Atlas of Cutaneous Branch Territories for the Diagnosis of Neuropathic Pain [1st ed.] 9783030459635, 9783030459642

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Claude J. Spicher Tara L. Packham Nadège Buchet Isabelle Quintal Pierre Sprumont

Atlas of Cutaneous Branch Territories for the Diagnosis of Neuropathic Pain

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Atlas of Cutaneous Branch Territories for the Diagnosis of Neuropathic Pain

Claude J. Spicher Dept Neurosciences and Movement Sciences University of Fribourg Fribourg, Switzerland

Tara L. Packham School of Rehabilitation Sciences McMaster University Hamilton, ON, Canada

Nadège Buchet Ergothérapie Romont Romont, Switzerland

Isabelle Quintal Centre Professionnel d’Ergothérapie Montreal, QC, Canada

Pierre Sprumont Department of Anatomy University of Fribourg Fribourg, Switzerland

Based on the original French version: Claude Spicher, Nadège Buchet, Isabelle Quintal, Pierre Sprumont, Atlas des territoires cutanés pour le diagnostic des douleurs neuropathiques, 3 ed., © 2017 Sauramps Medical ISBN 978-3-030-45963-5    ISBN 978-3-030-45964-2 (eBook) DOI 10.1007/978-3-030-45964-2 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Atlas of Cutaneous Branch Territories for the Diagnosis of Neuropathic Pain Claude J. Spicher Tara L. Packham Nadège Buchet Isabelle Quintal Pierre Sprumont

Contents

Part I Introduction������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������   3 Patients and Methods, Tutorial ������������������������������������������������������������������������������������������������������������������������������������������������������   7 Part II Trigeminal domain ������������������������������������������������������������������������������������������������������������������������������������������������������������������������  13 Occipital domain ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  17 Cervical domain ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  21 Brachial domain��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  25 Posterior-intercostal domain������������������������������������������������������������������������������������������������������������������������������������������������������  45 Lumbo-abdominal domain����������������������������������������������������������������������������������������������������������������������������������������������������������  51 Lumbo-femoral domain ����������������������������������������������������������������������������������������������������������������������������������������������������������������  57 Femoral domain��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  61 Sciatic domain������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  69 Sacral domain ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  85 Part III Conclusion ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  95 Index of Anatomical Plates��������������������������������������������������������������������������������������������������������������������������������������������������������������  96 Index of Tables��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������  98 Part IV Appendix I: Aesthesiography�������������������������������������������������������������������������������������������������������������������������������������������������������� 103 Appendix II: NOT Dermatomes ���������������������������������������������������������������������������������������������������������������������������������������������������� 105 Appendix III: Digital Nerves of the Hand ���������������������������������������������������������������������������������������������������������������������������������� 106

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Foreword to The First Edition in English The skin is defining of aesthetic appearance and while its features are of great importance to the practising clinician, its significance is often neglected by students. Once cut and peeled away during human anatomical dissection, the skin is disregarded as students trace the complicated and interesting pathways of major nerves and vessels and seek out different organs. Health sciences students may learn the functions of the skin in relation to its protection of the body from the external environment, prevention of loss of fluids, its immunological function, regulation of temperature and even mechanical support, but often do not appreciate or understand its importance in cutaneous innervation. This book is thus of great value to those health professionals who qualify as doctors, particularly surgeons, as well as physiotherapists and occupational therapists.

Why Is This So? This detailed atlas maps the cutaneous sensory nerves of the human body as emanating from, not passing to, the skin areas from which they convey sensitivity. Instead of using dermatomes, the authors use “domains” to depict the territories from which the nerves emanate. In this way the atlas is unorthodox, as it differs from other atlases of anatomy. The cutaneous domain is defined as having a set of sensory nerve endings whose axons carry a common sensitivity. It includes several “autonomous” territories that each exclusively emit their fibres to the same nerve branch. Every territory is surrounded by skin areas which project to different branches of the same domain. There are ten pairs of domains that roughly correspond to one cranial nerve (trigeminal domain) and nine spinal segments. The mapping of the domains in a centripetal manner is of importance from a clinical perspective as neuropathic pain generally presents distally and advances proximally. The “domains” described in this atlas can only be delineated in living subjects, rather than in unconscious immobile patients. Physical examination of over 3000 patients, in which the extension of the domains and their autonomous territories were measured, has been undertaken by aesthesiography and/or allodynography. Thus, the atlas is unique and indisputable. While of unquestionable importance to those clinicians assessing neurological disorders, the book will also be of great interest to anatomists, since it presents a novel viewpoint of anatomical facts. It is my great privilege to provide this foreword to the first English edition of the book, which is an updated and amended version of the third French version. The authors of the book, who are distinguished clinicians and anatomists, are to be congratulated on producing an evidence-based, concise presentation, which will be of great value to clinicians and anatomists alike. Beverley Kramer University of the Witwatersrand Johannesburg, South Africa President of the International Federation of Associations of Anatomists

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Foreword to the Second Edition (2013) At the outset the authors make it clear that this atlas has a radically different viewpoint compared to other atlases of cutaneous nerve distribution. Specifically, they mapped cutaneous sensation from the periphery towards the centre. For the cutaneous distribution of any given nerve, they mapped the most distal extent first, then moved proximally mapping medial and lateral boundaries until they approached the most proximal limit. This makes clinical sense because sensory neuropathies typically present distally and progress proximally. The clinical emphasis of the atlas is also obvious because it is based on maps obtained from over two thousand neuropathic pain patients (NPP), nearly double the number of patients mapped for the first edition of this atlas. This large sample of NPPs was validated by the contributions of several distinguished collaborators from around the world. There are also about a hundred clinical anatomy references. The astute observer will note variations in the maps of many of these references with each other and with this atlas. This is because the cutaneous distribution of sensory nerves varies among patients. To make this atlas valuable even though these distributions vary, the authors have chosen to illustrate the “largest territory of cutaneous distribution of the nerves.” Therefore, in a given patient, the distribution of a cutaneous nerve can be expected to fall within the boundaries outlined in this atlas. These maps cannot be precise, but at least the outer margins are given and this will be of value to the practitioner who sees these patients. In addition to the territory of innervation, maps for different sensations are also presented. For example, pain is perceived at lower thresholds than touch so the territory for pain sensation will typically be larger. This is due to the facts that receptors with different stimulus modalities are involved in receiving these sensations and different fibres conduct the impulses. In spite of these differences, touch (as defined by detection of a 0.7 g weight applied to the skin) is diminished in the same territory where pain is perceived. Although the maps for all territories of the body are clearly designed, one of the most useful features of this atlas is the summary of the maps of the intercostal nerves. This provides the clinician with an image that is easy to grasp and apply to numerous clinical situations. Also, many of the drawn maps are supplemented with photographs that make the distribution of the cutaneous nerves quite unambiguous. Furthermore, some judiciously chosen tables provide valuable references for busy clinicians. Finally, indexes of the anatomical territories and the tables at the end of the atlas provide a ready guide to any cutaneous nerve of interest. Stephen W. Carmichael Mayo Clinic Rochester, MN, USA

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Glossary Taking into account, as much as possible, taxonomies developed by international organisations for anatomy and pain (Federative Committee on Anatomical Terminology 1998; Loeser & IASP Taxonomy Working Group 2011). Aesthesiography: clinical examination sign of tactile hypoaesthesia obtained from the mapping of a cutaneous territory where a determined mechanical application force is NOT detected. Aesthesiometer: instrument used to measure the importance of tactile hypoaesthesia by bending a nylon filament, often termed monofilament. Allodynography: clinical examination sign of static mechanical allodynia obtained from the mapping of a cutaneous territory where a standardised mechanical stimulation provokes a pain of 3 cm on a Visual Analogue Scale (VAS). Autonomous territory of cutaneous origin: exclusive territory innervated by only one cutaneous nerve branch. Axiom: element from which knowledge is deducted following logical rules – Εὐκλείδης [Euclid] – Third Century before J.-C. – Elements of Geometry. Clinical anamnesis: term designating the questioning of the patient in order to precisely collect the different evocations of his pain symptoms – from old Greek Ἀνάμνησις [anamnêsis]. It is a crucial moment in the somatosensory therapist of pain's reasoning, and it is performed by means of the McGill Pain Questionnaire. It demands a good knowledge of clinical anatomy, especially of the territorial origin of every cutaneous branch. It is neither a self-report questionnaire nor a medical history. Cutaneous domain: set of cutaneous territories which have their origin in the different nervous branches involved in the same clinical setting, i.e. symptomatic trigeminal neuralgia. The skin is subdivided into ten cutaneous domains. Diagnostic testing of Aβ axonal lesions: panel of four very sensitive tests to diagnose tactile sense disorders. Distant vibrotactile counter-stimulation: technique that uses a comfortable tactile or vibratory agent at distance in order to allow the patient to perceive the stimulus in a comfortable manner. The skin portion to be stimulated is defined jointly by the patient and by the somatosensory therapist of pain. Largest territory of cutaneous origin: is thus the territory of a cutaneous branch delimited by the four cardinal points furthest from the autonomous territory. Mechanical allodynia: pain due to a mechanical stimulus which does not normally provoke pain. Neuralgia: painful condition resulting from spontaneous firing of a nerve following Aβ, Aδ and/or C axonal lesions. Neuropathic pain: pain caused by a lesion or disease of the somatosensory nervous system. Receptor field: range of activity on the skin of one neurofibre and its somatosensory primary neuron. Secondary aesthesiography: clinical examination sign of underlying tactile hypoaesthesia obtained from the mapping of a cutaneous territory where a determined mechanical application force is NOT detected the day when the allodynography becomes negative. Tactile hypoaesthesia: reduced perception of touch. Tactile sense: capacity of the cutaneous mechanoreceptors to detect tactile stimuli. Territory of cutaneous origin: set of receptor fields innervated by ascendant Aβ neurofibres of a cutaneous nerve branch. Underlying hypoaesthesia: tactile hypoaesthesia masked by a mechanical allodynia and revealed after its disappearance.

