Peripheral Nerve Surgery Lecture Notes PDF

PERIPHERAL NERVE SURGERY -EVALUATION AND MANAGEMENT OF ENTRAPMENT NEUROPATHIES -ADVANCED NERVE RELEASE ERIN NELSON, DPM, FACFAS, FAES, CWSP FOOT AND ANKLE SPECIALISTS OF AMES OBJECTIVES IDENTIFY THE MICROSCOPIC ANATOMY OF THE PERIPHERAL NERVE BE FAMILIAR WITH THE DERMATOMES OF THE LOWER EXTREMITY BE...

PERIPHERAL NERVE SURGERY -EVALUATION AND MANAGEMENT OF ENTRAPMENT NEUROPATHIES -ADVANCED NERVE RELEASE ERIN NELSON, DPM, FACFAS, FAES, CWSP FOOT AND ANKLE SPECIALISTS OF AMES OBJECTIVES IDENTIFY THE MICROSCOPIC ANATOMY OF THE PERIPHERAL NERVE BE FAMILIAR WITH THE DERMATOMES OF THE LOWER EXTREMITY BE FAMILIAR WITH THE COMMON CLASSIFICATION SYSTEMS OF PERIPHERAL NERVE INJURIES BE ABLE TO IDENTIFY EVALUATION AND TREATMENT PRINCIPLES FOR PERIPHERAL NERVE PAIN RECOGNIZE THE COMPONENTS OF THE PERIPHERAL NERVE EXAM AND EVALUATION DEMONSTRATE KNOWLEDGE OF INDICATIONS OF PERIPHERAL NERVE DECOMPRESSION SURGERY RULE #1 THE PERIPHERAL NERVOUS SYSTEM (PNS) IS CONNECTED TO THE CENTRAL NERVOUS SYSTEM (CNS) THE CNS AFFECTS THE PNS: ANXIETY, DEPRESSION, MEMORY LOSS, MOOD DISORDERS THE PNS AFFECTS THE CNS: ENTRAPMENT, TUMOR, METABOLIC NEUROPATHY RULE #2 ALWAYS LOOK UP HIGHER ETIOLOGY CAN BE MORE PROXIMAL (SCIATIC NERVE, SPINAL ROOT, SPINAL CORD OR BRAIN) ALWAYS TREAT THE MORE PROXIMAL PATHOLOGY FIRST FREQUENTLY COMBINED CENTRAL WITH PERIPHERAL RULE #3 ALWAYS TREAT STRUCTURAL AND METABOLIC PROBLEMS FIRST DISTAL NEUROPATHIC SYMPTOMS USUALLY DIMINISH OR RESOLVE AFTER TREATING UNDERLYING ETIOLOGY ESPECIALLY IN PRE-DIABETES, AUTOIMMUNE DISEASE AND VITAMIN D DEFICIENCY PERIPHERAL NERVE ANATOMY PERIPHERAL NERVE ANATOMY LOWER EXTREMITY DERMATOMES DERMATOMES NERVE ANATOMY DERMATOMES VS NERVE ANATOMY NERVE ENTRAPMENT IMPINGEMENT OF A PERIPHERAL NERVE TRUNK BY NEIGHBORING ANATOMIC STRUCTURES. MOST OFTEN OCCURS WHERE NERVE TRAVERSES A FIBRO-OSSEOUS TUNNEL FASCIA LAYERS EXOSTOSIS “A REGION OF LOCALIZED INJURY AND INFLAMMATION IN A PERIPHERAL NERVE CAUSED BY MECHANICAL IRRITATION FROM SOME IMPINGING NEIGHBORING ANATOMICAL STRUCTURE.” NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: PUBLISHED IN 1942 IN BRITISH MEDICAL JOURNAL H.J. SEDDON – PROFESSOR OF ORTHOPAEDIC SURGERY AT UNIVERSITY OF OXFORD DESCRIBED 3 TYPES OF NERVE INJURY BASED ON STUDY OF 460 CASES NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: NEUROPRAXIA (TRANSIENT BLOCK): DISRUPTION OF THE MYELIN SHEATH SUSCEPTIBLE NERVES: THICKLY MYELINATED LARGE DIAMETER RAPIDLY CONDUCTING TYPICAL CAUSES: PRESSURE COMPRESSION ENTRAPMENT CONTUSION NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: NEUROPRAXIA (TRANSIENT BLOCK): SHORT LIVED PARALYSIS MAY DEVELOP REPAIR CAN OCCUR IN DAYS TO MONTHS PATIENTS USUALLY FULLY RECOVER AS INJURY INVOLVES ONLY THE MYELIN SHEATH TREATMENT OPTIONS DECOMPRESSION, FASCIOTOMY, EXTERNAL NEUROLYSIS AND/OR INTERNAL NEUROLYSIS TO ALLOW THE NERVE TO GLIDE AND FUNCTION WITHOUT INHIBITION NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: AXONOTMESIS (LESION IN CONTINUITY): DAMAGE TO MYELIN AND AXON WALLERIAN DEGENERATION OF THE DISTAL NERVE SEGMENT EPINEURIUM AND PERINEURIUM SURROUNDING THE NERVE IS PRESERVED TYPICAL CAUSES: PROLONGED COMPRESSION TRACTION ISCHEMIA TOXINS NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: AXONOTMESIS (LESION IN CONTINUITY): DISTALLY: WALLERIAN DEGENERATION DISTAL AXON DEGRADATION PROXIMALLY: AXON AND NERVE CELL BODY CONVERT FROM NEUROTRANSMITTER PRODUCTION TO AXONAL REGENERATION NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: AXONOTMESIS (LESION IN CONTINUITY): AFFECTS MYELINATED AND UNMYELINATED FIBERS IN GENERAL; DUE TO MAINTENANCE OF SUPPORTIVE STRUCTURES NEW AXONS ARE ABLE TO REGENERATE AND GROW DOWN CORRESPONDING ENDONEURAL TUBE NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: AXONOTMESIS (LESION IN CONTINUITY): FUNCTIONAL RECOVERY IS DEPENDENT ON PROXIMITY OF LESION: PROXIMAL LESIONS HAVE WIDER DISTRIBUTION AS DISTANCE FROM SITE OF LESION TO END ORGAN INCREASES, FUNCTIONAL RECOVERY DIMINISHES. TREATMENT OPTIONS RESECT DISEASED PORTION TO BLEEDING EDGES CONDUIT-ASSISTED NERVE COAPTATION SHOULD BE PERFORMED NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: NEUROTMESIS (NERVE DIVISION): MOST DEVASTATING NERVE INJURY IMPLIES COMPLETE DISRUPTION OF A NERVE AS WELL AS ASSOCIATED CONNECTIVE TISSUE LACERATIONS GUNSHOTS FRACTURES SURGICAL TRAUMA BUDDING NEURITES UNABLE TO BRIDGE DEFECT NEURITES THAT DO BRIDGE OFTEN DO SO IN MALALIGNMENT RESULTING IN POOR REINNERVATION NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SEDDON’S CLASSIFICATION: NEUROTMESIS (NERVE DIVISION): REQUIRES SURGICAL INTERVENTION POSSIBLE OPTIONS NEURECTOMY EXCISION AND IMPLANTATION GRAFT NERVE CAP END TO SIDE NEURORRHAPHY NERVE FIBER REGENERATION OCCURS AT APPROXIMATELY 1MM/DAY NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SUNDERLAND’S CLASSIFICATION: 1951 EXPANSION OF SEDDON’S CLASSIFICATION 5 DEGREES (3 CLASSES OF INJURY) NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SUNDERLAND’S CLASSIFICATION: FIRST DEGREE (CLASS I): CONDUCTION DEFICIT WITHOUT AXONAL INTERRUPTION EQUIVALENT TO SEDDON’S NEUROPRAXIA NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SUNDERLAND’S CLASSIFICATION: SECOND DEGREE (CLASS II): AXON SEVERED WITHOUT BREACHING THE ENDONEURIUM BREAKDOWN OF MYELIN AND WALLERIAN DEGENERATION EMG CHANGES OF DENERVATION OCCUR REGENERATION FOLLOWS THE PATTERN OF AXONAL REGROWTH EQUIVALENT TO SEDDON’S AXONOTMESIS NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SUNDERLAND’S CLASSIFICATION: THIRD DEGREE (CLASS II): NERVE FIBER DISRUPTION LESION IN THE ENDONEURIUM EPINEURIEUM AND PERINEURIEUM REMAIN INTACT RECOVERY IS POSSIBLE BUT MAY REQUIRE SURGERY REGENERATION IS OFTEN IRREGULAR AND RESIDUAL DEFICITS ARE COMMON NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SUNDERLAND’S CLASSIFICATION: FOURTH DEGREE (CLASS II): ONLY EPINEURIUM REMAINS INTACT INJURY REQUIRES SURGICAL REPAIR NERVE ENTRAPMENT/INJURY CLASSIFICATIONS SUNDERLAND’S CLASSIFICATION: FIFTH DEGREE (CLASS III): COMPLETE TRANSECTION OF THE NERVE REQUIRES SURGICAL REPAIR TYPES OF NERVE INJURY I. NEUROPRAXIA (1ST DEGREE INJURY) COMPLETE RECOVERY, NO TINEL’S SIGN II. AXONOTMESIS (2ND DEGREE INJURY) COMPLETE RECOVERY, DISTALLY MOVING TINEL’S SIGN III. AXONOTMESIS (3RD DEGREE INJURY) INCOMPLETE RECOVERY MAY OCCUR ADVANCING TINEL’S INDICATES THE LEVEL OF REGENERATION IV. AXONOTMESIS (4TH DEGREE INJURY) NEVER SHOW SENSORY OR MOTOR RECOVERY V. NEUROTMESIS (5TH DEGREE INJURY) TOTAL NERVE TRANSECTION VI. 6TH DEGREE INJURY (NEUROMA IN CONTINUITY) MIXED PATTERN OF INJURY TYPES 1-5 SYMPTOMS MUSCLE WEAKNESS JOINT DYSFUNCTION NEUROPATHIC PAIN BURNING TINGLING NUMBNESS ACHING RESTLESS LEGS HISTORY AND CLINICAL EXAM THOROUGH HISTORY OF PRESENT ILLNESS- LISTEN TO YOUR PATIENT! REVIEW OF TRAUMA HISTORY, PMH, PSH, FAMILY HISTORY, SOCIAL HISTORY AND MEDICATIONS MOTOR REFLEXES SENSORY MOTOR ASSESS MUSCLE TONE STRAIGHT LEG TEST MUSCLE GRADING 0-5 GAIT EXAM/ASSESS BIOMECHANICS HIP FLEXORS ADDUCTORS ABDUCTORS QUADRICEPS HAMSTRINGS ANTERIOR LEG PERONEAL POSTERIOR LEG REFLEXES CLONUS RAPID DORSIFLEXION OF ANKLE POSITIVE TEST IS SUBSEQUENT PULSING OF THE FOOT OCCURS GREATER THAN 5 BABINSKI STROKE THE LATERAL ASPECT OF THE FOOT CURVING MEDIAL ACROSS THE BALL OF THE FOOT NORMAL TEST IS THE TOES ARE DOWNGOING NORMAL UP TO 1 YEAR OF AGE; POSITIVE IN ADULT CAN INDICATE UMN LESION DEEP TENDON REFLEXES PATELLAR- L4 ACHILLES- S1 SENSORY TINELS SIGN OVERLYING INVOLVED LOWER EXTREMITY NERVES PROVOCATION SIGN SEMMES WEINSTEIN MONOFILAMENT (5.07) TWO-POINT DISCRIMINATION OR PRESSURE SPECIFIED SENSORY DEVICE 8MM OR LESS PLANTAR HALLUX, DORSAL FOOT COMPARE UPPER AND LOWER EXTREMITIES (4MM OR LESS INDEX FINGER) WARTENBERG WHEEL-SHARP/DULL