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Part I Morphological and Functional Anatomy of the Peripheral Nerve
The Normal Nerve .. . . . . . . . . . . 2
Morpho-Functional Anatomy .. . . 2
General Organization of the Peripheral Nerve ... . . 2
The Structure and Physiology of the Nerves ... . . . 4
Axon ... . . . . 4
Cytoskeleton .. . . . . . . . . . . 4
Axonal Flow .. . . . . . . . . . . 4
Schwann Cell and Myelination.... . 6
Mechanical Properties of the Nerves ... . . . . . . . . . 7
Vascularization of the Peripheral Nerves ... . . . . . . 8
Neuromuscular Junction and Transmission ... . . . . 10
Main Mechanisms of Synaptic Formation ... . . . . . 12
The Injured Nerve .. . . . . . . . . . . 14
Physiology of the Damaged Nerve .... 14
Pathophysiological Mechanisms.... 14
Nerve Degeneration .. . . . . . . . . . 16
Mechanisms of Neural Repair .. . 18
Axonal Sprouting .. . . . . . . . . . 18
Neurotrophic Factors .. . . . . . . 20
Potential Functional Consequences ... . . . . . . . . . . 20
Functional Regeneration .. . . . . 20
Neuroplasticity ..20
Conclusion ... . . . . 21
Bibliography ... . . . 22
The Plexus... . . . . . 24
Data Learned from Embryology .. 24
Embryological Development of the Peripheral Nerves .. . . . . . . . . 24
Growth of Precursor Cells.. . . . 24
Development of Segmental Spinal Nerves ... . . . . . 24
Basal Lamina and Alar Lamina ... . . . . . . . . . . 24
Peripheral Nerve Pathways.... . 24
Formation of the Myelin Sheath... . . . . . . . . . . 24
Development of the Innervation of Limbs ... . . . . . . . 26
Introduction... . . 26
Notion of Motor Innervation.. . 26
Notion of Cutaneous Innervation ...26
Innervation of the Limbs in Adults .... 28
Origin and Constitution of the Limb Nerves ... . . . 28
The Notion of Plexus .. . . . . . . . . 32
Bibliography ... . . . 34
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Part II Nerves of the Upper Limb
The Brachial Plexus .. . . . . . . . . . 40
The Brachial Plexus .. . . . . . . . . . 40
Morphological Data .. . . . . . . . . . 40
The Brachial Plexus Relations .. . 42
At the Supraclavicular Level.. . 42
At the Infraclavicular Level .. . 44
Morphological Data: Sono Anatomy ... 48
Interventional Procedure.. . . . . . . 54
Neurostimulation of the Brachial Plexus ... . . . . . . 54
Interscalenic Track .. . . . . . . . . 54
Installation ..54
Equipment and Location.. . 54
Procedure ... 56
Supraclavicular Pathway.. . . . . 58
Installation ..58
Equipment and Location.. . 58
Procedure ... 58
Bibliography ... . . . 60
The Axillary Nerve.. . . . . . . . . . . 62
Peripheral Branches .. . . . . . . . . . 62
Morphological Data .. . . . . . . . . . 66
Origin ... . . . . . . 66
Path ... . . . . . . . . 66
Neurovascular Relations .. . . . . 66
Collateral Branches.. . . . . . . . . 66
Terminal Branches .. . . . . . . . . 66
Motor Function ..74
Sensitive Function.. . . . . . . . . . 74
Anastomoses ... . 74
Pathology ... . . . . . 76
Aetiology... . . . . 76
Clinical Significance .. . . . . . . . 76
Clinical Forms... 76
Explorations ... . 76
Treatment ... . . . 76
Morphological Data: Sono Anatomy ... 78
Installation... . . . 78
Equipment and Ultrasound Tracking ... . . . . . . . . . 78
Ultrasound Procedure .. . . . . . . 78
Interventional Procedure.. . . . . . . 82
Infiltration/Block Test .. . . . . . . 82
Indication ... 82
Out-of-Plane Technique .. . . . . 82
In-Plane Technology .. . . . . . . . 82
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Peripheral Nerve Stimulation .. 82
Surgical Procedure .. . . . . . . . . . . 84
Surgical Indications.. . . . . . . . . 84
Surgical Approaches .. . . . . . . . 84
Skin Incision.. . . . . . . . . . . 84
Nervous Exposure.. . . . . . . 84
Technical Pitfalls .. . . . . . . 84
The Musculocutaneous Nerve.. . 88
Morphological Data .. . . . . . . . . . 88