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Acknowledgements The authors gratefully acknowledge the following persons whose numerous comments, suggestions and criticism invaluably contributed to the conception of this atlas. In particular: • • • • • • •

Prof E.M. Rouiller The thousands of patients The somatosensory rehabilitation of pain co-therapists Bruno Maillard and other photographs The models The reviewers The members of our families

Contributors Furthermore, we would like to thank the following MDs, surgeons and anatomists for their thoroughly support and for their numerous comments, suggestions and criticism (in domain order) which invaluably contributed to the conception of this atlas:

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Philippe OTTEN HFR Fribourg - Cantonal Hospital Clinique Générale

Neurosurgeon, Trigeminal domain Fribourg (Switzerland)

Nikolai BOGDUK School of Biomedical Sciences and Pharmacy Faculty of Health and Medicine University of Newcastle

Anatomist, Pain Specialist, Occipital domain

Harold ELLIS Dept of Anatomy Guy’s Campus, King’s College University of London

Surgeon, Cervical domain London (United Kingdom)

François MOUTET Unit of Hand and Burn Reconstructive Surgery University Hospital of Grenoble

Hand Surgeon, Brachial domain Grenoble (France)

Nadine ATTAL Centre of Assessment and Treatment of Pain Ambroise-Paré Hospital

Neurologist, Posterior-intercostal domain Paris (France)

Ajith SIRIWARDENA University of Manchester Manchester Royal Infirmary

Surgeon, Lumbo-abdominal domain Manchester (United Kingdom)

Wassim RAFFOUL Plastic and Reconstructive Surgery Department Lausanne University Hospital

Plastic Surgeon, Lumbo-femoral domain Lausanne (Switzerland)

New Castle (Australia)

Christian FONTAINE University of Lille Nord de France Higher School of Teaching and Education

Orthopaedic Surgeon, Femoral domain Lille (France)

Pascal RIPPSTEIN Foot and Ankle Center Schulthess Clinic

Foot Surgeon, Sciatic domain Zürich (Switzerland)

Marc ZAFFRAN General medical practitioner Writer as Martin Winckler

General medical practitioner, Sacral domain Montreal (Québec, Canada)

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Part I

Introduction This first English edition of Atlas of cutaneous branch territories of the human body, stemming from the third French edition, deals with the clinical anatomy of the somatosensory nervous system. As the clinic gives us the opportunity to observe many more axonal lesions (axonotmesis) than complete transections (neurotmesis), the resultant cutaneous hypoaesthetic territories demarcated by mapping are partial. We therefore defined for each cutaneous nerve branch the autonomous territory and the boundary markers of the largest territory of cutaneous origin. This new edition illustrates the usefulness of anatomical knowledge for clinical practice. More precisely, it seeks to demonstrate how these topographic elements help in setting the orientation of the clinical anamnesisG (G ≡ see Glossary) and then in carrying out the clinical examination. The 3142 patients1 included in this research were recruited prospectively and consecutively from 2 July 2004 to 21 August 2019. Therefore, the topographic study could be carried out to produce 3133 aesthesiographiesG: maps of cutaneous hypoaesthetic territory. In this atlas, each anatomical plate of a cutaneous branch is a compilation of the careful assessment by processing tens, even hundreds, of observations seen in clinical practice. We also cross-referenced these 3133 aesthesiographies observed with data published in 99 anatomy books. Following this, the point of view of one expert was asked from each domain. These experts are contributors. It is reassuring to observe that the results of this new edition do not invalidate the cumulative results of the third edition, even if some points of the largest territory of cutaneous origin have moved of a couple of millimetres.

LargestG Territory of Cutaneous Origin It would have been tempting to encircle the entire maximum skin territory of origin for each nerve branch. However, this would have been confusing, suggesting that each lesion produces changes in tactile sensitivity throughout the entire maximum territory – which is NOT what we have observed. The purpose of this study is to instead define five topographic elements and to present them on an anatomical plate for each cutaneous nerve branch in the following way: 3. The most proximal point 4. The most radial point2

1. The autonomousG territory of cutaneous origin

5. The most ulnar point1

2. The most distal point

The largest territory of cutaneous origin is, therefore, the territory of a cutaneous nerve branch delimited by the four cardinal points furthest from the autonomous territoryG. For example, of all the aesthesiographiesG of the dorsal branch of ulnar nerve, we retained the one with the most radial point (Fig. 1).

Fig. 1 : The most radial point, on one of the axes of a cutaneous branch, of the largest territory of cutaneous origin. This shows, 4 is the most radial point observed of the dorsal branch of the ulnar nerve. The locations 1, 2, and 3 observed in our series of aesthesiographies of the dorsal branch of the ulnar nerve (n = 51) are not retained because they do not correspond to the “most radial” point of the largest territory of cutaneous origin of this branch A cutaneous branch cannot innervate the skin located beyond these boundaries. This way of limiting the largest area of cutaneous origin (Lanz von and Waschmuth, 1935) is one of the important contributions of this work. 1.  For simplicity, we have used masculine pronouns to refer to any single person. Further, for clarity we also refer to the person being assessed as the patient. Neither of these reference forms is intended to be exclusionary or devaluing.

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From Symptomatology to Neuropathic Semiology For this atlas to be a didactic tool, the clinician must accept this assumption: Axiom: When the patient reports neuropathic pain symptoms, he has axonal lesions of, at least, one cutaneous nerve branch, including Aβ neurofibres. After accepting this assumption, the next informative step is performing a clinical anamnesis to identify the neuropathic symptoms (Fig. 2). 1. Listing if neuropathic symptoms McGill Pain Questionnaire, painDETECT, S-LANSS, etc.

2. Hypothesis of the nerve branch damaged Five topographical elements of cutaneous origin

3a. Search for a numb territory Contact zone

3b. Nonvariable pain definition Visual Analogue Scale

4a. Partial tactile hypoaesthesia Aesthesiography

4b. Static mechanical allodynia Allodynography

5. Somaesthetic and/or neuropathic condition Stage of Ab axonal lesions

6a. Rehabilitation of hyposensitivity

6b. Distant vibrotactile counter-stimulation

Fig. 2 : Thesearch for the damaged cutaneous branch responsible for one or more neuropathic symptoms makes it possible to map 4a: an aesthesiography or 4b: an allodynography, and then to perform the corresponding treatment technique—6a or 6b

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We would like to emphasise the unique nature of the clinical anamnesis in the study of pain. In contrast to the gold rule of first listening to the patient, the initial anamnesis of neuropathic pain is accurately directed; it is the result of a precise questioning. It is only then that this particular time of the clinical anamnesis, when the patient remembers the painful symptoms, becomes a two-part narrative. In order to formulate the hypothesis of the injured cutaneous branch, using this atlas, it is necessary to recall the following clinical anatomy knowledge: 1. The localisation of the burning sensations, or even of heat, is circumscribed in the hypoaesthetic territory (Fig. 3).

Fig. 3 : Positive aesthesiography at 0.7 g (Semmes-Weinstein monofilament #3.84) of the lateral sural cutaneous nerve of a patient, performed on 9 April 2009 on the lateral surface of the right ankle. The aesthesiography circumscribes the hypoaesthetic territory of the skin portion where this aesthesiometer is not detected 2. The electrical character of the pain radiates toward the periphery to the most distal point of the largest territory of cutaneous origin – or radiates in an afferent way from this point. This constant search for the link between these neuropathic symptoms and the anatomical topography is the essential task of the somatosensory therapists of pain. These qualifiers – neuropathic symptoms – are listed in the different versions of the McGill Pain Questionnaire: burning/boiling sensation, radiating, tingling, numb, tender, etc.

From the Skin to the Brain The second important contribution of this work is the organisation of our research in a centripetal manner. As the somatosensory nervous system is afferent (from the Latin afferre: bring from the periphery to the centre), we have organised this atlas from the skin towards the brain. In this centripetal design, the superficial branch of radial nerve, for example, joins the radial nerve at the forearm – and does NOT leave it – which is contrary to the conceptualisation of muscular anatomy. The original bundles of neurofibres converge to form nerves. These nerves are thus fibre cables whose sizes are increasing as they get closer to the central nervous system. The sum of the information they carry regarding any nerve territory is therefore directly proportional to the number of fibres united in the nerve. However, painful disorders of skin sensitivity most often come from lesions where only a minority of those nerve fibres are injured. The traditional centrifugal anatomy has described in detail the different branches of nerves regularly visible. However, it does not describe the precise content of each one of these branches, or the exact topography of its territory of origin. This is precisely what the present atlas undertakes: it analyses the topography of the detected cutaneous origin of the transmitted sensations for each nerve branch. It is no longer a question of dissections but of reconstructions going up from the skin to the somatosensory cortices. With this teaching tool, the practitioner, therapist or doctor can examine a subject and exclude, or not, the existence of axonal lesions within a given nerve branch. Anatomy evolves. Providing new perspectives, both practical and functional, it still provides valuable and unexpected information for medicine and clinicians.