DISCRIMINATION, COMPARE BILATERAL MULDERS CLICK TUNING FORK HOT/COLD DIAGNOSTICS ELECTROMYOGRAPHY (EMG) AND NERVE CONDUCTION STUDIES (TESTS LARGE NERVE FIBERS) IMAGING-MAY INCLUDE XRAY, ULTRASOUND, MRI DIAGNOSTIC BLOCKS- PATIENTS MAP OUT PAIN RELIEF LOW VOLUME** MAKE SURE YOU ARE NOT INJECTING INTO THE NERVE (NOT TRYING TO ELICIT PARESTHESIA) MAY NEED BACK EVALUATED TO MAKE SURE THIS IS NOT THE SOURCE OF THE PAIN MAY INCLUDE X-RAYS, LUMBAR MRI PAIN SPECIALIST/INJECTIONS AT THE SPINAL LEVEL CENTRAL & PERIPHERAL PAIN COMBINED LAB WORKUP CBC WITH DIFF COMPLETE METABOLIC PROFILE (CMP) SERUM VITAMIN B12/FOLATE THYROXINE THYROID STIMULATING HORMONE (TSH) RHEUMATOID FACTOR (RF) ERYTHROCYTE SEDIMENTATION RATE (ESR) ANTINUCLEAR ANTIBODY SERUM PROTEIN ELECTROPHORESIS VITAMIN D LEVELS A1C NERVE BIOPSY EPIDERMAL NERVE FIBER DENSITY (ENFD) BENEFICIAL FOR SMALL-FIBER NEUROPATHY 3MM PUNCH BIOPSY ON SITES OF INTEREST RESULTED AS NUMBER OF SMALL NERVE FIBERS TRAVERSING THE DERMOEPIDERMAL JUNCTION IF NORMAL IN PATIENTS WITH PERIPHERAL NEUROPATHY SYMPTOMS, HIGH CORRELATION WITH ENTRAPMENT INTRAEPIDERMAL NERVE FIBER DENSITY THE PRESENCE OF DIFFUSE SWELLINGS ON IENF HAS BEEN SHOWN TO PREDICT THE PROGRESSION TO OVERT NEUROPATHY IN PATIENTS WITH HIV, DIABETES OR OTHER CAUSES OF SMALL FIBER NEUROPATHY TO CORRELATE WITH PARESTHESIA. EPIDERMAL NERVE FIBER DENSITY BIOPSY GOLD STANDARD TO DIAGNOSE SMALL FIBER NEUROPATHY (SFN) BIOPSY SITE LOWER LEG/CALF 2ND SITE DISTAL, PLANTAR FOREFOOT ON NWB SURFACE 50% OF SFN ARE MISDIAGNOSED OR UNDIAGNOSED EXAMPLES OF SFN: DIABETES, VITAMIN DEFICIENCY, AUTOIMMUNE DISEASE, ETC POSITIVE BIOPSY FURTHER WORKUP PRACTICAL PAIN MANAGEMENT TEXTBOOK CONSERVATIVE TREATMENT OPTIONS ADDRESSING BIOMECHANICS MEDICATIONS ORAL INJECTIONS PHYSICAL THERAPY* MULTIDISCIPLINARY APPROACH TREATING OR REFERRING TO TREAT METABOLIC CONDITIONS DIABETES MELLITUS AND NERVE ENTRAPMENT TWO METABOLIC CHANGES IN THE PERIPHERAL NERVES OF DIABETIC PATIENTS THAT CAUSE THE NERVE TO BE SUSCEPTIBLE TO CHRONIC COMPRESSION INCREASE WATER CONTENT WITHIN THE NERVE AS THE RESULT OF GLUCOSE BEING METABOLIZED INTO SORBITOL INCREASED WATER CONTENT=INCREASED NERVE VOLUME DECREASE IN THE SLOW ANTEROGRADE COMPONENT OF AXOPLASMIC FLOW AXOPLASMIC FLOW TRANSPORTS THE LIPOPROTEINS NECESSARY TO MAINTAIN AND REBUILD THE NERVE INCREASED EXTERNAL PRESSURE CREATES INCREASED INTRANEURAL PRESSURE CAUSING DECREASED BLOOD FLOW DECOMPRESSION IN THE DIABETIC PATIENT DIAGNOSIS OF SUPERIMPOSED NERVE ENTRAPMENT IN DIABETIC PATIENTS WITH DIABETIC PERIPHERAL NEUROPATHY RELIES ON ELIMINATION OF OTHER