We have a second interspace neuroma right here, third interspace stump neuroma.
Already had a previous neuroma surgery -- how long ago?
"2 years." 2 years ago? And it came back already. You can feel it by squeezing.
I'm squeezing with this hand and then I'm pushing up and down with this one, I can feel
that neuroma in here and I can feel the neuroma here now. Her main pain when she came in was
underneath the second, she also had it underneath the third and now she's numb, so I gave her
a little local anesthetic here and a local anesthetic up here in preparation for the
radiofrequency ablation. So we're gonna go ahead and get that done, get that started.
We're gonna take a look at the ultrasound -- we're gonna go look at the ultrasound image
what a neuroma looks like, I'm gonna go -- this is pinky number 2, pinky number 3,
pinky number 4, you can see number 4 it's over here 4, 3 & 2 that's how we're gonna orientate ourselves
on this ultrasound, and a lot of times people have no idea what they're looking at on the ultrasound
they can't find any neuromas. Well here you go, here's a nice little round neuroma between 2 & 3 is a
nice big neuroma which was what she's feeling. I'm gonna ask you to relax your foot for me,
okay I'm gonna squeeze, you see the dark -- the nice round circle actually you see that,
it moves a little bit, dark round circle, can you see that neuroma right here?
Again, we're gonna see it move right there, that's the object that we're gonna go in
and do radiofrequency on. Now I'm feeling a little click on the foot, that's called the motor sign.
That's the click of the neuroma, again we're looking at that neuroma between two and three,
that's the one we're gonna hit, that's the one that didn't have surgery on.
Okay that's the one, again, rechecking it, that's where my probe is going.
And number three, between number two and three here, maybe between three and four,
I take that back, between 3 and 4, that's third and fourth toe here.
It's not as clear because she already had surgery in there already but you can see some scar tissue
in there, you can still see the little roundness going on in there, it's not as big you see the tissue there
it's a little bit unrecognized but you still see when I squeeze, some tissue moving up and down
right there underneath, you see that, I'm gonna do it one more time, that tissue right over underneath
the knuckle there causing her the pain when she walks. When she's walking that's where it's gonna
go and she's gonna step right on that, that's gonna be painful.
Again we're gonna go to 2 and 3 now, we're gonna look at that neuroma, we're gonna go ahead
and you see it very well-visualized right there. Look at that, a little circle right there you see that,
again we're gonna keep our eyes on this one, this right here, I'm going to squeeze it,
I'm gonna compact that nerve.
Now, people say how do you find these neuromas on an ultrasound? Well I'm used to looking at it for
nerve blocks, I use it for nerve block here to see the nerve, inject it there so it takes a little bit of
experience to get to find these neuromas but once you do they're pretty easy to find on the ultrasound.
As you can see we just did a quick examination of two spaces. She's already numb, she's ready for
radio frequency ablation, we're gonna get it started.
So we're gonna turn off the camera for a second until --
This is between the second and third toe again, 2, 3, and 4. That's the neuroma.
You see the vessel pumping right here? That's the artery, that's the nerve right here,
see the pumping artery and that's the stump neuroma right here, not as organized,
a bunch of scar tissue, she recently had surgery so we're not gonna rehash that we're gonna go ahead -
I'm gonna ahead for the radiofrequency, I'm gonna start putting a probe in, again, remember that
that's the one I'm gonna hit first 'cause that's the biggest one.
So I'm gonna go in from the top down, she's already numb, mind you, so she's not going to feel it
very much. I'm gonna go down, break the skin, take the probe out, you can see the movement now,
you see that nerve being moved by my probe right there. You see that little --
this is a patient wide awake looking at me playing around with her foot here, so --
again we're gonna keep the probe right by here. You can see my probe coming up on the bottom
right here, you see the little metallic probe right there. I'm going right into that nerve right there,
alright we're gonna feel that, see the metallic probe right there hitting on that nerve. So I'm gonna stop
I'm gonna stop the ultrasound images right there because I know I'm in the nerve, I'm gonna touch it
right here just to make sure I'm not too deep. I'm right at the nerve, now we're gonna go ahead,
I'm gonna take the radio frequency probe. This is the radiofrequency tip, again this is the tip that's
gonna burn to ninety degrees Celsius, it's gonna burn that nerve. Okay we're gonna be right here,
stay right in there, double check the placement and nothing beats manual touch because I can feel
how big her nerves are, so it's not moving now because the probe is right in it.