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Patients and Methods, Tutorial Patients The 3142 patients included in this research were recruited prospectively and consecutively from 2 July 2004 to 21 August 2019. They are patients experiencing chronic neuropathic pain referred to the Somatosensory Rehabilitation Centre.1 In order to study a group as homogeneous as possible, we restricted this topographical research to patients whose skin was accessible for accurate evaluation: they did not show hypersensitivity to touch, that is, they did not present mechanical allodyniaG. Inclusion criterion: a diagnosis of Aβ axonal lesionsG (n = 5241) Exclusion criterion: a positive allodynographyG (n = 2108) It should be noted that patients who had previously a positive allodynography (exclusion criterion) at the first assessment session, and who subsequently presented a positive secondary aesthesiographyG after resolution of the allodynia, were excluded. If the presence of this underlying hypoaesthesia can no longer be proven, the boundary of these secondary aesthesiographies remains unclear. Indeed, while certain receptive fields detect the aesthesiometer, some other neighbouring receptor fields may perceive a stimulus as unpleasant though no longer painful. This other physiological state of the skin can then generate false positives, in other words, an aberrant clinical examination. This prospective research is based on 3133 aesthesiographiesG, the first step of the diagnosis of Aβ axonal lesions – distributed according to each cutaneous domainG of the human body in the following way: 1. Trigeminal domain     2. Occipital domain      3. Cervical domain       4. Brachial domain       5. Posterior-intercostal domain  6. Lumbo-abdominal domain  7. Lumbo-femoral domain   8. Femoral domain      9. Sciatic domain        10. Sacral domain       

n = 94 n = 65 n = 41 n = 706 n = 155 n = 104 n = 147 n = 358 n = 1314 n = 149

Methods The aesthesiography (Létiévant 1869, 1873; Spicher and Kohut 2001; Spicher 2003; Spicher and Quintal 2013) The aesthesiography (Fig. 3, “Introduction” chapter) is the mapping of a hypoaesthetic skin territory representationally reported on diagrams or photographs. The aesthesiometerG used for the entire human body is the 0.7 g aesthesiometer (Semmes-Weinstein monofilament #3.84), except: –– For the dorsal surfaces of the hand and foot: 0.4 g (Semmes-Weinstein monofilament #3.61) –– For palmar and plantar surfaces: 0.2 g (Semmes-Weinstein monofilament #3.22) –– For the face: 0.1 g (Semmes-Weinstein monofilament #2.83) It should be noted that this evidence draws from very important information for the somatosensory rehabilitation of neuropathic pain: the normative values for pressure perception threshold.

1. Somatosensory Rehabilitation Centre; Clinique Générale; 6, Hans-Geiler Street; CH-1700 Fribourg (Switzerland).

 

1

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Norms for Pressure Perception Threshold (PPT) (Weinstein 1962; Bell-Krotoski et al. 1994; Spicher et al. 2013) 0.1 g on palmar and plantar surfaces. #3.22 aesthesiometer is detected. 0.3 g on dorsal surface of the hand and foot. #3.61 aesthesiometer is detected. 0.6 g on the rest of the body. #3.84 aesthesiometer is detected. The goal of the Pressure Perception Threshold (PPT) research is to determine the minimum pressure detected at a specific point. For this test, it is necessary to select 15 out of the 20 aesthesiometers of the Semmes-­Weinstein monofilaments kit graded from 0.03 to 75.0 g. Within the aesthesiography, we determine the most hyposensitive contact area, touching the skin and questioning the patient. It is in this area that a precise point, reproduced on the sheet of the aesthesiography, will be determined for the realisation of the PPT (Quintal et al. 2013).



The Cardinal Point: Topographic Element

The dots indicate where the 0.7 g application is not detected. The largest area of cutaneous origin is bounded by its four cardinal points; e.g. the most distal point (Fig. 3, “Introduction” chapter). The green dot corresponds (Fig. 1) to the most radial point, for example, observed in our series. In some boards, a brown point (Fig. 1) corresponds to a point farther from the autonomous territory than the green cardinal point which we have observed, but which is published in the literature (referred to on the board and cited, also in brown, in the list of references). Other points published in the literature are not retained because they are less distant from the autonomous territory: Testut (1897), Tinel (1916), Tubiana and Thomine (1990) and Doyle and Botte (2003).

Fig. 1 : The most radial point, on one of the axes of a cutaneous branch, of the largest territory of cutaneous origin. In this figure, 3 is the most radial point published by Sunderland (1978) in the literature; 2 is the most radial point observed in the dorsal branch of the ulnar nerve; 1 is another point published by Létiévant (1869, 1873), but not retained, because it is not “most radial” of the largest area of cutaneous origin of this branch



The Arrow

The arrow (Fig. 1, “Introduction” chapter) indicates the axis and the direction along which the aesthesiometer is applied; either the longitudinal axis or the transversal axis, or even the metacarpophalangeal axis, the metatarsophalangeal axis, etc.



The Triangle

The triangle indicates the point from which the measures were taken. It corresponds to the theoretical point of origin (0,0) of the orthogonal axes (x,y).

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How to Read the Anatomical Plates Designation that describes the surface of the autonomous territory

Medial cutaneous nerve of thigh Ramus femoris medialis, nervus saphenus

The usual pathway of the nerve branch

The most proximal point Medial surface

The most posterior point Medial surface

Autonomous territory Medial surface

The most anterior point Medial surface

The most distal point Medial surface

Femoral domain Anatomical plate 8.4 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory 9

Part II

Trigeminal domain Introductory Summary

The tactile sensitivity is transmitted from the skin of the face by the three divisions of the trigeminal nerve (ophthalmic, maxillary and mandibular nerves) over the trigeminal ganglion to the spinal trigeminal nucleus, which extends from the upper cervical segments of the spinal cord to the lower brainstem

Ophthalmic nerve, division of trigeminal nerve [V1] Nervus ophtalmicus, nervus trigeminus

The most proximal point Lateral surface

The most lateral point Lateral surface

Ellis et al. (2007)

Autonomous territory Frontal surface

The most medial point Frontal surface

The most distal point Frontal surface

The most distal point Nasociliary nerve

Trigeminal domain Anatomical plate 1.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

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Maxillary nerve, division of trigeminal nerve [V2]

Nervus maxillaris, nervus trigeminus

The most proximal point Lateral surface

The most inferior point Lateral surface

Autonomous territory Anterior surface

The most distal point Anterior surface

The most superior point Lateral surface

Salasche et al. (1988)

Trigeminal domain Anatomical plate 1.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

15

Mandibular nerve, division of trigeminal nerve [V3] Nervus mandibularis, nervus trigeminus

Brachial domain

The most proximal point Lateral surface

The most superior point Lateral surface

Autonomous territory Anterior surface

The most distal point Anterior surface

The most inferior point Lateral surface

Hall-Craggs (1986)

Trigeminal domain Anatomical plate 1.3 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

16

Occipital domain Introductory Summary

This domain roughly corresponds to the upper part of the neck. It includes the cutaneous origins of the greater occipital and third occipital nerves behind, and of the lesser occipital and great auricular nerves laterally. The former directly convey the tactile information into the posterior branches of C2 and C3 while the latter feed them into the ansa cervicalis

21

Greater occipital nerve Nervus occipitalis major

The most proximal point Occipital surface

The most medial point Occipital surface

Autonomous territory Occipital surface

The most distal point Anterior surface

The most anterior point Lateral surface

Schünke et al. (2005)

Occipital domain Anatomical plate 2.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

18



Great auricular nerve Nervus auricularis magnus

The most proximal point Lateral surface

The most medial point Occipital surface

Autonomous territory Lateral surface

The most anterior point Lateral surface

3

1

The most distal point Lateral surface

2

1 Backhouse et al. (1986) 2 Trotter et al. (1907) 3 Williams et al. (1995)

Occipital domain Anatomical plate 2.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

19



Autonomous territories of cutaneous origin Posterior branches

Greater occipital nerve (Posterior branch of 2nd cervical nerve)

3rd occipital nerve (Posterior branch of 3rd cervical nerve)

Anterior branches

Lesser occipital nerve of cervical plexus (C2)

Great auricular nerve of cervical plexus (C3)

Occipital domain Table I : The 4 posterior or anterior branches that can induce occipital neuralgia Occipitalisneuralgie

20

Cervical domain Introductory Summary

This tactile sensitivity from the lower part of the neck’s skin is forwarded by the cervical plexus (transverse cervical and supraclavicular nerves) and by the direct posterior branches of the 4th, 5th, 6th, 7th and 8th cervical nerves towards the cervical segments of the spinal cord

Transverse cervical nerve Nervus transversus colli

The most proximal point Lateral surface

The most superior point Lateral surface

Autonomous territory Lateral surface

The most distal point Lateral surface

The most inferior point Lateral surface

Backhouse et al. (1986)

Cervical domain Anatomical plate 3.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

22



Autonomous territories of cutaneous origin Posterior branches Posterior branch of 4th cervical nerve

Posterior branch of 5th cervical nerve

Anterior branches Transverse cervical nerve of cervical plexus (C3)

Supraclavicular nerve of cervical plexus (C4)

Posterior branch of 6th cervical nerve

See table III

Posterior branch of 7th cervical nerve

See table IV

Posterior branch of 8th cervical nerve

See table V

Cervical domain Table II : The seven posterior or anterior branches that can induce cervical neuralgia Cervicalisneuralgie 23

Summary 32 Posterior family : posterior cord of brachial plexus i.e. Posterior cutaneous nerve of forearm

38 Lateral family : lateral cord of brachial plexus

i.e. Palmar branch of median nerve

42 Medial family : medial cord of brachial plexus

i.e. Dorsal branch of ulnar nerve

Brachial domain

Organization of the chapter according to the cords of brachial plexus

25

Brachial domain Introductory Summary

The skin sensory information from hand, forearm, elbow, arm and axilla is emitted towards the brachial plexus along the musculocutaneous, medial cutaneous of arm, medial cutaneous of forearm, median, ulnar, radial and axillary nerves. These seven nerves first converge into three cords, then intermingle their fibres that ultimately merge into a superior (C5, C6), a middle (C7) and an inferior (C8, Th1) trunk

1.