CAUSES OF NEUROPATHY NERVE DECOMPRESSION OF ENTRAPMENT HAS THE POTENTIAL TO DECREASE PAIN, IMPROVE BALANCE AND SENSATION, DECREASE RISK FOR REULCERATION AND AMPUTATION** DEPENDING ON SYMPTOMS, DECOMPRESSION MAY INCLUDE THE COMMON PERONEAL NERVE, DEEP PERONEAL NERVE (UNDER EHB), TARSAL TUNNEL AND BRANCHES (OR SOLEAL SLING) AND SUPERFICIAL PERONEAL NERVE (IDEAL) CRITERIA FOR DECOMPRESSION IN DIABETIC PATIENT WELL CONTROLLED A1C- 8 OR BELOW PAIN POSITIVE TINEL’S SIGN OVER AN ENTRAPPED NERVE RESPONSE TO PERIPHERAL NERVE BLOCK NERVE DECOMPRESSION PROXIMAL TIBIAL NERVE DECOMPRESSION (SOLEAL SLING) COMMON PERONEAL SUPERFICIAL PERONEAL DEEP PERONEAL SAPHENOUS SURAL TARSAL TUNNEL (INCLUDING MEDIAL AND LATERAL PLANTAR NERVES AND MEDIAL CALCANEAL BRANCH) COMMON DIGITAL NERVE INCISION PLACEMENT GOALS 1.ALLOW ACCESS TO THE NERVE THAT IS BEING DECOMPRESSED 2.PROVIDE THE BEST COSMETIC RESULT 3.AVOID HIGH TENSION AREAS 4.BE ABLE TO MAKE BIGGER SURGERY UNDER LOUPE MAGNIFICATION SOLEAL SLING DECOMPRESSION PRESENTATION OF ENTRAPMENT- PERSISTENT PLANTAR PAIN, PAIN OR TIGHTNESS IN THE CALF, TENDERNESS OF THE TIBIAL NERVE WHEN PALPATED BELOW THE SOLEAL SLING, RECURRENT/CONTINUED PAIN AFTER TARSAL TUNNEL RELEASE NEED TO ASSESS AT TARSAL TUNNEL AS WELL RESPOND TO PROXIMAL TIBIAL NERVE BLOCK SOLEAL SLING DECOMPRESSION COMMON PERONEAL (FIBULAR) NERVE PRESENTATION- MAY HAVE WEAKNESS OF EHL*, TA OR DROPFOOT TYPICALLY, SLOW ONSET MAY BE AFTER SEVERE ANKLE SPRAIN POSITIVE TINEL’S AND/OR PROVOCATION SIGN AT THE LEVEL OF THE FIBULAR NECK MUST ALSO ASSESS OTHER DISTAL NERVES TO SEE IF THERE IS MORE THAN ONE ENTRAPMENT IMPROVEMENT WITH DIAGNOSTIC NERVE BLOCKS-MAY NEED TO BLOCK DISTAL NERVES FIRST TO RULE OUT DISTAL ENTRAPMENT INCISION FOR COMMON PERONEAL (FIBULARIS) DECOMPRESSION SUPERFICIAL PERONEAL (FIBULAR) NERVE PRESENTATION: HIGH ASSOCIATION WITH PREVIOUS LATERAL ANKLE SPRAIN IF MOTOR WEAKNESS-NEED TO ASSESS COMMON PERONEAL NERVE POSITIVE TINEL’S SIGN AND/OR PROVOCATION SIGN 10-15 CM PROXIMAL TO THE LATERAL MALLEOLI BETWEEN THE TIBIAL CREST AND FIBULA IS VERY DIAGNOSTIC OF ENTRAPMENT INVERSION WITH TESTING PROVOCATION SIGN HAS INCREASED VALUE DIAGNOSTIC INJECTIONS- THERE IS ANATOMICAL VARIABILITY TO BRANCHES IN THE LATERAL AND/OR ANTERIOR COMPARTMENT AND INJECTIONS MAY HELP IDENTIFY ANOMALIES SUPERFICIAL PERONEAL (FIBULAR) NERVE DECOMPRESSION DEEP PERONEAL (FIBULAR) NERVE MAY BE REFERRED TO THE ANTERIOR TARSAL TUNNEL SYNDROME PRESENTATION: PAIN IN THE DORSUM OF THE FOOT FREQUENTLY CORRELATED WITH AN OSSEOUS ETIOLOGY SUCH AS EXOSTOSIS COULD BE ENTRAPPED AT THE EXTENSOR