Sept ultrasound case of the month

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Sept ultrasound case of the month

  1. 1. Ultrasound Case of the Month September 2013
  2. 2. 53 year old female with right forefoot pain and tingling in the toes
  3. 3. Sagittal Axial Grayscale Images Through the Third Webspace
  4. 4. 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 + + + +
  5. 5. Diagnosis: Third Webspace Neuroma
  6. 6. Neuroma Case Points
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. Neuromas: US • Typically hypoechoic on US
  11. 11. Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler
  12. 12. Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler • Can see continuity with the digital nerve
  13. 13. Neuromas: US • Typically hypoechoic on US • May be hypervascular on power Doppler • Can see continuity with the digital nerve Digital Nerve Neurom a
  14. 14. 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
  15. 15. Neuromas: MRI • Teardrop shaped
  16. 16. Neuromas: MRI • Teardrop shaped • Iso/hypointense on T1 and iso/hyperintense T2
  17. 17. Neuromas: MRI • Teardrop shaped • Iso/hypointense on T1 and iso/hyperintense T2 • May be associated with intermetatarsal edema/bursitis
  18. 18. Neuromas: MRI • Teardrop shaped • Iso/hypointense on T1 and iso/hyperintense T2 • May be associated with intermetatarsal edema/bursitis • Variable enhancement or nonenhancing
  19. 19. Neuromas: Treatment • Conservative: Modify footwear, US- guided steroid/lidocaine injection
  20. 20. 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
  21. 21. Neuromas: Treatment • Conservative: Modify footwear, US- guided steroid/lidocaine injection • Advanced: Alcohol injections, radiofrequency ablation, and cryoablation
  22. 22. 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)
  23. 23. 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”
  24. 24. 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
  25. 25. 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

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