2.

3.4.5.

1. Superficial branch 2. Posterior cutaneous nerve of forearm 3.

Radial nerve

Posterior cutaneous nerve of arm

POSTERIOR cord of brachial plexus C5-C6

4. Inferior lateral cutaneous nerve of arm 5. Superior lateral cutaneous nerve of arm

Axillary nerve

Brachial domain

Table III : The family of five nerves of the POSTERIOR cord of brachial plexus Fasciculus posterior, plexus brachialis 27

Superficial branch of radial nerve Ramus superficialis, nervus radialis

The most proximal point Dorsal surface

The most ulnar point Dorsal surface

Autonomous territory Dorsal surface bis

The most radial point Dorsal surface bis

1 2

Most distal points Dorsal surfaces

1 Aumüller et al. (2007)

Brachial domain Anatomical plate 4.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory 28



Posterior cutaneous nerve of forearm Nervus cutaneus antebrachii posterior

The most proximal point Posterior surface

The most medial point Posterior surface

Autonomous territory Posterior surface

The most distal point Posterior surface

The most lateral point Posterior surface

Anderson (1978)

Brachial domain Anatomical plate 4.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

29

Posterior cutaneous nerve of arm Nervus cutaneus brachii posterior

The most proximal point Posterior surface

The most medial point Posterior surface

Autonomous territory Posterior surface

The most lateral point Lateral surface

The most distal point Posterior surface

Brachial domain Anatomical plate 4.3 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

30



Inferior lateral cutaneous nerve of arm

Nervus cutaneus brachii lateralis inferior

The most proximal point Lateral surface

The most posterior point Lateral surface

Autonomous territory Lateral surface

The most anterior point Lateral surface

The most distal point Lateral surface

Brachial domain Anatomical plate 4.4 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

31

Superior lateral cutaneous nerve of arm Nervus cutaneus brachii lateralis superior

The most proximal point Posterior surface

The most superior point Latero-superior surface

Autonomous territory Lateral surface

The most distal point Anterior surface

The most inferior point Lateral surface

Lanz von and Waschmuth, (1938)

Brachial domain Anatomical plate 4.5 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

32

1.

2. 3.

1. Common and proper palmar digital nerves Median nerve 2. Palmar branch

3. Lateral cutaneous nerve of forearm

LATERAL cord of brachial plexus C6-C7 Musculocutaneous nerve

Brachial domain Table IV : The family of three nerves of the LATERAL cord of brachial plexus Fasciculus lateralis, plexus brachialis

33

 ommon and proper palmar, and dorsal, C digital nerves of median nerve

Nervi digitales palmares communes et proprii, et rami dorsales, nervus medianus

The most proximal point Palmar surface

The most radial point Radial surface

Autonomous territory Palmar surface

The most ulnar point Palmar surface

Tinel (1916[1917])

Brachial domain Anatomical plate 4.6 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

34



Palmar branch of median nerve

Ramus palmaris, nervus medianus

The most proximal point Anterior surface

The most lateral point Anterior surface

Autonomous territory Anterior surface

The most medial point Anterior surface

The most distal point Palmar surface

Brachial domain Anatomical plate 4.7 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

35

Lateral cutaneous nerve of forearm Nervus cutaneus antebrachii lateralis

The most proximal point Lateral surface

The most anterior point Lateral surface

Autonomous territory Lateral surface

The most distal point Lateral surface

The most posterior point Lateral surface

Backhouse et al. (1986)

Brachial domain Anatomical plate 4.8 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

36

6. 5. 4. 3. 2.

1.

1. Common and proper palmar digital nerves

Ulnar nerve

Left MEDIAL cord of brachial plexus

2. Palmar branch

3. Dorsal branch

C8-Th2 Medial antebrachial cutaneous nerve 5. anterior, 4. posterior branches

6. Medial brachial cutaneous nerve

Brachial domain Table V, left : The family of six nerves of the left MEDIAL cord of brachial plexus Fasciculus medialis, plexus brachialis 37

1.

2. 3. 4. 5. 6.

1. Common and proper palmar digital nerves

2. Palmar branch

Ulnar nerve

Right MEDIAL cord of brachial plexus

3. Dorsal branch

Medial antebrachial cutaneous nerve 4. posterior, 5. anterior branches

6. Medial brachial cutaneous nerve

Brachial domain Table V, right : The family of six nerves of the right MEDIAL cord of brachial plexus Fasciculus medialis, plexus brachialis 38

C8-Th2



Common and proper palmar*, and dorsal, digital nerves of ulnar nerve

Nervi digitales palmares communes et proprii, et rami dorsales, nervus ulnaris

The most proximal point Palmar surface

The most radial point Palmar surface

Autonomous territory Palmar surface

The most ulnar point Ulnar surface

Trotter et al. (1907)

Brachial domain Anatomical plate 4.9 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory * see appendix III

39

Palmar branch of ulnar nerve Ramus palmaris, nervus ulnaris

The most proximal point Anterior surface

The most lateral point Anterior surface

Autonomous territory Anterior surface

The most medial point Anterior surface

1 2

The most distal point Palmar surface

1 Ludwig (1967) 2 Schünke et al. (2005)

Brachial domain Anatomical plate 4.10 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

40



Dorsal branch of ulnar nerve

Ramus dorsalis, nervus ulnaris

The most proximal point Dorsal surface

The most ulnar point Ulnar surface

Autonomous territory Dorsal surface

The most distal point Dorsal surface

The most radial point Dorsal surface

Sunderland (1978)

Brachial domain Anatomical plate 4.11 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

41

Posterior branch of medial cutaneous nerve of forearm Ramus posterior, nervus cutaneus antebrachii medialis

The most proximal point Lateral surface

The most anterior point Lateral surface

Autonomous territory Lateral surface

The most posterior point Lateral surface

The most distal point Dorsal surface

Brachial domain Anatomical plate 4.12  the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

42



Anterior branch of medial cutaneous nerve of forearm Ramus anterior, nervus cutaneus antebrachii medialis

The most proximal point Medial surface

The most posterior point Medial surface

Autonomous territory Medial surface

The most anterior point Medial surface

The most distal point Anterior surface

Brachial domain Anatomical plate 4.13 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

43

Medial cutaneous nerve of arm Nervus cutaneus brachii medialis

The most proximal point Medial surface

The most posterior point Posterior surface

Autonomous territory Medial surface

The most anterior point Medial surface

The most distal point Medial surface

Brachial domain Anatomical plate 4.14 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

44

Intercostobrachial nerve Nervus intercostobrachialis

Posterior-intercostal domain

Table VI : The nerve branches that can induce intercostobrachial neuralgia Thoracointercostobrachialneuralgie

45

Posterior-intercostal domain Introductory Summary 

The skin sensitivity of the thorax and of the anterior surface of abdomen is relayed to the intercostal and subcostal nerves that feed into the anterior branches of the thoracic nerves. The tactile sensitivity of the back is transmitted to the posterior branches of the thoracic nerves

Posterior-intercostal domain Anatomical plate 5.1 : territories of cutaneous origin of posterior branches of the 12 thoracic (Th) nerves

47

Posterior-intercostal domain Anatomical plate 5.2 : territories of cutaneous origin of 10 lateral cutaneous branches of the 12 thoracic (Th) nerves

48

Posterior-intercostal domain Anatomical plate 5.3 : territories of cutaneous origin of anterior pectoral cutaneous branches of the 12 thoracic (Th) nerves

49

In summary

posterior branch

lateral cutaneous branch

anterior pectoral cutaneous branch

Posterior-intercostal domain

Three branches that can induce a Thoracic Neuralgia of the 4th thoracic (Th 4) nerve: See plate 5.1 : posterior branch Ramus posterior See plate 5.2 : lateral cutaneous branch Ramus cutaneus lateralis See plate 5.3 : anterior pectoral cutaneous branch Ramus cutaneus anterior pectoralis

50

Autonomous territories of cutaneous origin Anterior branches:

Posterior branch Lateral

Superior clunial nerve I

Abdominal

Iliohypogastric nerve (L1): Lateral and abdominal cutaneous branches

Ø

Superior clunial nerve II

Ilio-inguinal nerve (L1): Abdominal cutaneous branch

Lumbo-abdominal domain

Table VII : The five posterior or anterior branches that can induce lumbo-abdominal neuralgia Lumbabdominalisneuralgie

51

Lumbo-abdominal domain Introductory Summary

The sensory information from the skin of groin and antero-lateral genitals is delivered to the lateral and abdominal cutaneous branch of the iliohypogastric nerve to the ilio-inguinal nerve via its abdominal and anterior labial/scrotal branches, and eventually to the Lumbar plexus and the posterior roots of its spinal nerves. Each of those branches originates from a specific autonomous cutaneous territory and its surrounding area

Iliohypogastric nerve Nervus iliohypogastricus

See anatomical plate:

5.1

Posterior surface

See anatomical plate: VII.

