacement surgery (very common and almost never recognized by the orthopedic surgeon who has done the surgery) to low back pain or sometimes just a feeling of weakness in the foot. Patients may complain of the usual nerve symptoms such as burning or numbness, but may often complain of a feeling of tightness in their leg or “ankle pain.” Common peroneal (fibular) nerve entrapment is frequently associated with low back involvement in a double crush phenomenon.
A Guide To The Anatomy Of The Common Peroneal (Fibular) Nerve
Anatomists now refer to the common peroneal nerve as the common fibular nerve with divisions into the deep and superficial fibular nerves. The sciatic nerve originates from the L4, L5, S1, S2 and S3 nerve roots in the sacral plexus of the lower back. The sciatic nerve divides variably, ranging from proximal division patterns in the upper thigh to distal divisions down into the level of the popliteal fossa, into its two terminal branches: the tibial nerve and the common peroneal (fibular) nerve.8
As the common peroneal (fibular) nerve courses around the lateral aspect of the leg, it lies against the fibular neck with the fascia of the peroneus (fibular) longus muscle superficial, which forms a very tight tunnel. At this level, there are numerous motor branches that innervate the peroneus (fibular) longus nerve, which divides into its superficial and deep branches. This bifurcation can be variable at the level where it actually divides and the nerve has very little capability of excursion at this level in contradistinction to its laxity in the popliteal fossa. Often, there is a very dense band of the deep fascia of the peroneus (fibular) longus muscle at the most posterior portion of the muscle, which binds the nerve down onto the surface of the fibular neck.