| 제목 |
Novel beginner-friendly landmarks for US-guided injection of Baxter nerve in cadaveric model |
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The Catholic University of Korea Seoul St. Mary`s Hospital , Department of Rehabilitation Medicine1, The Catholic University of Korea, College of Medicine, Catholic Institute for Applied Anatomy, Department of Anatomy2, The Incheon Catholic University Graduate School, Department of Biomedical Art3 |
| 저자 |
Inah Kim1*, Yong Seok Nam2, Kyung Eun Nam1, Minsuk Kang1, Min Young Ahn3, Jong In Lee1† |
Introduction: Baxter’s neuropathy has been implicated in up to 20% of chronic heel pain cases. However, no consensus has been made to which surface landmarks serves the best role to identify Baxter’s nerve (BN) and its entrapment site in ultrasonography. In addition, there has been suggestions that it is quite challenging for less experienced practitioners to locate this small nerve by using ultrasound. In this context, the aim of this cadaveric study is (1) to settle novel beginner-friendly anatomical landmarks for ultrasound-guided injection of BN in cadaveric model and (2) to describe affecting factors for identifying BN such as anatomical variations of BN or quadratus plantae (QP) muscle.
Methods: We first tried to find surface landmarks which has been frequently used as in the Heimkes triangle, and sought for new landmarks of good inter-examiner reproducibility using 10 lower limbs of 5 fresh cadavers. We appointed three bony landmarks; point P as the most medially protruded point on medial malleolus, point Q as navicular tuberosity, and point B as the center of calcaneus. The concordance of point P, Q, and B was evaluated by two examiners and analyzed by Kruskal-Wallis and Mann-Whitney test. Then, 24 lower limbs of 12 fresh cadavers were dissected to localize BN entry point to AH and QP, in relationship with novel surface landmarks of good concordance approved on the primary research. Also, Branching patterns of BN and variants of QP muscle were evaluated.
Results: The point P and Q had smaller difference between examiners than the point B. The rectangular coordinate system was constituted by the origin (point P), x-axis which was extension line of PQ and y-axis, the perpendicular line to x-axis which xy plane touches calcaneal tuberosity. We defined X value divided by PQ length converted in percentage as Ratio X, and Y value divided in PQ length converted in percentage as Ratio Y. Average of measures in all the 24 specimens regarding entry point of BN to AH upper border were as followed; Ratio X 51.92% and Ratio Y 92.27%. Average of measures in all the 21 specimens regarding entry point of BN to medial head of QP were as followed; Ratio X 61.25% and Ratio Y 99.80%. BN arose from lateral plantar nerve (LPN) in 20 out of 24 specimens. In 2 specimens, BN branched off from the bifurcation point of medial plantar nerve (MPN) and LPN and in 2 specimens, directly from tibial nerve (above branching point of LPN and MPN). Agenesis of medial head of QP muscle was found in 3 out of 24 specimens.
Discussion: Deducing from the concordance statistics, utilizing our new landmarks would offer enhanced precision in localizing BN entrapment site, especially for beginners. Increasing the diagnostic and therapeutic accuracy of this complicated syndrome would possibly provide the advanced guideline for many incurable podiatric patients.
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Landmarks marked with marker pen and ultraviolet-visible pen. Points marked by ultraviolet-visible pen are only visible with ultraviolet light on.
Anatomical dissection of the tibial nerve and its branches. Type 1, 2, and 3 presented from left to right.
Rectangular coordinate system for landmarks. Rectangular coordinate system was constituted by the origin (point P), x-axis which was extension line of PQ and y-axis, the perpendicular line to x-axis which xy plane touches calcaneal tuberosity.
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