5.2

Lateral surface

5.3

Anterior surface

7.1

6.2

Lumbo-abdominal domain Anatomical plate 6.1 : Spinal nerve L1 and its superior and inferior neighbours: Superior clunial nerve I, iliohypogastric nerve with its lateral and abdominal branches

53

Abdominal cutaneous branch of ilio-inguinal nerve Ramus cutaneus abdominalis, nervus ilioinguinalis

The most proximal point Anterior surface

The most superior point Anterior surface

Autonomous territory Anterior surface

The most inferior point Anterior surface

1

The most distal point Anterior surface

2

1 Steward (2000) 2 Backhouse et al. (1986)

Lumbo-abdominal domain Anatomical plate 6.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

54



Anterior labial nerves ♀/ anterior scrotal nerves ♂ Nervi labiales anteriores ♀ / nervi scrotales anteriores ♂

Lumbo-abdominal domain

Table VIII : Territory of cutaneous origin of anterior labial nerves ♀ or anterior scrotal nerves ♂

55

Lumbo-femoral domain Introductory Summary

The skin of the lateral surface of the thigh feeds its sensory impulses into the lateral cutaneous nerve of thigh, while the genitofemoral nerve receives by its femoral branch similar impulses from the proximal anterior surface of the thigh and by its genital branch similar impulses from the proximal medial surface of the thigh. The middle third of the medial surface of thigh is sending its information over the small cutaneous branch of the obturator nerve. All impulses are relayed to the upper part of the lumbo-sacral plexus

Lateral cutaneous nerve of thigh Nervus cutaneus femoris lateralis

The most proximal point Lateral surface

The most posterior point Lateral surface

Autonomous territory Lateral surface

The most anterior point Lateral surface

The most distal point Lateral surface

Lumbo-femoral domain Anatomical plate 7.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

58



Femoral branch of genitofemoral nerve Ramus femoralis, nervus genitofemoralis

The most proximal point Anterior surface of trunk

The most lateral point Anterior surface

Autonomous territory Anterior surface

The most medial point Anterior surface

The most distal point Anterior surface

Lumbo-femoral domain Anatomical plate 7.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

59

Genital branch of genitofemoral nerve Ramus genitalis, nervus genitofemoralis

The most proximal point Medial surface

The most posterior point Medial surface

Autonomous territory Medial surface

The most anterior point Medial surface

The most distal point Medial surface

Middle third Cutaneous branch of obturator nerve

Lumbo-femoral domain Anatomical plate 7.3 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

60

Femoral domain Introductory Summary

The skin of the middle and distal thirds of the anterior surface is sending its information over the anterior branches of the femoral nerve. The medial surfaces of the foot, leg and knee emit their impulses towards the saphenous nerve. The tactile information of the lateral surface of the knee is sending, as well, its impulse to the saphenous nerve via the infrapatellar branch. Each of these branches originates from a specific autonomous cutaneous territory and its surrounding area

63

5.

4.

3. 2.

1. Terminal branch (Medial surface)

2. Medial cutaneous nerves of leg (Medial surface)

Femoral nerve left

3.

Saphenous nerve

Infrapatellar branch (Lateral surface)

L1-L3-L5 4. Medial cutaneous nerve of thigh (Medial surface)

5. Anterior cutaneous branches (Anterior surface)

Femoral domain

Table IX, left : The family of five left branches that can induce femoral neuralgia Femorisneuralgie 62

1.

1.

2.

3. 4.

5.

1. Terminal branch (Medial surface) 2. Medial cutaneous nerves of leg (Medial surface) 3.

Saphenous nerve Femoral nerve right

Infrapatellar branch (Lateral surface)

L1-L3-L5 4. Medial cutaneous nerve of thigh (Medial surface)

5. Anterior cutaneous branches (Anterior surface)

Femoral domain

Table IX, right : The family of five right branches that can induce femoral neuralgia Femorisneuralgie 63

Terminal branch of saphenous nerve Ramus terminalis, nervus saphenus

The most proximal point Medial surface

The most superior point Dorsal surface

Autonomous territory Medial surface

The most inferior point Plantar surface

The most distal point Medial surface

Femoral domain Anatomical plate 8.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

64



Medial cutaneous nerves of leg Rami cruris mediales, nervus saphenus

The most proximal point Medial surface

The most posterior point Medial surface

Autonomous territory Medial surface

The most anterior point Medial surface

The most distal point Medial surface

Femoral domain Anatomical plate 8.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

65

Infrapatellar branch of saphenous nerve Ramus infrapatellaris, nervus saphenus

The most proximal point Medial surface

The most superior point Anterior surface

Autonomous territory Lateral surface

The most inferior point Lateral surface

The most distal point Lateral surface

Femoral domain Anatomical plate 8.3 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

66



Medial cutaneous nerve of thigh Ramus femoris medialis, nervus saphenus

The most proximal point Medial surface

The most posterior point Medial surface

Autonomous territory Medial surface

The most anterior point Medial surface

The most distal point Medial surface

Femoral domain Anatomical plate 8.4 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

67

Anterior cutaneous branches of femoral nerve Rami cutanei anteriores, nervus femoralis

The most proximal point Anterior surface

The most lateral point Anterior surface

Autonomous territory Anterior surface

The most distal point Anterior surface

The most medial point Anterior surface

Bommas-Ebert et al. (2006)

Femoral domain Anatomical plate 8.5 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

68

Sciatic domain Introductory Summary

The skin covering the dorsum of foot sends its tactile information to the superficial peroneal nerve, except a small area in the first inter-digital space that feeds into the deep peroneal nerve. The tibial nerve collects the tactile impulses from the sole and the medial border of foot. The lateral surface of heel and of foot emits its impulses towards the sural nerve, which proximally splits to reach the lateral sural cutaneous nerve. All the information ultimately is collected by the lowest part of the lumbo-sacral plexus

71

70

L4-S3

Sciatic nerve left

Tibial nerve

Nervus fibularis

nerve

Common fibular

Nervus plantaris lateralis

Nervus plantaris medialis

Nervus cutaneus surae lateralis

Nervus fibularis profondus

Nervus fibularis superficialis

Lateral plantar nerve

Medial plantar nerve

nerve

Lateral sural cutaneous

Deep peroneal nerve

Superficial peroneal nerve

71

Sciatic domain

Rami calcanei laterales, nervus suralis

Nervus cutaneus dorsalis lateralis, nervus suralis

Table X, left : The family of eight left nerve branches that can induce sciatic neuralgia Ischiadicusneuralgie

Nervus ischiadicus

Nervus tibialis

Rami calcanei mediales

(Létiévant,1869)

Aesthesiography of a transection of sciatic nerve at thigh level

of sural nerve

Lateral calcaneal branches

nerve

Lateral dorsal cutaneous

Medial calcaneal branches

72

Lateral plantar nerve

Medial plantar nerve

Lateral sural cutaneous nerve

Deep peroneal nerve

Superficial peroneal nerve

Nervus plantaris lateralis

Nervus plantaris medialis

Nervus cutaneus surae lateralis

Nervus fibularis profondus

Nervus fibularis superficialis

Tibial nerve

Nervus fibularis

Common fibular nerve

L4-S3

Sciatic nerve right

73

Sciatic domain

Nervus tibialis

Nervus ischiadicus

Table X, right : The family of eight right nerve branches that can induce sciatic neuralgia Ischiadicusneuralgie

Rami calcanei laterales, nervus suralis

Lateral calcaneal branches of sural nerve Aesthesiography of a transection of sciatic nerve at thigh level (Létiévant, 1869)

Nervus cutaneus dorsalis lateralis, nervus suralis

Rami calcanei mediales

Lateral dorsal cutaneous nerve

Lateral calcaneal branches

Superficial peroneal nerve Nervus fibularis superficialis

The most proximal point Dorsal surface

The most lateral point Dorsal surface

Autonomous territory Dorsal surface

The most medial point Dorsal surface

The most distal point Dorsal surface

Sciatic domain Anatomical plate 9.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

74



Deep peroneal nerve Nervus fibularis profundus

The most proximal point Dorsal surface

The most lateral point Dorsal surface

Autonomous territory Dorsal surface

The most medial point Dorsal surface

The most distal point Dorsal surface

Sciatic domain Anatomical plate 9.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

75

Lateral sural cutaneous nerve Nervus cutaneus surae lateralis

The most proximal point Lateral surface

The most anterior point Lateral surface

Autonomous territory Lateral surface

The most posterior point Lateral surface

The most distal point Lateral surface

Sciatic domain Anatomical plate 9.3 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

76



Medial plantar nerve Nervus plantaris medialis

The most proximal point Plantar surface

The most lateral point Plantar surface

Autonomous territory Plantar surface

The most distal point Plantar surface

The most medial point Plantar surface

Anderson(1978)

Sciatic domain Anatomical plate 9.4 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

77

Lateral plantar nerve Nervus plantaris lateralis

The most proximal point Plantar surface

The most lateral point Plantar surface

Autonomous territory Plantar surface

The most distal point Plantar surface

The most medial point Plantar surface

Schünke (2005)

Sciatic domain Anatomical plate 9.5 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

78



Medial calcaneal branches Rami calcanei mediales

The most proximal point Medial surface

The most anterior point Medial surface

Autonomous territory Medial surface

The most posterior point Medial surface

The most distal point Plantar surface

Sciatic domain Anatomical plate 9.6 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

79

Lateral dorsal cutaneous branch of sural nerve Nervus cutaneus dorsalis lateralis

The most proximal point Lateral surface

The most dorsal point Lateral surface

Autonomous territory Lateral surface

The most distal point Lateral surface

The most lateral point Lateral surface

Tinel (1916 [1917])

Sciatic domain Anatomical plate 9.7 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

80



Lateral calcaneal branches of sural nerve Rami calcanei laterales, nervus suralis

The most proximal point Lateral surface

The most posterior point Lateral surface

Autonomous territory Lateral surface

The most anterior point Lateral surface

The most distal point Plantar surface

Sciatic domain Anatomical plate 9.8 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

81

Medial terminal branch of superficial peroneal nerve Ramus terminalis medialis, nervus fibularis superficialis

