Sept  ultrasound case of the month
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Sept ultrasound case of the month

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Sept  ultrasound case of the month Sept ultrasound case of the month Presentation Transcript

  • Ultrasound Case of the Month September 2013
  • 53 year old female with right forefoot pain and tingling in the toes
  • Sagittal Axial Grayscale Images Through the Third Webspace
  • Grayscale Images Through the Third Webspace + D = 15.1 mm x D = 7.4 mm xx xx Sagittal and axial grayscale sonographic images at the level of the third metatarsal head demonstrate an ovoid hypoechoic mass + + + +
  • Diagnosis: Third Webspace Neuroma
  • Neuroma Case Points
  • Neuroma Case Points Tibial n. Medial Plantar n. Lateral Plantar n. • Fibrosis, local vascular proliferation, and edema adjacent to an enlarged digital branch of the medial or lateral plantar nerves
  • Neuroma Case Points Tibial n. Medial Plantar n. Lateral Plantar n. • Fibrosis, local vascular proliferation, and edema adjacent to an enlarged digital branch of the medial or lateral plantar nerves • Found on the plantar side of the transverse metatarsal ligament
  • Neuroma Case Points Tibial n. Medial Plantar n. Lateral Plantar n. • Fibrosis, local vascular proliferation, and edema adjacent to an enlarged digital branch of the medial or lateral plantar nerves • Found on the plantar side of the transverse metatarsal ligament • Patients present with metatarsalgia
  • Neuromas: US • Typically hypoechoic on US
  • Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler
  • Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler • Can see continuity with the digital nerve
  • Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler • Can see continuity with the digital nerve Digital Nerve Neurom a
  • Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler • Can see continuity with the digital nerve • Sonographic Mulder‟s sign: Palpable „click‟ from the neuroma popping out of the intermetatarsal space upon tranverse compression of the metatarsal heads while the transducer applies pressure on the plantar surface of the neuroma
  • Neuromas: MRI • Teardrop shaped
  • Neuromas: MRI • Teardrop shaped • Iso/hypointense on T1 and iso/hyperintense T2
  • Neuromas: MRI • Teardrop shaped • Iso/hypointense on T1 and iso/hyperintense T2 • May be associated with intermetatarsal edema/bursitis
  • Neuromas: MRI • Teardrop shaped • Iso/hypointense on T1 and iso/hyperintense T2 • May be associated with intermetatarsal edema/bursitis • Variable enhancement or nonenhancing
  • Neuromas: Treatment • Conservative: Modify footwear, US- guided steroid/lidocaine injection
  • Neuromas: Treatment This 34 year old dancer has a history of two prior steroid injections of a second webspace neuroma. Note the foci decreased echogenicity consistent with scarring. Foci of increased echogenicity are related to microbubble formation and the inherent contrast effect of the steroid/ anesthetic mixture
  • Neuromas: Treatment • Conservative: Modify footwear, US- guided steroid/lidocaine injection • Advanced: Alcohol injections, radiofrequency ablation, and cryoablation
  • Neuromas: Treatment 36 year old male with a third webspace neuroma, status post prior steroid/anesthetic injection with only temporary relief US guided placement of a cryoablation needle into the third webspace neuroma Post cryoablation image with formation of an “ice ball” (see next slide)
  • Neuromas: Treatment Cryoablation of neuromas typically involves 2-3 cycles of freezing with intervening shorter cycles of thawing, resulting in the formation of the characteristic “ice ball”
  • Neuromas: Treatment • Conservative: Modify footwear, US- guided steroid/lidocaine injection • Advanced: Alcohol injections, radiofrequency ablation, and cryoablation • Surgical: Resection of the neuroma, interdigital nerve, and/or transverse metatarsal ligament release
  • References • Bencardino J, Rosenberg ZS, Beltran J, et al. Morton‟s neuroma: is it always symptomatic? AJR Am J Roentgenol 2000; 175: 649-653 • Hughes RJ, Ali K, Jones H, et al. Treatment of Morton‟s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AHR Am J Roentgenol 2007;188: 1535-1539 • Quinn TJ, Jacobson JA, Craig JG, et al. Sonography of Morton‟s Neuromas. AJR Am J Roentgenol 2000;174: 1723-1728 • Sofka CM, Adler RS, Ciavarra GA, et al. Ultrasound-guided Interdigital Neuroma Injections: Short-term Clinical Outcomes after a Single Percutaneous Injection- Preliminary Results. HSSJ, 2007;3: 44-49 • Neumann V, O‟Connor RJ, Bush D. Cryoprobe treatment: an alternative to phenol injections for painful neuromas after amputation. AJR Am J Roentgenol, 2008;191: W313