Decompression of the Lateral Sural Cutaneous Nerve to Relief Chronic Exertional Lower Leg Pain After More Than 30 Years - Rare or often Overlooked ?
Andreas Gohritz, MD; Dirk J Schaefer, MD
University Hospital Basel, Basel, Switzerland
Introduction: The Lateral sural cutaneous nerve (LSCN) derives from a variable network of both the tibial nerve and the common fibular nerve and supplies the upper lateral aspect of the lower limb below the knee. Isolated entrapment of this nerve has only been reported very rarely.
Case report: We report an exceptional case of a 65-year old male patient who suffered from severe bilateral exertional lower leg pain since more than 3 decades, mostly during jogging for more than about 20 min - not during normal walking. He presented with localized stabbing and burning pain of his lateral calf with irradiation into his lateral foot. Cutaneous sensitivity, tenderness and a positive Tinel sign were detected over the distribution of the LSCN. Motor function and reflexes were normal. Multiple conservative treatments, including local injections as well as bilateral surgical fasciotomies (to treat exercise-induced compartment syndrome) failed to reduce his symptoms. After 2 infiltrations of the LSCN with Lidocain 2% symptoms disappeared, but later recurred.
Results: Surgical decompression of LSCN was performed after preoperative marking of its most tender point over the lateral calf. The nerve derived from the common peroneal nerve bilaterally and was decompressed by cutting a strong fribrous band which seemed to be an extension of the deep facia extending into the gastrocnemius and peroneus longus muscle. The patient reported fading of his symptoms and has been completely painfree since about 1 month postoperativly.
Discussion: Only 4 reports of entrapment of the LSCN were published in the literature to date, the first case in 1998. Only 2 progressed to surgery and to the best of our knowledge this is the first bilateral occurance which was succesfully treated by surgical decompression. Diagnosis of this rare entrapment may be difficult due to variable innervation patterns and overlap in the lateral calf and the obscurity of this nerve which may be compressed by local tumors (cysts), tendons or fascial structures.
Conclusion: The LSCN is a little-known and cutaneous sensory nerve with high anatomic variability. Mononeuropathy of this nerve should be considered in pure sensory symptoms at the lateral calf. Due to difficult diagnosis, entrapment of the LSCN may be more common than its rare description in literature. Surgical neurolysis may resolve pain and paraesthesia if conservative measures have failed.
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