The most proximal point Dorsal surface

The most lateral point Dorsal surface

Autonomous territory Dorsal surface

The most medial point Dorsal surface

The most distal point Dorsal surface

Sciatic domain Anatomical plate 9.9 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

82

 Intermediate terminal branch of superficial peroneal nerve Ramus terminalis intermedius, nervus fibularis superficialis

The most proximal point Dorsal surface

The most lateral point Dorsal surface

Autonomous territory Dorsal surface

The most medial point Dorsal surface

The most distal point Dorsal surface

Sciatic domain Anatomical plate 9.10 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

83

Lateral terminal branch of superficial peroneal nerve Ramus terminalis lateralis, nervus fibularis superficialis

The most proximal point Dorsal surface

The most lateral point Dorsal surface

Autonomous territory Dorsal surface

The most medial point Dorsal surface

The most distal point Dorsal surface

Sciatic domain Anatomical plate 9.11 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

84

Sacral domain Introductory Summary

The middle clunial nerves carry their impulses from the middle part of the buttocks' skin to the posterior branches of the sacral and coccygeal spinal nerves. The lowest part of the buttocks’ cutaneous cover and the thigh’s posterior surface forward their sensory impulses to the sacral plexus via the inferior clunial nerves and the posterior cutaneous nerve of the thigh. The skin surrounding the anus (via the anococcygeal nerve) and covering the perineum and the posterior genitals (by way of the posterior labial/scrotal nerves) emits its sensory impulses over the pudendal nerve inside the pelvis to the sacral and coccygeal plexuses

Posterior cutaneous nerve of thigh Nervus cutaneus femoris posterior

The most proximal point Posterior surface

The most medial point Posterior surface

Autonomous territory Posterior surface

The most lateral point Posterior surface

The most distal point Posterior surface

Sacral domain Anatomical plate 10.1 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

86



Inferior clunial nerves Nervi clunium inferiores

The most proximal point Posterior surface

The most medial point Posterior surface

Autonomous territory Posterior surface

The most distal point Posterior surface

The most lateral point Posterior surface

Aumüller (2007)

Sacral domain Anatomical plate 10.2 : the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory

87

Anococcygeal nerve, branch of coccygeal plexus Nervus anococcygeus

Inferior rectal nerves of pudendal nerve

Nervi rectales inferiores

Posterior labial nerves 䗠/ posterior scrotal nerves 䗢 of pudendal nerve Nervi labiales posteriores 䗠㻌/ nervi scrotales posteriores 䗢

Sacral domain Anatomical plate 10.3 : territories of cutaneous origin of three cutaneous nerve branches of perineum

88

Autonomous territories of cutaneous origin

Medial cluneal nerve I

Medial cluneal nerve II

Medial cluneal nerve III

Medial cluneal nerve IV

Posterior branch of st 1 coccygeal nerve

Sacral domain

Table XI : The five posterior nerve branches that can induce sacral neuralgia Sacralisneuralgie

89

90

C6 C7 C8 Th1

Brachial Neuralgia (Posterior cord of brachial plexus) Brachial Neuralgia (Lareral cord of brachial plexus) Brachial Neuralgia (Medial cord of brachial plexus) Brachial Neuralgia (Medial cutaneous nerve of arm) Intercostobrachial Neuralgia Intercostal Neuralgia Subcostal Neuralgia

Posterior branch of 6th cervical nerve

Posterior branch of 7th cervical nerve

Posterior branch of 8th cervical nerve

Posterior branch of 1st thoracic nerve

Posterior branch of 2nd thoracic nerve

Posterior branches from 3rd to 11th thoracic nerve

Posterior branch of 12th thoracic nerve

Th12

Th3 to Th11

Th2

C5

C4

C3

C2

Root

Brachial Neuralgia (Superior-cutaneous nerve of “arm”)

Cervical Neuralgia (Transverse cervical nerve)

Associated domains

Posterior branch of 5th cervical nerve

Posterior branch of 4th cervical nerve

3rd occipital nerve (Posterior branch of 3rd cervical nerve)

Greater occipital nerve (Posterior branch of 2nd cervical nerve)

Posterior branches

91

Co

Posterior branch of 1st coccygeal nerve

Table XII : The posterior nerve branches for distant counter-stimulations

S5

Ø: Does NOT exist

S3

Sacral Neuralgia of which Pudendal Neuralgia

Medial cluneal nerve III

S4

S2

Sacral Neuralgia of which Pudendal Neuralgia

Medial cluneal nerve II

Medial cluneal nerve IV

S1

Sacral Neuralgia of which Pudendal Neuralgia

L5

Ø: Does NOT exist

Medial cluneal nerve I

L4

L3

Femoral Neuralgia (seldom)

Posterior branch of 3rd lumbar nerve

Posterior branch of 4th lumbar nerve

L2

Lumbo-abdominal Neuralgia

Superior cluneal nerve II

L1

Lumbo-abdominal Neuralgia

Superior cluneal nerve I

Part III

Conclusion

This atlas of clinical anatomy strives to confirm ‫[ קבלה‬Qabbala ≡ tradition] from a “new” afferent point of view. This reco­gnising is NOT a fight against the clinical anatomy tradition. It is built on the listening of daily patient’s complaints. Since July 2004, instead of being disturbed by the possible discrepancies between the description of their symptoms, i.e. burning sensation, and the traditional neuroanatomic description of distribution territories, we chose to acknowledge the validity of their symptoms and change our clinical examination. Consequently, burning sensations can take place in the territorial origin of one or more nerve branches. Axiom: When the patient reports neuropathic pain symptoms, he has axonal lesions of, at least, one cutaneous nerve branch, including Aβ neurofibres. The need to address the difference between medical descriptions and the patient’s experience in neuropathic pain indicators was reported in scientific literature 40 years ago. To Ulf Lindblom and co-author (1979), the symptom of neuralgia which is the centre of concern is, of course, the pain itself. Of secondary importance are the somatosensory abnormalities which often occur in the painful area (Lindblom and Verrillo 1979). We have uniformly documented these somatosensory abnormalities not only to provide an objective and reproducible measurement (Packham et al. 2019) of the phenomena, but, as well, to inform treatment strategies by anatomic localisation of the nerve lesion. The psycho-physical mapping procedure relies on both a standardised stimulus from calibrated monofilaments and a predetermined threshold of intensity perception (3 cm on a visual analogue scale). Together, the (1) standardised stimulus application, (2) prescribed mapping process, (3) calibrated response and (4) somatotopic documentation provide a clear and compelling neurological examination reconciling the symptom experience to the related neuroanatomic territories. This new afferent point of view to consider the somatosensory nervous system presents another representation for the concept of dermatomes. These dermatomal maps are highly variable across the literature – we have collected 17 unique maps of dermatomes from different sources – and NOT useful to look for tactile hypoaesthesia of partial lesions of peripheral cutaneous branch nerve. The dermatomes are the representational maps of the neurophysiological consequences of nerve root transection. In 19 years of searching, we have found only one methodological description of the procedure for such mapping. The 1932 Nobel Prize winner for Medicine, Charles Sherrington mapped the hypoalgesia – and NOT the tactile hypoaesthesia – after the transection of one root per rhesus macaque (Sherrington 1901). However, maps of dermatomes are useful to decide the indication – or NOT – of neurosurgery in the condition of discal hernia. “It is hard to say ‘no’ when one opposes a greater number. It is also critical as one finds himself in the role of the offender. By saying that the Earth is round, whilst we clearly see it is flat, we stand as a deviant, almost abnormal. The statement is considered profane if the inference conflicts with the Literature. He who could think such a thing should be burnt at the stake” (Cyrulnik 2016). The 3142 neuropathic pain patients documented in this atlas were referred to the Somatosensory Rehabilitation Centre by 622 physicians from every speciality: general medical practice, pain medicine, neurology, orthopaedic surgery, hand surgery, foot surgery, abdominal surgery, plastic surgery, neurosurgery, obstetrics, rheumatology, otorhinolaryngology, gynaecology and dentistry. They requested a detailed examination of the clinical neuroanatomy of their patients and recommendations for therapeutic strategies to address their pain.

95

Index of Anatomical Plates Anatomical plates illustrating the five topographical elements of tactile sensation, as defined by the four cardinal points of the largest territory of cutaneous origin plus its autonomous territory. Trigeminal Domain 1.1 Ophthalmic nerve, branch of trigeminal nerve [V1] 1.2 Maxillary nerve, branch of trigeminal nerve [V2] 1.3 Mandibular nerve, branch of trigeminal nerve [V3]

Occipital Domain .1 2 2.2

Greater occipital nerve Great auricular nerve

Cervical Domain 3.1 Transverse cervical nerve

Brachial Domain .1 4 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14

Superficial branch of radial nerve Posterior cutaneous nerve of forearm Posterior cutaneous nerve of arm Inferior lateral cutaneous nerve of arm Superior lateral cutaneous nerve of arm Common and proper palmar, and dorsal, digital nerves of median nerve Palmar branch of median nerve Lateral cutaneous nerve of forearm Common and proper palmar, and dorsal, digital nerves of ulnar nerve Palmar branch of ulnar nerve Dorsal branch of ulnar nerve Posterior branch of medial cutaneous nerve of forearm Anterior branch of medial cutaneous nerve of forearm Medial cutaneous nerve of arm

Posterior-intercostal Domain 5.1 Posterior branches of the 12 thoracic nerves 96

.2 5 5.3

10 lateral cutaneous branches of the 12 thoracic nerves Anterior pectoral cutaneous branches of the 12 thoracic nerves

Lumbo-abdominal Domain 6.1 6.2

Iliohypogastric nerve Abdominal cutaneous branch of ilio-inguinal nerve

Lumbo-femoral Domain .1 7 7.2 7.3

Lateral cutaneous nerve of thigh Femoral branch of genitofemoral nerve Genital branch of genitofemoral nerve

Femoral Domain .1 8 8.2 8.3 8.4 8.5

Terminal branch of saphenous nerve Medial cutaneous nerves of leg Infrapatellar branch of saphenous nerve Medial cutaneous nerve of thigh Anterior cutaneous branches of femoral nerve

Sciatic Domain .1 9 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11

Superficial peroneal nerve Deep peroneal nerve Lateral sural cutaneous nerve Medial plantar nerve Lateral plantar nerve Medial calcaneal branches Lateral dorsal cutaneous branch of sural nerve Lateral calcaneal branches of sural nerve Medial terminal branch of superficial peroneal nerve Intermediate terminal branch of superficial peroneal nerve Lateral terminal branch of superficial peroneal nerve

Sacral Domain 0.1 Posterior cutaneous nerve of thigh 1 10.2 Inferior clunial nerves from posterior cutaneous nerve of thigh 10.3 Three nerve branches of perineum 97

Index of Tables

98

I.

