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accommodatedinover-the-countershoes.Peoplewithamputationsorunusualsizesmayalso
benefit. Reducing pressure onthe diabetic foot ulcer is anintegral component ofeffective
wound management.82 Ill-fitting shoes should be replaced. Asmall or superficial ulcer can
benefitfromtheuseofahealingsandalmadefromasurgicalshoecontaininganinsoleoffelt
or plastazote, which can then be apertured to properly off-load ulcers. Plastazote can be
custom moldedtothefootor,depending onits density,dynamicallymoldedaroundareasof
increased pressure during ambulation using its thermoplastic properties, thus redistributing
weight-bearingforceseffectively.82Totalavoidanceofweightbearingwiththeuseofbedrest,
crutch-assistedambulation,orutilizingawheelchairisthemosteffectivemethodtooff-load
the ulcerated foot.75 Thetotal contact cast has beenaccepted as thebestoverall method to
reduceweightfromaspecificareaofincreasedpressureandapplyamoreevendistributionof
weight-bearingforcesacrosstheentireforefoot.
83
Following healing of ulcer, walking/running-style footwear and in-depth shoes can be
accommodatedwithvariousorthosesforlong-termmanagement.Inthepresenceofsignificant
deformity,custom-moldedshoescanbeusedtoaccommodatedeformityanddecreasepressure
on areas of prominenceandthus decrease the possibilityof recurrence of a diabetic ulcer.
Moldedanklefootorthosesandsimilardevicesmaysupporttheotherwiseunstablefootand
anklesegmentsandthusdecreaseulcerativerisk.82Reducingthepossibility(orthedegree)of
obesitymaybehelpfulindecreasingplantarpressures intheulcer-pronefootandshouldbe
partoftheoverallgoalsofanutritionmanagementprogram.
82
SURGERY
The goal of surgery is to heal any existing ulcer and/or preventthe development of future
ulcers. Itis achievedbydecreasing focal pressures throughsurgical reductionofassociated
bonyprominence while preservingpedal functionalstability. Surgeryis performed eitherin
response to an ulcer history (prior or current) or as prophylactic surgery to decrease the
probability of developing future ulcers.84 It is also indicated in cases of nonreversible
ischemia resulting inamputation.Surgeryincludes incision anddrainage ofadeepabscess,
debridementofnecrotictissuefortheacuteactiveinfection,ablativewithpartialortotalfoot
and possible leg amputation. Definitive surgery is applied with vascular analysis and
intervention as needed.85 The literature supports the conclusion that diabetes is not a
contraindicationfor prophylacticfoot surgeryand is especiallyworthconsidering for those
patientswhocannotbeaccommodatedbyfootwearmodificationsandrelatedorthoses.
86
Amputationisacommonsequela,andthelevelofamputationisdeterminedbytheareain
whichviableboneandsofttissuearenoted.Inaddition,thespecificprocedureselectedtakes
intoconsiderationtheanticipatedpostoperativefunctionalcapacityofthepatient.Avarietyof
forefoot,midfoot,rearfoot,andlegamputationsareavailable.
Closure can be achieved through secondary, primary, or delayed primary closure.
Secondarywoundhealingiscommonlyutilizedforpatientswhendealingwithaninfectionthat
necessitatestissueresectiontotheextentthatprimaryclosureisnotaviableoption.87Keeping
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the wound open allows for daily flush, and wound packing may be required.88 Delayed
primaryclosuremaybeusedwhenawoundinfectionhasresolved.Plasticsurgicaltechniques
utilizingsplit- andfull-thickness skingrafts andflapsare other optionsthatmaybeused to
avoid secondary wound healing and accelerate ulcer resolution. Primary closure can be
considered fornoninfectedwoundsorthosewherethereis confidencethatthe infectionhas
beenfullyeradicatedduringthedefinitivesurgery.Allpatientsmustbeassessedindividually
fortheselectionofthesurgical procedureandclosuretechniquethatbestmeetstheirneeds.
Transmetatarsal amputationhealing can be expected ina majority of diabetic patients after
adequaterevascularization,butcannotbepredictedbyangiographicfindings.Effortsshouldbe
made to achieve primary wound closure.37 Thirty-day readmission rates following primary
lower extremityamputationinpatientswithdiabetes were highat >10%. Both medical and
surgicalcomplications,manyofwhichwereunavoidable,contributedtoreadmission.
89
CONCLUSION
The literature consistently demonstrates that the pedal complications of diabetes are
significant,withtheultimategoalofpreventionoffootulcers.Thetreatmentofdiabeticfoot
ulcersisbestaccomplishedbyutilizingamultidisciplinaryteam.Theprimarycaredoctoris
key in coordinating the integration of the necessary specialists in the management of the
ulcerated patient. Members of the “team approach” may include physicians in any of the
following specialties: family practice, internal medicine, endocrinology, infectious disease,
neurology, radiology and imaging, vascular disease, podiatrists/orthopedics, orthotics and
prosthetics,andothersasnecessary.