Origin ... . . . . . . 88
Path ... . . . . . . . . 88
Neurovascular Relations .. . . . . 88
Collateral Branches.. . . . . . . . . 94
Terminal Branches .. . . . . . . . . 94
Motor Function ..94
Sensitive Function.. . . . . . . . . . 94
Anastomoses ... . 94
Pathology ... . . . . . 103
Aetiology... . . . . 103
Clinical Signs ... 103
Explorations ... . 103
Treatment ... . . . 103
Morphological Data: Sono Anatomy ... 106
Installation... . . . 106
Equipment and Location.. . . . . 106
Ultrasound Procedure .. . . . . . . 106
Interventional Procedure.. . . . . . . 112
Infiltration/Test Block .. . . . . . . 112
Indication ... 112
In-Plane Technology.. . . . . 112
Peripheral Nerve Stimulation (PNS)... . . . . . . . . . . 112
Surgical Procedure .. . . . . . . . . . . 114
Surgical Indications.. . . . . . . . . 114
Surgical Approaches .. . . . . . . . 114
Skin Incision.. . . . . . . . . . . 114
Nervous Exposure.. . . . . . . 114
Technical Pitfalls.. . . . . . . . . . . 114
The Radial Nerve ..118
Morphological Data .. . . . . . . . . . 118
Origin ... . . . . . . 118
Path ... . . . . . . . . 118
Neurovascular Relations .. . . . . 118
Collateral Branches.. . . . . . . . . 124
Terminal Branches .. . . . . . . . . 124
Motor Function ..124
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Sensitive Function.. . . . . . . . . . 128
Anastomoses ... . 128
Pathology ... . . . . . 134
Posterior Interosseous Nerve Syndrome... . . . . . . . 134
Aetiology... . . . . 134
Clinical Signs ... 134
Clinical Forms... 134
Explorations ... . 134
Treatment ... . . . 134
Interventional Procedure.. . . . . . . 144
PNS ... . . . . . . . . 144
Surgical Procedure .. . . . . . . . . . . 146
Surgical Indications.. . . . . . . . . 146
Surgical Approaches .. . . . . . . . 146
On the Arm ..146
At the Elbow.. . . . . . . . . . . 148
Technical Pitfalls.. . . . . . . . . . . 148
The Median Nerve .. . . . . . . . . . . 152
Morphological Data .. . . . . . . . . . 152
Origin ... . . . . . . 152
Path ... . . . . . . . . 152
Neurovascular Relations .. . . . . 152
Collateral Branches.. . . . . . . . . 162
Terminal Branches .. . . . . . . . . 162
Motor Function ..162
Sensitive Function.. . . . . . . . . . 162
Anastomoses ... . 162
Pathology ... . . . . . 172
Anterior Interosseous Nerve Syndrome ... . . . . . . . 172
Aetiology... . . . . 172
Clinical Significance .. . . . . . . . 172
Explorations ... . 172
Treatment ... . . . 172
Carpal Tunnel Syndrome .. . . . 172
Clinical Signs ... 174
Anatomical Atypias .. . . . . 174
Clinical Atypias .. . . . . . . . 174
Differential Diagnosis.. . . . . . . 174
Treatment ... . . . 174
Morphological Data: Sono Anatomy ... 176
Installation... . . . 176
Equipment and Location.. . . . . 176
Ultrasound Procedure .. . . . . . . 176
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Interventional Procedure.. . . . . . . 180
PNS ... . . . . . . . . 180
Ultrasound Pathology .. . . . . . . . . 182
Surgical Procedure .. . . . . . . . . . . 184
Surgical Approaches .. . . . . . . . 184
Skin Incision.. . . . . . . . . . . 184
On the Arm ..184
At the Elbow.. . . . . . . . . . . 184
At the Forearm .. . . . . . . . . 186
By Hand ... . 188
Technical Pitfalls.. . . . . . . . . . . 188
Surgical Pathology .. . . . . . . . . . . 190
Electronic Supplementary Material ...152
The Ulnar Nerve... 194
Morphological Data .. . . . . . . . . . 194
Origin ... . . . . . . 194
Path ... . . . . . . . . 194
Neurovascular Relations .. . . . . 204
Collateral Branches.. . . . . . . . . 204
Terminal Branches .. . . . . . . . . 204
Motor Function ..204
Sensitive Function.. . . . . . . . . . 204
Anastomoses ... . 204
Pathology ... . . . . . 214
Cubital Tunnel Syndrome .. . . . 214
Aetiology... . . . . 214
Clinical Significance .. . . . . . . . 214
Clinical Forms... 214
Explorations ... . 214
Treatment ... . . . 216
