Abstract
Historically, the use of ultrasound (US) in the management of peripheral nervous system (PNS) pathology has been limited to diagnostic confirmation or guidance for interventional injections. This technical case series will demonstrate the utility and versatility of preoperative US-guided needle localization for the excision of lower extremity neuromas and other pathology of the PNS. Five patients with symptomatic lower extremity PNS tumors were retrospectively reviewed. This case series corroborates the technical nuances of localizing lower extremity neuromas by US-guided needle and wire placement prior to operative excision. This was achieved by a multidisciplinary team that included plastic surgery, neurosurgery, and radiology. Five patients had US-guided needle localization of a lower extremity PNS target prior to operative intervention. Three patients had lower extremity neuromas of varying origins, including the lateral femoral cutaneous nerve (LFCN), saphenous nerve, and sural nerve. The remaining two patients had a sciatic nerve sheath Schwannoma and a femoral nerve glomus tumor. Under sonographic visualization, a needle was advanced to the target perimeter and withdrawn, leaving behind a percutaneous guidewire. This technique simplified the marking of the nerve course prior to dissection and led to efficient intraoperative identification of all five PNS tumors without any complications. Preoperative US-guided needle localization led to safe, accurate, and efficient perioperative and intraoperative identification of neuromas and other PNS tumors of the lower extremity prior to excision. By reducing the challenges of nerve identification in a scarred tissue bed, this multidisciplinary approach may decrease postoperative patient morbidity.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Wu J, Chiu DT. Painful neuromas: a review of treatment modalities. Ann Plast Surg. 1999;43(6):661–7.
Zabaglo M, Dreyer MA. Neuroma. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK549838/. [October 1, 2022]
Krishnan KG, Pinzer T, Schackert G. Coverage of painful peripheral nerve neuromas with vascularized soft tissue: method and results. Neurosurgery. 2005;56(2 Suppl):369–78.
Guse D, Moran S. Outcomes of the surgical treatment of peripheral neuromas of the hand and forearm: a 25-year comparative outcome study. Ann Plast Surg. 2013;71(6):654–8.
Ernberg LA, Adler RS, Lane J. Ultrasound in the detection and treatment of a painful stump neuroma. Skeletal Radiol. 2003;32(5):306–9.
Poppler LH, Parikh RP, Bichanich MJ, et al. Surgical interventions for the treatment of painful neuroma: a comparative meta-analysis. Pain. 2018;159(2):214–23.
Thomas RH, Burke C, Howlett D. A technical note: pre-operative ultrasound-guided wire localization in head and neck surgery. Eur Arch Otorhinolaryngol. 2011;268(5):743–6.
Carai A, Fenu G, Sechi E, Crotti FM, Montella A. Anatomical variability of the lateral femoral cutaneous nerve: findings from a surgical series. Clin Anat. 2009;22(3):365–70.
Thomas AJ, Bull MJ, Howard AC, Saleh M. Peri operative ultrasound guided needle localisation of amputation stump neuroma. Injury. 1999;30(10):689–91.
Wijntjes J, Borchert A, van Alfen N. Nerve ultrasound in traumatic and iatrogenic peripheral nerve injury. Diagnostics (Basel). 2020;11(1):30.
Jose J, Smith MK, Kaplan LD, Lesniak BP, Levi AD. Ultrasound-guided needle localization of the saphenous nerve for removal of neuroma in the infrapatellar branches: technical report. Neurosurgery. 2014;75(6):717–22.
Mahakkanukrauh P, Chomsung R. Anatomical variations of the sural nerve. Clin Anat. 2002;15(4):263–6.
Marsland D, Dray A, Little NJ, Solan MC. The saphenous nerve in foot and ankle surgery: its variable anatomy and relevance. Foot Ankle Surg. 2013;19(2):76–9.
Adkison DP, Bosse MJ, Gaccione DR, Gabriel KR. Anatomical variations in the course of the superficial peroneal nerve. J Bone Joint Surg Am. 1991;73(1):112–4.
Hanna A. The lateral femoral cutaneous nerve canal. J Neurosurg. 2017;126(3):972–8.
Purayidathil MJ, Manjaly G, Howlett DC. Removal of an impalpable thyroglossal cyst using ultrasound-guided wire localisation – a technical note. Clin Otolaryngol. 2007;32(2):141–2.
Diaz A, Burks SS, Jose J, Levi AD. Ultrasound-guided needle localization wires in peripheral nerve injuries with long segmental defects: technical case report. Oper Neurosurg (Hagerstown). 2020;20(1):E60–5.
Provost N, Bonaldi VM, Sarazin L, Cho KH, Chhem RK. Amputation stump neuroma: ultrasound features. J Clin Ultrasound. 1997;25:85–9.
Rissanen TJ, Mäkäräinen HP, Kiviniemi HO, Suramo II. Ultrasonographically guided wire localization of nonpalpable breast lesions. J Ultrasound Med. 1994;13(3):183–8.
Moss HA, Barter SJ, Nayagam M, Lawrence D, Pittam M. The use of carbon suspension as an adjunct to wire localisation of impalpable breast lesions. Clin Radiol. 2002;57(10):937–44.
Quinn PS, Sieunarine K, Lawrence-Brown M, Tan P. Intramuscular haemangiomas: hookwire localization prior to surgical excision: report of four cases. ANZ J Surg. 2001;71(1):62–6.
Breeze J, Williams MD, Howlett DC. Ultrasound guided localisation during the excision of an impalpable branchial cyst. Br J Oral Maxillofac Surg. 2008;46(8):686–7.
Chettiar K, Sriskandan N, Thiagaraj S, Desai AU, Ross K, Howlett DC. The use of ultrasound-guided wire localisation in orthopaedics. J Bone Joint Surg Br. 2009;91(5):659–61.
Rutten MJ, Schreurs BW, van Kampen A, Schreuder HW. Excisional biopsy of impalpable soft tissue tumors. US-guided preoperative localization in 12 cases. Acta Orthop Scand. 1997;68(4):384–6.
Hanna AS, Ehlers ME, Lee KS. Preoperative ultrasound-guided wire localization of the lateral femoral cutaneous nerve. Oper Neurosurg (Hagerstown). 2017;13(3):402–8.
Gofeld M, Bristow SJ, Chiu S, Kliot M. Preoperative ultrasound-guided mapping of peripheral nerves. J Neurosurg. 2013;119(3):709–13.
Osorio JA, Breshears JD, Arnaout O, et al. Ultrasound-guided percutaneous injection of methylene blue to identify nerve pathology and guide surgery. Neurosurg Focus. 2015;39(3):E2.
Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233–6.
Haldeman CL, Baggott CD, Hanna AS. Intraoperative ultrasound-assisted peripheral nerve surgery. Neurosurg Focus. 2015;39(3):E4.
Kaminsky S, Griffin L, Milsap J, Page D. Is ultrasonography a reliable way to confirm the diagnosis of Morton’s neuroma? Orthopedics. 1997;20(1):37–9.
Shankar H. Ultrasound-guided sciatic neuroma block for treatment of intractable stump pain. J Clin Anesth. 2008;20(6):483–4.
Beggs I. Pictorial review: imaging of peripheral nerve tumours. Clin Radiol. 1997;52(1):8–17.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Finkelstein, E.R., Buitrago, J., Jose, J. et al. Lower extremity peripheral nerve pathology: Utility of preoperative ultrasound-guided needle localization before operative intervention. Skeletal Radiol 52, 1997–2002 (2023). https://doi.org/10.1007/s00256-023-04347-y
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00256-023-04347-y