Treatmentofdiabeticfootulcersrequiresathoroughunderstandingofthefactorsinvolved
inthe development of open wounds and their healing mechanisms. Necrotic tissuemustbe
removedandexcised.Inaddition,weight-bearingforcesandshearmustberemovedfromthe
woundsurfacethrougheffectiveoff-loading.
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T
hischapterprovidesanoverviewofneuromusculardiseasesinthelowerextremities.As
entire books havebeen written onthesubject, the goalis to provide the reader witha
pertinent rather than a comprehensive review of neuromuscular disease in the lower
extremities.Forcompleteness,thechapterbeginswithananatomicaldescriptionofthelumbar
spine and cauda equina followed by selected common complications in this region, which
whilenotpartofthelowerlimbsperse,producesignificantneurologicdeficitsaffectingthe
lowerextremities.Theremainderofthechapterisorganizedanatomically,rostraltocaudal,
beginningwiththelumbosacralplexus,followedbythigh,leg,ankle,andfoot,andendingwith
peripheral neuropathies. Each section begins with an anatomic description, followed by an
approachtodiagnosis,andendswithadiscussionofspecificetiologies.
THELUMBARSPINEANDCAUDAEQUINA
LumbarSpineAnatomy
BoneandSoftTissue
The lumbar spine exhibits a normal lordosis starting at L1. As the patient bends forward,
reducing the lordosis, the spinal canal straightens, giving more room to the cord, often
alleviatingsymptomsinpatientswithlumbarspinalstenosis.
The vertebral body sits anterior to thespinal cord, supported by an intervertebral disc
consistingofasoftnucleuspulposusandathickannulusfibrosis.Thediscslowlydesiccates
over time, leading to height loss, and in combination with trauma, obesity, and genetic
predispositioncanleadtolumbardischerniationmorefrequentlyatL4–L5,L5–S1.
1
There are five lumbar vertebrae. For each vertebra, the pedicle extends laterally and
posteriorlyonbothsides,formingthemarginoftheintervertebralforamen(e.g.,theL1pedicle
formsthesuperiormarginoftheL1–L2foramen,andtheL2pedicleformstheinferiorforamen
margin). Superior andinferior articulating processes extendfrom the pedicles andform the
articulatingfacetjointsthatlocktheadjacentvertebraeintoplace.Asthepedicleextendsmore
posteriorly, theyturnmedially,formingthe lamina.Thelaminathenfuses atthe midlineand
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extendsposteriorlyandinferiorlyasthespinousprocess(Fig.6-1).
The supraspinous ligament covers the spinous processes and interspinous ligament
posteriorly. The interspinous ligament fills the space between the spinous processes. The
ligamentum flavum covers the spinous processes and interspinous ligament anteriorly. The
anteriorandposteriorlongitudinalligamentscoverthevertebralbodiesandtheintervertebral
discs.
SpinalCordandCaudaEquina
ThespinalcordnormallyterminatesinthelumbarspineatL1/2–L2/3astheconusmedullaris.
Thefilum terminale,anextensionofthe pia,tethers the conus medullarisapextothedorsal
coccyx. Filum tractionontheconus,most commonlyfrom developmental abnormalities, can
produceatetheredcordsyndromeconsistingofweaknessandsensorylossinthelegsaswell
asfecalandurinaryincontinence.
2
Spinalnervesofthelumbarandsacralregionoriginatefromthecaudaequina,thebundle
ofnervesthatoriginatesfromthestartoftheconusmedullaris.Thenerverootshaveavery
specific orientationwithinthecaudaequina,withthe mostanterior nervesexiting asthe L5
rootandexitinginananteriortoposteriororderastheS1–S5roots(Fig.6-2).3Compression
ofthesenervesproducesthecaudaequinasyndrome(CES).
SpinalCordVascularSupply
ArterialsupplytoL1(startingfromT1)isprovidedbytheradiculararteriesthatbranchfrom
the intercostal arteriesfromthe aorta.ThearteryofAdamkiewicz,whichbranchesfromthe
aorta,entersthespinalcordbetweenT8andL4,usuallyontheleft,andsuppliesmostofthe
lowerspinalcord;embolitothisvesselusuallyleadtoinfarctionoftheanteriortwo-thirdsof
the spinal cord, causing weakness, pain, and loss of temperature sensation. The general
orientationofarteriesrelativetothespinalcolumnisshowninFigure6-3.
Inside the spinal canal, from the radicular artery, the radiculopial artery branches and
movesposteriorlytoformtheposteriorspinalarteriesandsupplytheposteriorone-thirdofthe
spinalcord.Inaddition,theradiculomedullarybranchoftheradiculararteryformstheanterior
spinalartery.Thesearteriessupplytheanteriortwo-thirdsofthespinalcord(Fig.6-4).