Ulnar Tunnel Syndrome (Guyon’s Canal) ... . . . . . 216
Aetiology... . . . . 216
Clinical Signs ... 216
Clinical Forms... 216
Explorations ... . 216
Treatment ... . . . 216
Morphological Data: Sono Anatomy ... 218
Installation... . . . 218
Equipment and Location.. . . . . 218
Ultrasound Procedure .. . . . . . . 218
Interventional Procedure.. . . . . . . 230
Anaesthetic Block of the Ulnar Nerve in the Elbow (Figure U34a).230
Anaesthetic Block of the Ulnar Nerve in the Ulnar Canal (Figure U34b) . . . . . . . 230
Ulnar Nerve PNS .. . . . . . . . . . 232
Surgical Procedure .. . . . . . . . . . . 234
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Surgical Approaches .. . . . . . . . 234
On the Arm ..234
At the Elbow.. . . . . . . . . . . 234
At the Forearm .. . . . . . . . . 236
Technical Pitfalls.. . . . . . . . . . . 236
By Hand ... . 238
Main Technical Trap .. . . . . . . . 238
The Suprascapular Nerve .. . . . . 242
Morphological Data .. . . . . . . . . . 242
Origin ... . . . . . . 242
Path ... . . . . . . . . 242
Neurovascular Relations .. . . . . 242
Collateral Branches.. . . . . . . . . 242
Terminal Branches .. . . . . . . . . 242
Motor Function ..242
Pathologies ... . . . . 245
Aetiology... . . . . 245
Clinical Significance .. . . . . . . . 245
Explorations ... . 245
Treatment ... . . . . . 245
Morphological Data: Sono Anatomy ... 248
Installation... . . . 248
Equipment and Location.. . . . . 248
Ultrasound Procedure .. . . . . . . 248
Interventional Procedure.. . . . . . . 250
Infiltration/Test Block .. . . . . . . 250
RFP ... . . . . . . . . 250
PNS ... . . . . . . . . 250
Surgical Procedure .. . . . . . . . . . . 252
Surgical Approaches .. . . . . . . . 252
Skin Incision.. . . . . . . . . . . 252
Nervous Exposure.. . . . . . . 252
The Long Thoracic Nerve .. . . . . 254
Morphological Data .. . . . . . . . . . 254
Origin ... . . . . . . 254
Path ... . . . . . . . . 254
Neurovascular Relations .. . . . . 254
Terminal Branches .. . . . . . . . . 254
Motor Function ..254
Pathologies ... . . . . 257
Aetiology... . . . . 257
Clinical Significance .. . . . . . . . 257
Treatment ... . . . 257
Bibliography ... . . . 259
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Part III Nerves of the Lower Limb
The Lumbosacral Plexus .. . . . . . 266
Morphological Data .. . . . . . . . . . 266
The Lumbar Plexus .. . . . . . . . . 266
The Sacral Plexus .. . . . . . . . . . 268
The Obturator Nerve.. . . . . . . . . 280
Peripheral Branches .. . . . . . . . . . 276
Morphological Data .. . . . . . . . . . 280
Origin ... . . . . . . 280
Path ... . . . . . . . . 280
Neurovascular Relations .. . . . . . . 280
Collateral Branches.. . . . . . . . . 288
Terminal Branches .. . . . . . . . . 288
Motor Function ..288
Sensitive Function.. . . . . . . . . . 288
Anastomoses ... . 288
Pathology ... . . . . . 294
Obturator Neuralgia .. . . . . . . . 294
Aetiology... . . . . 294
Clinical Significance .. . . . . . . . 294
Explorations ... . 294
Treatment ... . . . 294
Morphological Data: Sono Anatomy ... 296
Installation... . . . 296
Equipment and Location.. . . . . 296
Ultrasound Procedure .. . . . . . . 296
Interventional Procedure.. . . . . . . 300
Infiltration/Test Block .. . . . . . . 300
Indication ... 300
Technique ... 300
PNS... . . . . . 300
RFP... . . . . . 300
Surgical Procedure .. . . . . . . . . . . 302
Surgical Indications.. . . . . . . . . 302
Skin Incision.. . . . . . . . . . . 302
Nervous Exposure.. . . . . . . 302
Technical Pitfalls.. . . . . . . . . . . 302
The Femoral Nerve .. . . . . . . . . . 308
Morphological Data .. . . . . . . . . . 308
Origin ... . . . . . . 308
Path ... . . . . . . . . 308
Neurovascular Relations .. . . . . 308
Collateral Branches.. . . . . . . . . 308
Terminal Branches .. . . . . . . . . 314
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Motor Function ..314