The four posterior or anterior branches that can induce occipital neuralgia

II.

The seven posterior or anterior branches that can induce cervical neuralgia

III.

The family of five nerves of the POSTERIOR cord of brachial plexus

IV.

The family of three nerves of the LATERAL cord of brachial plexus

. V

The family of six nerves of the left MEDIAL cord of brachial plexus The family of six nerves of the right MEDIAL cord of brachial plexus

VI.

The nerve branches that can induce intercostobrachial neuralgia

VII.

The five posterior or anterior branches that can induce Lumbo-abdominal Neuralgia

VIII.

Territory of cutaneous origin of anterior labial nerves or anterior scrotal nerves

I X.

The family of five left branches that can induce femoral neuralgia The family of five right branches that can induce femoral neuralgia

. X

The family of eight left nerve branches that can induce sciatic neuralgia The family of eight right nerve branches that can induce sciatic neuralgia

XI.

The five posterior nerve branches that can induce sacral neuralgia

XII.

The posterior nerve branches for distant counter-stimulations

References Anderson, J.E. (1978). Grant’s Atlas of Anatomy (7th ed.). Baltimore: The Williams & Wilkins Company. Aumüller, G. & Aust, G. (2007). Anatomie. Stuttgart: Thieme, collection Duale Reihe. Backhouse, K.M. & Hutchings, R.T. (1986). Color Atlas of Surface Anatomy; clinical and applied. Baltimore: Williams & Wilkins. Bommas-Ebert, U., Teubner, P. & Voss, R. (2006). Kurzlehrbuch Anatomie und Embryologie (2. Auflage). Stuttgart, New York City: Georg Thieme Verlag. Bell-Krotoski, J.A., Weinstein, S. & Weinstein, C. (1994). Testing sensibility, including touch-pressure, two-point discrimination, point localization, and vibration. J Hand Ther, 7, 114-122. Cyrulnik, B. (2016). Ivres paradis, bonheurs héroïques. Paris: Odile Jacob. Doyle, J.R. & Botte, M.J. (2003). Surgical Anatomy of the Hand & Upper Extremity. Philadelphia, Baltimore, New York City, London, Buenos Aires, Hong Kong, Sydney, Tokyo: Lippincott Williams & Wilkins. Ellis, H. (1997). Clinical Anatomy: A revision and applied anatomy for clinical students (9th ed.). Oxford, London, Edinburgh, Malden, Carlton, Victoria, Paris, Berlin, Wien: Blackwell Science Ldt. Hall-Craggs, E.C.B. (1986). Anatomy as a Basis for Clinical Medicine (2nd Printing). Baltimore, Munich: Urban & Schwarzenberg. Lanz von, T. & Wachsmuth, W. (1935). Praktische Anatomie; Erster Band / Dritter Teil Arm. Berlin: Julius Springer. Lanz von, T. & Wachsmuth, W. (1938). Praktische Anatomie; Erster Band / Vierter Teil Bein und Statik. Berlin: Julius Springer. Létiévant, E. (1869). Phénomènes physiologiques et pathologiques consécutifs à la section des nerfs du bras. Lyon médical, 3, 150-164, 225-243, 298-320, planches I à VI. Létiévant, E. (1873). Traité des sections nerveuses: physiologie pathologique, indications – procédés opératoires. Paris: J.-B. Baillère. (réédité sous: Association française pour l’avancement des sciences (2013 [1875]). Esthésiographie, par le « Dr Jean-Joseph-Emile Létiévant ». Paris: Hachette). Lindblom, U. & Verrillo, R.T. (1979). Sensory functions in chronic neuralgia. J Neurol Neurosurg Psychiatry, 42(5), 422-435. Ludwig, K.S. (1967). Planche II : Membre supérieur; publicité de l’Optalidon. Bâle: Sandoz. Packham, T.L., Spicher, C.J., MacDermid, J.C. & Buckley, D.N. (2019). Allodynography: reliability of a new procedure for objective clinical examination of static mechanical allodynia. Pain Med. https://doi.org/10.1093/pm/pnz045 Quintal, I., Noël, L., Gable, C., Delaquaize, F., Bret-Pasian, S., Rossier, Ph., Annoni, J.M., Maupas, E. & Spicher, C.J. (2013). La méthode de rééducation sensitive de la douleur. Encyclopédie Médico-Chirurgicale (EMC), Kinésithérapie-Médecine physique-Réadaptation, 26-469-A-10, 1-16. Salasche, S.J., Bernstein, G. & Sensarik, M. (1988). Surgical Anatomy of the Skin. Norwalk, Connecticut: Appleton & Lange. Schünke, M., Schulte, E. & Schumacher, U. (2005). Prometheus: Lernatlas der Anatomie. Stuttgart, New York City: Georg Thieme Verlag. Sherrington, C.S. (1901). The spinal roots and dissociative anaesthesia in the monkey. J Physiol, 27(4-5), 360-371. Spicher, C. & Kohut, G. (2001). Jean Joseph Emile Létiévant: A review of his contributions to surgery and rehabilitation. J Reconstr Microsurg, 17(3), 169-177.

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Spicher, C.J. & Quintal, I. (2013). La méthode de rééducation sensitive de la douleur (2ème édition) – Préface : R. Melzack. Montpellier, Paris : Sauramps Médical. Spicher, C., Buchet (- Desfoux), N. & Sprumont, P. (2013). Atlas des territoires cutanés du corps humain : Esthésiologie de 240 branches (2e édition) – Préface : S.W. Carmichael (Mayo Clinic). Montpellier, Paris : Sauramps médical. Spicher, C., Barquet, O., Quintal, I., Vittaz, M. & de Andrade Melo Knaut, S. (2020). DOULEURS NEUROPATHIQUES: Évaluation clinique & rééducation sensitive (4e édition) – Préface: F. Moutet. Montpellier, Paris: Sauramps Médical. Steward, O. (2000). Functional Neuroscience. New York City, Berlin, Heidelberg: Springer Verlag. Sunderland, S. (1978). Nerves and nerve injuries (2nd ed.). Edinburgh, London, New York City: Churchill Livingstone. Testut, L. (1897). Traité d’anatomie humaine, T II: Névrologie – organes des sens. Paris: Octave Doin. Tinel, J. (1916). Les blessures de nerfs. Paris: Masson. Trotter, W.M. & Davis, H.M. (1907). The exact determination of areas of altered sensibility. Rev Neurol Psychiatry, 38, 134-246. Tubiana, R. & Thomine, J.-M. (1990). Examen de la sensibilité. In R. Tubiana & J.-M. Thomine (Eds.), La main, Anatomie fonctionnelle et examen clinique (Coll. Abrégés) (pp 189-206). Paris: Masson. Weinstein, S. (1962). Tactile sensitivity of the phalanges. Percept Motor Skills, 14, 351-354. Williams, L.P., Bannister, L.H., Berry, M.M., Collins, P., Dyson, M., Dussek, J.E. & Ferguson, M.W.J. (1999). Grays’s Anatomy: the Anatomy Basis of Medicine and Surgery (38th; ed. 2nd Printing). Edinburgh, London, New-York City, Philadelphia, Sydney, Toronto: Churchill Livingstone.

To learn more: Federative Committee on Anatomical Terminology (1998). Terminologia Anatomica: International Anatomical Terminology. Stuttgart: Thieme. Finnerup, N.B., Haroutounian, S., Kamerman, P., Baron, R., Bennett, D.L., Bouhassira, D., Cruccu, G., Freeman, R., Hansson, P., Nurmikko, T., Raja, S.N., Rice, A.S., Serra, J., Smith, B.H., Treede, R.D. & Jensen, T.S. (2016). Neuropathic pain: an updated grading system for research and clinical practice. PAIN®, 157(8), 1599-1606. Hirschfeld, L. (1866). Névrologie et esthésiologie: Traité et iconographie du système nerveux. Paris: Victor Masson & fils. Moore, K.L. & Dalley, A.F. (2001). Anatomie médicale; aspects fondamentaux et applications cliniques (2e tirage de la traduction française de la 4e édition de Moore, K.L. & Dalley, A.F. [1999]. Anatomy Clinically oriented. Baltimore: Lippincott Williams & Wilkins). Paris, Bruxelles: de Boeck. Rouvière, H. (1948). Anatomie humaine, descriptive et topographie, T II: Membres, système nerveux central (6e édition). Paris: Masson. Spicher, C. (2003). Manuel de rééducation sensitive du corps humain. Genève, Paris: Médecine & Hygiène. (Translated in English as: Spicher, C.J. [2006]. Handbook for Somatosensory Rehabilitation – Foreword: A.L. Dellon. Montpellier, Paris: Sauramps Médical). Spicher, C.J., Mathis, F., Degrange, B., Freund, P. & Rouiller, E.M. (2008a). Static Mechanical Allodynia is a Paradoxical Painful HYPO-aesthesia : Observations derived from neuropathic pain patients treated with somatosensory rehabilitation. Somatosens Mot Res, 25(1), 77-92. Spicher, C.J., Ribordy, F., Mathis, F., Desfoux, N., Schönenweid, F. & Rouiller, E.M. (2008b). L’allodynie mécanique masque une hypoesthésie: Observations topographiques de 23 patients douloureux neuropathiques chroniques. Doul & Analg, 21, 239-251. Weber, E.M.W. (1978). Schemata der Leitungsbahnen des Menschen: Nervi spinales Tabula III. Berlin, Heidelberg: Springer Verlag.