RETINACULUM BUT MORE COMMONLY AT THE 1ST AND 2ND METATARSAL BASES POSITIVE TINEL’S SIGN OVERLYING THE POINT OF ENTRAPMENT TYPICALLY, THE PATIENT DOES NOT TOLERATE A SHOE ON THE TOP OF THE FOOT SAPHENOUS NERVE NOT GENERALLY DECOMPRESSED BECAUSE THERE IS NO NATURAL ENTRAPMENT SITE THE NERVE MAY BE ENTRAPPED DUE TO TRAUMA/SURGERY SURAL NERVE NOT GENERALLY DECOMPRESSED BECAUSE THERE IS NO NATURAL ENTRAPMENT SITE THE NERVE MAY BE ENTRAPPED DUE TO TRAUMA/SURGERY SURAL NERVE DECOMPRESSION TARSAL TUNNEL (TIBIAL NERVE AND BRANCHES) THREE TERMINAL BRANCHES OF THE TIBIAL NERVE: MEDIAL CALCANEAL, MEDIAL AND LATERAL PLANTAR PROXIMAL ENTRAPMENT (COMPRESSION OF TIBIAL NERVE) AND DISTAL ENTRAPMENT (COMPRESSION OF ONE OR MORE TERMINAL BRANCHES) PRESENTATION-VARIABLE SYMPTOMS THAT CAN INCLUDE PAIN, BURNING, STABBING, THE FEELING OF SWELLING WITHIN FOOT OR ANKLE AND/OR NUMBNESS TYPICALLY THERE ARE MULTIPLE COMPLAINTS HIGH ASSOCIATION OF DUAL ENTRAPMENT (DOUBLE CRUSH) WITH A MORTON’S ENTRAPMENT HIGH ASSOCIATION OF MEDIAL ANKLE OR FOOT NERVE ENTRAPMENT WITH HEEL PAIN DIAGNOSIS: POSITIVE TINEL’S, POSITIVE PROVOCATION SIGN, DECREASED 2 POINT DISCRIMINATION ON THE PULP OF THE PLANTAR HALLUX COMBINED WITH SYMPTOM DESCRIPTORS TARSAL TUNNEL (TIBIAL NERVE AND BRANCHES) DECOMPRESSION COMMON DIGITAL NERVE DECOMPRESSION PRESENTATION: PAIN THAT RADIATES TO THE DIGITS, POSITIVE MULDERS CLICK SURGERY: OPEN DECOMPRESSION, PERCUTANEOUS DECOMPRESSION, ENDOSCOPIC DECOMPRESSION RECOMMEND DECOMPRESSION, NEURECTOMY TYPICALLY NOT NEEDED AND SHOULD TRY TO AVOID ADVANCED NERVE SURGERY NEURECTOMY NERVE REPAIR NERVE TRANSFER NERVE GRAFT PERIPHERAL NERVE STIMULATION PERIPHERAL NERVE STIMULATOR CASE 1: SUPERFICIAL PERONEAL NERVE DECOMPRESSION A 62-YEAR-OLD MALE THAT PRESENTS TO THE CLINIC WITH PAIN IN HIS RIGHT 3RD, 4TH AND 5TH DIGITS PAIN HAS BEEN PRESENT FOR 15 YEARS. BALANCE DIFFICULTIES IN THE MORNING. PAIN IS WORSE WITH SHOES ON AND WORSE AT NIGHT HE IS UNDER THE CARE OF A CHRONIC PAIN MANAGEMENT FOR HIS BACK PAIN CASE 1: SUPERFICIAL PERONEAL NERVE DECOMPRESSION PMH: ARTHRITIS, MI, CORONARY ARTERY DISEASE, HYPERCHOLESTEREMIA, HYPERTENSION, CHRONIC BACK PAIN, DEPRESSION, ESOPHAGEAL REFLUX, COPD PSH: CARDIAC STENTS 1997, 2010, RIGHT KNEE ARTHROSCOPY, RIGHT KNEE REPLACEMENT, HAND SURGERY B/L SOCIAL HISTORY: ¼ PACK PER DAY (DOWN FROM 1 PPD), NO ALCOHOL OR ELICIT DRUG USE MEDS: AMLODIPINE, ASA, DULOXETINE, GABAPENTIN, MORPHINE, NARCAN, NICOTINE PATCH, NITROSTAT, NORTRIPTYLINE, OXYCODONE, PRAVASTATIN, SERTRALINE CASE 1: SUPERFICIAL PERONEAL NERVE DECOMPRESSION OBJECTIVE: DP/PT PULSES PALPABLE, CFT