Sensitive Function.. . . . . . . . . . 314
Anastomoses ... . 314
Pathology ... . . . . . 320
Femoral Nerve Syndrome or Femoral Neuralgia ... 320
Aetiology... . . . . 320
Clinical Significance .. . . . . . . . 320
Explorations ... . 320
Treatment ... . . . 320
Morphological Data: Sono Anatomy ... 322
Installation... . . . 322
Equipment and Location.. . . . . 322
Ultrasound Procedure .. . . . . . . 322
Interventional Procedure.. . . . . . . 326
Infiltration/Test Block .. . . . . . . 326
Indications ..326
Technique ... 326
PNS... . . . . . 326
RFP... . . . . . 326
Morphological Data: Sonoanatomy ...328
Installation... . . . 328
Equipment and Location.. . 328
Ultrasound Procedure .. . . . 328
Interventional Procedure.. . . . . . . 332
Infiltration/Test Block .. . . . . . . 332
Indication ... 332
Technique ... 332
PNS ... . . . . . . . . 332
Indications ..332
Technique ... 332
RFP ... . . . . . . . . 332
Indication ... 332
Technique ... 332
Surgical Procedure .. . . . . . . . . . . 336
Surgical Indications.. . . . . . . . . 336
At the Femoral Trigone .. . 336
Technical Pitfalls.. . . . . . . . . . . 336
The Sciatic Nerve ..340
Morphological Data .. . . . . . . . . . 340
Origin ... . . . . . . 340
Path ... . . . . . . . . 340
Neurovascular Relations .. . . . . 346
Collateral Branches.. . . . . . . . . 346
Terminal Branches .. . . . . . . . . 346
Motor Function ..346
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Sensitive Function.. . . . . . . . . . 346
Anastomoses ... . 346
Pathology ... . . . . . 356
Aetiology... . . . . 356
Clinical Significance .. . . . . . . . 356
Clinical Forms... 356
Explorations ... . 356
Treatment ... . . . 356
Morphological Data: Sono Anatomy ... 358
Installation... . . . 358
Equipment and Location.. . . . . 358
Ultrasound Procedure .. . . . . . . 358
Piriformis Syndrome.. . . . . . . . 358
Interventional Procedure.. . . . . . . 364
Infiltration/Test Block .. . . . . . . 364
Indication ... 364
Technique ... 364
PNS ... . . . . . . . . 364
Technique ... 364
Surgical Procedure .. . . . . . . . . . . 366
Surgical Indications.. . . . . . . . . 366
Surgical Approaches .. . . . . . . . 366
On the Buttock .. . . . . . . . . 366
At the Thigh .. . . . . . . . . . . 368
Technical Pitfalls.. . . . . . . . . . . 368
The Tibial Nerve... 372
Morphological Data .. . . . . . . . . . 372
Origin ... . . . . . . 372
Path ... . . . . . . . . 372
Neurovascular Relations .. . . . . 372
Collateral Branches.. . . . . . . . . 380
Terminal Branches .. . . . . . . . . 380
Motor Function ..380
Sensitive Function.. . . . . . . . . . 380
Anastomoses ... . 380
Pathology ... . . . . . 386
Soleus Syndrome .. . . . . . . . . . 386
Aetiology... . . . . 386
Clinical Significance .. . . . . . . . 386
Explorations ... . 386
Treatment ... . . . 386
Tarsal Tunnel Syndrome .. . . . . 388
Aetiology... . . . . 388
Clinical Significance .. . . . . . . . 388
Clinical Forms... 388
Explorations ... . 388
Treatment ... . . . 388
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Morphological Data: Sono Anatomy ... 390
Installation... . . . 390
Equipment and Location.. . . . . 390
Ultrasound Procedure .. . . . . . . 390
Interventional Procedure.. . . . . . . 394
Infiltration/Test Block .. . . . . . . 394
Infiltration at the Proximal Part of the Tibial Nerve.. . . . . . . . . 394
Technique ... . . . 394
Indication ... 396
Technique ... . . . 396
RFP... . . . . . 396
PNS... . . . . . 396
Sural Nerve..398
Installation... . . . 398
Equipment and Location.. . . . . 398
Ultrasound Procedure .. . . . . . . 398
Infiltration/Test Block .. . . . . . . 400
Indications ..400
Technique ... 400
RFP... . . . . . 400
Surgical Procedure .. . . . . . . . . . . 402
Surgical Indications.. . . . . . . . . 402
In the Leg ... 402
Skin Incision.. . . . . . . . . . . 402