The probe is right in that nerve so the nerve and the probe is moving at the same time right now.
So I'm confident we're in there, we're not too deep, we're not to deep to cause soft tissue burn,
but we're deep enough to be in that nerve itself. Again, the nerve is moving, not too deep,
perfect, move again the probe, go ahead, the assistant is gonna turn on the temperature,
we're going to go up to ninety degrees Celsius, we have hit ninety degree Celsius right now
and we're gonna start the timer for 90 seconds.
So nothing exciting happens for 90 seconds as that is burning at 90 degrees.
Do you feel anything -- pain or burning?
"Just a tiny bit of heat there but... " Perfect. That's the procedure itself,
of the radio frequency. I'll burn there about 2 or 3 times per nerve, again I search with
the other ultrasound by GE, great imaging get it in there exactly right in there so there's
no complication of open surgery, you got a regrowth like you, a two-year -- you had a
regrowth and then painful, we go in there we're looking at a lot of scar tissue, we're just
doing something called a 'space-ecting', we're taking out everything in that space.
So that's not really the ideal way to do things and there's 50% chance of complications of
open surgery so I tend not to like to do that. This is the better way to do it and patients typically
get 50 percent relief to 100 percent relief for the first treatment. Second treatment in a month
or so later we go up to 80 to 100% relief without even having to do surgery.
That's all I do, there's no cuts and we just go ahead we direct the probe and burn in particular areas.
Very accurate, ultrasound is accurate.
"How old is this therapy, this treatment?"
This therapy has been around for many years, it has actually been around for the back of the neck
and for tumors -- of cancerous tumors but it just has not been used on foot as much but it's the same
exact concept. Inject the nerve, find the nerve, you can burn the nerve, it is the same exact thing.
"Makes sense to me." Yeah, so I know I'm in the general vicinity so for the second burn
I'm just gonna move my probe up right about here.
Surgically I -- I feel the nerve in my thumb right here,
I'm gonna go a little bit further, deeper before I get the nerve right here.
Probe is right in it, okay cool.
Now we're gonna burn for another 90 seconds.
And we're gonna stop recording until...
I am here in the third interspace right here, there's a little bit of scar tissue in the stump neuroma,
we'll gonna take a look at the ultrasound image.
We're gonna see that my probe again is pushing in the soft tissue right here,
that's the interspace that I'm in right now,
so we're gonna take a look at it, again the probe is through the scar tissue the neuroma is...
again I'm pushing right here, boom, I'm right at it so the accuracy of this is pretty good,
the probe is going in, see the soft tissue, the probe is coming in, you'll see when I push in
it's gonna pull right into this neuroma, this stump neuroma right there
I'm pushing right into it, you can see that probe coming right in
the patient being a pharmacist can appreciate some of the anatomy here
So right here, again we're going right in
that's tissue right there, it's all scar tissue, stump neuroma, etcetera, again, this is just my probe,
I'm going in towards your third metatarsal and you can see my probe going out
coming back in right about there, okay?
So the placement is very accurate, again you see that probe bouncing in there
that's where your neuroma was or your stump neuroma and I'm right next to it.
All I have to do is burn the tissue around there
it's gonna help you get the pain relief that we need.
So you see that stump regrowth neuroma and then I'm gonna do it by hand
push it by hand, okay I feel the soft tissue, get the trocar out, okay
the blunt tip now, a lot of scar tissue right at the site, okay,
we can confirm it with ultrasound
and a lot of scar tissue
go ahead and reposition this
no more crunch
you can see my probe move
some resistance because all of the scar tissue in here but now the probe is moving with the nerve.
right here
Look at that, my probe is moving with the nerve now, I don't feel any independent moving nerve
because the probe is right at it
we saw it already on the ultrasound
this is just placing it right at the center of that nerve
we're gonna go and again readjust position, noted as good, do the click test again
the probe is right in the nerve
go 90 seconds
So part of it is by visualization, the other part is by feel.
So now we're burning at 90 degrees Celsius right now for 90 seconds and we are
hitting that right now, and here we go.
Good.