Dr. Miranda is Assistant Professor of Neurosurgery at the Icahn School of Medicine at Mount Sinai, and Director of Peripheral Nerve for the Department of Neurosurgery. He narrates the challenging case of a young female patient who presented with debilitating left foot numbness, tingling, and a sharp, burning pain throughout the inner part of her foot after having been seen by podiatry, neurology, pain management, and vascular surgery specialists at other hospitals for diagnostic workups. She was evaluated for Morton’s neuroma, radiculopathy, blood clots, complex regional pain syndrome, tarsal tunnel syndrome, peripheral neuropathy, and circulation issues.
While electromyography and nerve conduction studies “had not suggested significant abnormalities, we examined her and we found that by stretching the nerves around the ankle area, we could reproduce her pain. On her outside MRI, we could see the tibial nerve passing through the tarsal tunnel seemed a bit swollen or thickened, slightly inflamed. We saw this clue and chased it further up the leg using ultrasound, and we were able to find this cystic lesion, or swelling in the nerve above the ankle closer to the mid-shin area, away from the site of her initial pain,” says Dr. Miranda.
“While the patient was focused on her foot pain, and her previous evaluations were focused on the ankle region, we hypothesized that perhaps the intrafascicular stretching of her nerve fibers above was producing this kind of ‘double crush’ phenomenon, where the area downstream in the nerve was generating a lot of pain, because of the strings being pulled up above. Fortunately, a lesion like this is surgically treatable.”
Three months after removing the cystic lesion, “the stabbing pain was completely gone, the patient felt 70 percent improved and, by six months, there was no pain at all, just some residual numbness in the heel, and her walking was back to normal,” Dr. Miranda says.
“Within the field of peripheral nerve surgery,” concludes Dr. Miranda, “and, certainly when it comes to finding these rare, intraneural cystic lesions as clinicians, we need to think of all sorts of possibilities to get the best possible outcomes for our patients.”
Watch the video:
An adult patient experienced debilitating foot pain with no clear cause. Through advances in peripheral nerve neurosurgery, a rare tibial nerve lymphangioma was identified. Surgical removal restored mobility and resolved pain.