So this is Dr. Lam, we're gonna do a block -- a PT block
A PT ankle block just to numb up the nerve at the bottom of the foot.
We're preparing for the radiofrequency ablation for the bottom of the foot, the neuroma right
here. So how does a neuroma look and feel like? Well, they feel a little click right here,
I squeeze -- third interspace is most common -- it pops, the patient can confirm the pop. Oh yeah.
Correct. So here's what we're gonna do. In order to not interfere with the radiofrequency ablation,
I numb up the nerve about the ankle right here. This nerve is the tarsal tunnel, it goes all
the way down into the foot. Now when you do this when we have to do surgery on the bottom of the
foot or any procedure on the bottom of foot or even the tarsal tunnel syndrome, so this nerve,
believe it or not, goes all the way to the bottom and we'll see the bottom of foot turn
red when we get the block going and you'll be totally numb on the bottom. So here we go,
we'll gonna do this live on the ultrasound and go from there. Give a little bit of a prep.
For the students -- for the podiatric medical students or anesthesia students
out there we are looking at the -- I'm scanning -- yeah hold the nerve, hold the knee please,
so basically I'm having her knee held, sometimes patients have this kind of jerk reaction that is
just a reflex reaction when we hit the PT nerve with the needle. So here we're gonna go ahead,
I'm gonna look at that screen right now okay? I have my probe right on the medial side of the
ankle, I prepped the skin already, now you see that is the nerve right here that I'm looking at,
I'm putting it right here into the middle of my probe. Zuly, my assistant is gonna go
spray right in the middle, I'm gonna go ahead and get get a bounce between the two screens slowly,
between the screen and the patient it gets bounced between the two, now you can see that the needle,
the medication is going into around the nerve, I'm a little bit anterior so I'm gonna redirect
the needle posteriorly, right here I'm right at the nerve. Do you feel that? It's going into your
toes or your big toe at least, see the fascicle of the nerve separating right there, yeah right?
And this is PT block, very accurate PT block, and you know we're always taught in school to block
around the medial ankle, okay you feel that? I'm right in the fascicle of the PT nerve now on the
branch of the PT nerve, you can see, you feel that going in? Yeah. So I'm in the fascicle of the PT
and you see the medication going in expanding that, so now you can see the medicine within the
PT nerve, we're going up and down, you're doing alright? Mhmm. Beautiful, the two branches right
there we see the PT nerve the two branches, I'm gonna go more proximally, are you okay?
Mm-hmm. Any pain, tingling, nausea? No. Good, funny taste in the mouth? No. [laughs]
Okay the reason why I ask about that is you know, if any of the local went into a vein etcetera,
which can happen very rare but you can have a metallic taste in the mouth which is
for the students here, that is one of the complications of getting a local in there.
Again I'm looking proximally to where I injected, I'm going distal to where I injected, I see all this fluid
right around the PT nerve right here. So I'm pretty confident the PT nerve is blocked, we're can see
some hyperemia if you look at the foot right now.
If you look at the foot right now the hyperemia is gonna start to kick in very soon we're gonna
come back very shortly, the foot's gonna turn beet right on the bottom so we're good with that.
Now since we're talking about neuromas here in this video we're gonna take a look at this neuroma,
like a sneak peak, now the hard block is done, we're gonna go on to the bottom, more gel please,
okay right here we're gonna take a look at the neuroma right now, I'm scanning the bottom,
you're doing okay? Am I hurting you? No. Okay good. Sorry.
Right here I am pushing down, now look at the ultrasound screen again one more time
so I'm gonna go ahead, I'm gonna decrease the depth so to get more concentration, now this is
the third piggy, this is the fourth piggy, this is the third piggy, fourth piggy, okay so nerve is in between
these two. Right there, that enhancement is the neuroma right there, we see that on the screen.
Now we're gonna -- I'm squeezing the metatarsals, you see that nerve is pretty solid in there,
pretty nice-sized solid neuroma right there, even better you see that.
That's where we're gonna stick our probe in, probe it right into that nerve and we're gonna go ahead and
pretty much burn it.
Again we'll squeeze it a few times, you can see that nerve in the third interspace right there.
So we're gonna pause it now and we'll come back when we're doing the radiofrequency ablation.
Here we go. Radiofrequency ablation, she's numbed up already, we're ready to go.
Do you feel my fingernail? She does not, the block worked, beautiful.
So we're gonna go ahead, we are gonna be on the third interspace, I can fairly well in there.
Okay so the block is done we're gonna go right now.
This is the size of a normal needle actually, there's nothing special, the trocar.
Any pain? I'm fine just when you talk needle. [laughs]
No, nothing, guess I shouldn't listen [laughs]
So I put it right into third and the fourth neuroma right now
If I can pop it, I can feel it, now we're right in it. Right in the mid substance, go ahead we're gonna put the
probe right in there, okay I'm gonna confirm it one more time before we start.
Okay it's no longer popping 'cause this is right into the lesion itself.
Pretty big lesion, we're gonna go ahead, 90.
The temperature's gonna go up to 90 degrees Celsius,
once it hits 90 degrees Celsius we're gonna start the timer.
Slowly heating up, we were talking about Celsius here, hold on and now, go.
This is the timer.
So here we go, do you feel anything?
Not a thing. Well it's 90 degrees Celsius in there right now and burning the nerve.
90 degrees Celcius. And the numbing medicine worked.
Okay, off. Off.
I just reposition it until it hits the ball of the neuroma right now,
before I was at the stalk back here and then it's gonna fan out, it's gonna be a big bulge right here
and it's gonna split again so I'm right at the ball of the neuroma
the thickest part the neuroma right now. Temperature, back up.
We're going back to 90 and we're gonna go ahead. Perfect.
So you don't feel a thing, right? so that nerve block worked. Yes, it did.
It's magical how that works, right? [laughs]
Just waiting for the countdown.
And then what I'll do, I'll reposition, the last one I'll reposition it so it will just go
a little bit further into the ball and burn it one
more time so three shrinking positions in there will help to shrink that nerve.
Where did you travel from? Are you local here?
Kent City, yeah Kent City, it's very cold. This is our cold front right now. [laughs]
Minus eight the other day. Oh boy. Good news you're here.
We get a lot of patients who travel from all over United States to get
this treatment done, it works really well.
One more time, beautiful, last one, go for it.
In about one month we'll come back, we'll do it again. Okay, um will there be swelling?
Minor, pain-wise nothing a little Tylenol, Motrin can't handle, get some ice on it.
When? As soon as you can. As soon as I can? Okay.
This is the radio frequency, very simple, very very efficient, I can feel the neuroma
we're going right for it and the other one we saw the neuroma, we saw the nerve
right here on the side going down, so that's how we get the block effective, efficient.
It wasn't too bad right? No, it wasn't. So in four weeks it's the exact same process. Okay.
Okay good, here we go. I'm taking this it out, I put in alcohol, this is the alcohol solution,
four percent alcohol solution right in here, go ahead and put it right into that nerve now,
with the same goal of neurolysis or damaging the neuroma itself, gonna hit that area.
Done, that is that, voila. Radiofrequency number one done,
not too bad right? No. You did wonderful.