4,5
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FIGURE6-1.Illustrativeandradiographicviewsofthelumbarspine(FromMooreKL,AgurAM,DalleyAF.Clinically
OrientedAnatomy.7thed.Philadelphia,PA:WoltersKluwer;2009,withpermission).
Venousdrainagefromthelowerspinalcordisthesameasfromtherestofthecord.They
drainintoanirregularepiduralvenousplexusthatcommunicateswiththepedicularveinsand
ultimatelydrainsintothevenacavae(Fig.6-5).Lumbarneedleprocedurescanpuncturethese
veins and produce bleeding, and can lead to significant hematomas in patients with
coagulopathies.
CommonLumbarSpineandCaudaEquinaComplications
EpiduralSteroidInjection
Lowbackpainisacommoncomplaint,hasitshighestincidenceinthethirddecade,with1yearincidenceofanybackpainbetween1%and36%andrecurrencebetween24%and80%.
6
Epidural steroid injections (ESIs) remain a popular nonsurgical intervention for low back
pain.Althoughthereisliteraturesupportingitsefficacy,
7,8
theFoodandDrugAdministration
has notapproved epidural corticosteroid injections for low back painat this time because
serious neurologic events, including paraplegia, quadriplegia, and brain and spinal cord
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infarction,havebeenreportedwithandwithoutuseoffluoroscopy.
9
ComplicationratesforESIremainlowoverallat2.4%,10forintralaminarandinterlaminar
andtransforaminalapproaches,withconflictingreportscomparingrelativecomplicationrates
betweenthetechniques.
10,11
Infectious complications,including epiduralabscess, meningitis,
discitis, and osteomyelitis, are about 1% to 2%.12 The incidence of epidural hematoma is
about 1 per 150,000 and increases to 2% in patients using anticoagulants.13 Ideally, oral
anticoagulationshouldbediscontinued,andprothrombintimenormalized.Thisusuallytakes1
to2 days.In patientstaking coumadin,the International Normalized Ratio (INR) shouldbe
definitelylessthan3,buttherearenodefinitiveguidelinesforINRbetween1.5and3.Platelet
functionshouldalsobenormalized,whichcanmeanholdingtheantiplateletagentfor5to10
days.
14
FIGURE6-2.Illustrativeandradiographicviewsofthelumbarspinalcordandcaudaequinarelativetotheir
surroundingosseousstructure(FromMooreKL,AgurAM,DalleyAF.ClinicallyOrientedAnatomy.7thed.
Philadelphia,PA:WoltersKluwer;2009,withpermission).
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FIGURE6-3.Thespinalarteriesrelativetothelumbarspine(FromMooreKL,AgurAM,DalleyAF.Clinically
OrientedAnatomy.7thed.Philadelphia,PA:WoltersKluwer;2009,withpermission).
Surprisingly,intravascularinjectioncanbefrequent,ashighas21.3%inthetransforaminal
approachwithfluoroscopicguidance.15Althoughthisdoesnotleadtoanadverseoutcomeper
se, instilling thelocal corticosteroid intravascularly subjectsthe patientto painandanxiety
associatedwithneedleprocedureswithoutensuingbenefits.Duralpunctureisanothernotable
complicationinESI.Cerebrospinalfluid(CSF)flashbackindicativeofduralpuncturemaynot
necessarilybepresent,especiallyinthetransforaminalapproach.16AsidefromaCSFleakthat
mayrequirebloodpatching,injectionofintrathecalanestheticcanleadtotransientascending
weaknessorsensoryloss,whichcanspreadashighasC2.Rarely,seriouscomplicationssuch
asrespiratorydepressioncanalsooccur.Notably,theusual6to8mLofanestheticusedinESI
isnottypicallysufficienttoproducesignificantadverseevents.
12
EpiduralAnesthesia
Epidural anesthesia can lead to dural puncture in 0.4% to 6% of patients when used in a
variety of abdominal and lower extremity surgeries.17 A persistent CSF leak after dural
puncture canlead toapostural headachealleviatedwithrecumbence.There is noevidence
correlatingthelengthofpostpuncturerecumbencetoincidenceofpostduralpunctureheadache.
However,thereisanassociationwithneedlegauge(11%to28%with20gauge,3%to25%
with25gauge,3%to8%with26gauge,and0%to2%with29gauge).18Incasesofpersistent
headache,anepiduralbloodpatchisusuallyapplied,withasuccessrateof36%to57%for
thefirstpatch,increasingwithsubsequentpatching.Interestingly,althoughtheorizedtospread,
clot,andoccludetheleak,theexactmechanismforbloodpatchinghasnotbeendetermined.
19
Further, there is no consensus between blindpatching and patchingafter a radiologic CSF
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