Nervous Exposure.. . . . . . . 402
Technical Pitfalls.. . . . . . . . . . . 402
Surgical Indications.. . . . . . . . . 404
At the Ankle .. . . . . . . . . . . 404
Skin Incision.. . . . . . . . . . . 404
Nervous Exposure.. . . . . . . 404
Technical Pitfalls.. . . . . . . . . . . 404
The Fibular Nerve .. . . . . . . . . . . 408
Morphological Data .. . . . . . . . . . 408
Origin ... . . . . . . 408
Path ... . . . . . . . . 408
Neurovascular Relations .. . . . . 408
Collateral Branches.. . . . . . . . . 408
Terminal Branches .. . . . . . . . . 414
Motor Function ..414
Sensitive Function.. . . . . . . . . . 414
Anastomoses ... . 414
Pathology ... . . . . . 420
Fibular Nerve Injury .. . . . . . . . 420
Aetiology... . . . . 420
Clinical Significance .. . . . . . . . 420
Clinical Forms... 420
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Explorations ... . 420
Treatment ... . . . 420
Morphological Data: Sono Anatomy ... 422
Installation... . . . 422
Equipment and Location.. . . . . 422
Ultrasound Procedure .. . . . . . . 422
Identification of the Common Fibular Nerve in the Cervix .. . . 422
Deep Fibular Nerve.. . . . . . . . . 424
Installation ..424
Equipment and Location.. . 424
Ultrasound Procedure .. . . . 424
Superficial Fibular Nerve .. . . . 424
Installation ..424
Equipment and Location.. . 424
Ultrasound Procedure .. . . . 424
Interventional Procedure.. . . . . . . 432
Infiltration/Test Block at the Fibula Neck... . . . . . . 432
Technique ... 432
Surgical PNS Implantation at the Fibula Neck ... . . 432
Technique ... 432
Infiltration/Test Block at the Tarsal Tunnel... . . . . . 432
Indication ... 432
Technique ... 432
RFP... . . . . . 432
Surgical Procedure .. . . . . . . . . . . 434
Surgical Indications.. . . . . . . . . 434
In the Leg ... 434
Technical Pitfalls.. . . . . . . . . . . 434
PNS by Surgery at the Fibula Neck ... . . . . . . . . . . 434
The Lateral Cutaneous Nerve.. . 438
Morphological Data .. . . . . . . . . . 438
Origin ... . . . . . . 438
Path ... . . . . . . . . 438
Neurovascular Relations .. . . . . 438
Terminal Branches .. . . . . . . . . 438
Sensitive Function.. . . . . . . . . . 442
Pathology ... . . . . . 444
Meralgia Paraesthetica .. . . . . . 444
Aetiology... . . . . 444
Clinical Significance .. . . . . . . . 444
Morphological Data: Sono Anatomy ... 446
Installation... . . . 446
Equipment and Location.. . . . . 446
Ultrasound Procedure .. . . . . . . 446
Interventional Procedure.. . . . . . . 450
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Infiltration/Test Block .. . . . . . . 450
Indication ... 450
Technique ... 450
PNS ... . . . . . . . . 450
Indication ... 450
Technique ... 450
RFP ... . . . . . . . . 450
Technique ... 450
Surgical Procedure: Lateral Femoral Cutaneous Nerve Decompression . . . . . . . . . . 452
Surgical Description .. . . . . . . . 452
Skin Incision.. . . . . . . . . . . 452
Nervous Exposure.. . . . . . . 452
The Other Nerves..456
The Iliohypogastric Nerve .. . . . . 456
Morphological Data .. . . . . . . . 456
Origin ... . . . . . . 456
Path ... . . . . . . . . 456
Neurovascular Relations .. . . . . 456
Collateral Branches.. . . . . . . . . 456
Terminal Branches .. . . . . . . . . 456
Sensitive Function.. . . . . . . . . . 456
Anastomoses ... . 456
The Ilioinguinal Nerve .. . . . . . . . 458
Morphological Data .. . . . . . . . 458
Origin ... . . . 458
Path ... . . . . . 458
Neurovascular Relations.. . 458
Terminal Branches .. . . . . . 458
Sensitive Function .. . . . . . 458
Pathology ... . . . . . 460
Entrapment Neuropathies of the Ilioinguinal Nerve and of the Hypogastric Nerve... . 460
Aetiology... . . . . 460
Clinical Significance .. . . . . . . . 460
Clinical Forms... 460
Treatment ... . . . 460
Bibliography ... . . . 462
Index ... . . . . . . . . . 464

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