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Preoperative Ultrasound-Guided Needle Localization Before Excision of Lower Extremity Neuromas: A Technical Case Series
Emily R Finkelstein, BS1; Taylor Smartz, BS2; Emily Errante, PhD2; Joanne Buitrago, MD2; Jean Jose, MD3; Allan D Levi, MD, PhD2; Kyle Y Xu, MD1; S. Shelby Burks, MD2
1University of Miami, Miami, FL; 2University of Miami Health System, Miami, FL; 3Jackson Memorial Hospital, Miami, FL

Background: Neuromas are painful collections of unorganized axon fibers resulting from trauma, amputation, or surgical procedures. Despite ultrasound (US) being a widely utilized and easily accessible imaging modality, its use in the management of neuromas has thus far been limited to diagnostic confirmation or guidance for steroid and anesthetic injections. This technical case series will demonstrate the utility of preoperative US-guided curved-needle localization for surgical excision of lower extremity neuromas.
Methods: The course of five patients with symptomatic lower extremity neuromas were retrospectively reviewed. The case series corroborates the technical nuances of localizing lower extremity neuromas by US-guided curved needle and wire placement prior to operative neuroma excision. This approach was developed by a multidisciplinary team including plastic surgery, neurosurgery, and radiology.
Results: Four patients had US-guided needle localization of their lower extremity neuromas the morning of planned operative excision. Two patients had neuromas in the lateral femoral cutaneous nerve, one patient had a saphenous nerve neuroma, and the remaining patient had multiple neuromas, with the most significant tumors located in the peroneal distribution and sciatic nerve sheath. One additional patient had US-guided sural nerve hydrodissection and nerve release by radiology. All five patients had a history of one or more US-guided nerve blocks with a steroid and anesthetic mixture leading to symptomatic relief confirming the neuroma. Localization of neuroma by color doppler sonography was performed following local anesthetic injection of lidocaine without epinephrine. After US-guided needle advancement, a wire was left percutaneously and secured with steri strips and a tegaderm dressing before transferring the patient to the operating room for surgical excision. Preoperative ultrasound-guided wire placement allowed for simplified marking of the nerve course prior to initial dissection and efficient identification of the neuroma through scarred tissue for excision. There were no complications related to needle-localization in any of the five patients.
Conclusion: Preoperative US-guided curved-needle localization led to the safe and accurate identification of neuromas from multiple origins in the lower extremity. In addition to diagnostic confirmation and injections for symptomatic relief, this multidisciplinary approach using US-guidance may be beneficial in defining planes for dissection and reducing challenges in the identification of neuromas in a scarred bed.


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