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Part IV

Appendix I: Aesthesiography In order to outline a hypoaesthetic territory, some basic material is needed: nylon filaments of different diameters (Semmes-Weinstein/von Frey) named aesthesiometers because they are used to objectify and measure the sense of touch. Four different aesthesiometers are theoretically enough to assess the different parts of the body with four different application forces: 0.1 g, 0.2 g, 0.4 g or 0.7 g. Aim of Aesthesiography To map the boundaries of the tactile hypoaesthesia.

Materials ●●

●● ●●

A4 graph paper, if necessary A3 (in America: 8.5 × 11 or 11 × 17 in.) depending on the size of the body part to be assessed. The mapping of the aesthesiography should be drawn to 1/1 scale. Four aesthesiometers: 0.1 g [Semmes-Weinstein monofilament #2.83], 0.2 g [#3.22], 0.4 g [#3.61] and 0.7 g [#3.84]. Green felt-tip pen.

Choice of Aesthesiometer by the Somatosensory Therapist of Pain

Generally, the aesthesiometer is chosen at 0.1 g above the normal value: 0.1 g at the face, 0.2 g at the volar surface of hands and feet, 0.4 g at the dorsal surface of hands and feet and 0.7 g at the rest of the body (Spicher et al. 2020). When using one of those aesthesiometers, if the boundaries of the territory seem imprecise, determine in a descending series starting at 75 g the last aesthesiometer detected on the contralateral side of the affected area. Then choose the second to last aesthesiometer in this series. For example, if on the contralateral side 1.2  g [#4.08] is the last aesthesiometer detected, perform the test with the 1.5 g [#4.17] aesthesiometer.

 escription of the Procedure D E xplanation to the Patient The aesthesiometer is shown to the patient who is told that he is going to be touched with it in order to determine the territory where his tactile sense is lowered and where he feels less. He is asked to close the eyes or to look away by turning the head. The patient has to say “touched” as soon as he detects the stimulus. If he does not detect anything, no response is needed, of course. P osition The limb to be assessed should be stabilised by the examiner, if necessary. Type of Stimulation ●●

●●

The application force to be applied to the aesthesiometer by the somatosensory therapist of pain is the minimum required to bend the nylon filament. The stimulation of the skin must not last more than 2 s. Therefore, the interval between each application is 10 s, the pause lasting 8 s.

L ocation The goal is to create a polygon of at least four points. The therapist must choose a reference point marked Δ from which he will be able to measure, on both the x and y-axes the distance between the reference point and the first point that the patient does not detect. This point must be reported on the previously traced drawing of the investigated part of the body. The somatosensory therapist of pain has to operate a mental translation between the limb and the sheet of paper. The reference point will be indicated on the tracing by the symbol Δ; i.e. the most distal part of a finger, the end of a scar, etc. (Spicher et al. 2020).

103

Testing With the selected aesthesiometer, look for the first point undetected by the patient. Progressing centimeter by centimeter from distal to proximal, along the longitudinal axis of the territory of cutaneous origin of the damaged nerve branch, until the patient vocalises that he was touched. ●● Then move back on the same axis, millimeter by millimeter, from proximal to distal in order to find the first detected point. ●● Next, move forward again, millimeter by millimeter, from distal to proximal, in order to find the first distal undetected point along this axis. This is the first point of the polygon that will outline the hypoaesthetic territory. ●● Measure the distance between this determined point and the reference point Δ, and record the point from the reference on the drawing with a green felt-tip pen. ●● Draw an arrow to indicate the direction to which the aesthesiometer was applied along the axis. ●● Conduct the same procedure in order to find the first undetected point along the same longitudinal axis, but this time starting from proximal to distal; this is the second point of the polygon. ●● Along a transversal axis bisecting the segment composed of the two first topographical elements (see below), similarly look for the third and fourth points of the polygon first from medial to lateral for the third point then from lateral to medial for the fourth point. ●●

Result With the green felt-tip pen, trace a polygon connecting the four points to outline the hypoaesthetic territory. For example: positive 0.7 g aesthesiography of the lateral sural cutaneous nerve, conducted on 9 April 2009 on the lateral side of the right ankle (Fig. 3, page 5) This mapping is a clinical examination sign which confirms the hypothesis of a damaged nerve branch.

104

 ppendix II: NOT Dermatomes Theoretical reconstruction of the partial tactile hypoaesthesia A observed on the 3133 aesthesiographiesG of this atlas: maps of cutaneous hypoaesthetic territories and the neurophysiological consequences of Aβ neurofibres lesions. They are NOT dermatomes: the representational maps of the neurophysiological consequences of C neurofibres lesions and root transections that induce hypoalgesia.

105

Proper palmar ulnar digital nerve D2 Proper palmar radial digital nerve D3 Proper palmar ulnar digital nerve D3 Proper palmar radial digital nerve D4 Proper palmar ulnar digital nerve D4 Proper palmar radial digital nerve D5 Proper palmar ulnar digital nerve D5 Proper dorsal radial digital nerve D1 Proper dorsal ulnar digital nerve D1 Proper dorsal radial digital nerve D2 Proper dorsal ulnar digital nerve D2

Median nerve

Proper palmar radial digital nerve D2

Plate 4.6

Ulnar nerve

Proper palmar ulnar digital nerve D1

Plate 4.9

Superficial branch of radial nerve

Proper palmar radial digital nerve D1

Common and proper palmar, and dorsal, digital nerves of

Appendix III: Digital Nerves of the Hand

Plate 4.1

Proper dorsal radial digital nerve D4 Proper dorsal ulnar digital nerve D4 Proper dorsal radial digital nerve D5 Proper dorsal ulnar digital nerve D5

106

of ulnar nerve

Proper dorsal ulnar digital nerve D3

Dorsal branch

Proper dorsal radial digital nerve D3

Plate 4.11

About the Authors In 2004, Claude J. Spicher, Certified Hand Therapist Switzerland, founded the Somatosensory Rehabilitation Centre of the human body at the Clinique Générale, a member of the Swiss Medical Network. He is a scientific collaborator for the Department of Neurosciences and Movement Sciences, University of Fribourg (JM Annoni), and an affiliate member of the School of Physical and Occupational Therapy, Faculty of Medicine, McGill University (Montreal). Since 2004, he is editor-in-chief of the e-News Somatosens Rehab, the official e-journal of the Somatosensory Rehabilitation of Pain Network (SRPN)—www.neuropain.ch. Claude has given more than three hundred invited presentations in Europe, USA, Canada and Japan. He has published books and articles in several internationally renowned publications such as Somatosens Mot Res, J Reconstr Microsurg and Pain Med. Tara L. Packham, PhD, Certified Somatosensory Therapist of Pain (CSTP©), is an occupational therapist and assistant professor in the School of Rehabilitation Sciences at McMaster University, Hamilton (ON), Canada. She conducts clinical research in neuropathic pain, particularly related to upper extremity conditions and injuries. Her research program me` also emphasises outcome measurement and moving research into practice. Tara has published multiple papers on these topics and presented over hundred times at national and international meetings on these topics. She is active in the International Association for the Study of Pain, their special interest group on Complex Regional Pain Syndrome (CRPS), the Canadian Pain Society and the Canadian and American Societies of Hand Therapists. She also serves on the editorial boards of the J Hand Ther and Pain Med, and the scientific advisory board for the International Consortium for CRPS research. Nadège Buchet, CSTP®, OT, graduated from Institut de Formation en Ergothérapie de Rennes (France). As an instructor with the SRPN, she has taught in Lausanne, Mulhouse and Montpellier. Nadège has published in several renowned publications. Since 2010, she has been a co-author of this atlas. Isabelle Quintal, MSc(c), CSTP®, BSc OT, graduated from the University of Montreal, and lecturer in the occupational and physical therapy programmes at University of Montreal. She is working in Centre Professionnel d’Ergothérapie (Montreal). As an instructor with the SRPN, Isabelle has taught in Brussels, Freiburg, Montpellier and Montreal. She has published in several internationally renowned publications such as Encyclopédie Médico-Chirugicale and J Hand Ther. Since 2013, she has been a co-author of Rééducation sensitive des douleurs neuropathiques, and since 2017, she has been a co-author of this atlas. Pierre Sprumont is an emeritus professor of anatomy at the Faculty of Science and Medicine of the University of Fribourg (Switzerland). He was educated as a physician and specialist in internal medicine. He has published over sixty scientific articles on the relationships between ovary and immunity, on the cellular mechanisms of brain oedema, on the anatomical terminologies and their early history. He is the past-secretary of the Federative International Programme on Anatomical Terminologies (FIPAT), where he mainly dealt with the ontologies of anatomical entities. He still participates in the FIPAT “Informatics” working group, which he co-ordinated for 6 years.

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