SLR - August 2015 - Edward Lee
Neurovascular Bundle Decompression without Excessive Dissection for Tarsal Tunnel Syndrome
Reference: Kim K, Isu T, Morimoto D, Sasamori T, Sugawara A, Chiba Y, Isobe M, Kobayashi S, Morita A. Neurovascular Bundle Decompression Without Excessive Dissection for Tarsal Tunnel Syndrome. Neurol Med Chir (Tokyo). 2014;54(11): 901-6.
Scientific Literature Review
Reviewed By: Edward Lee, DPM
Residency Program: Wyckoff Heights Medical Center
Podiatric Relevance: Tarsal tunnel syndrome is a neuropathy caused by the entrapment and compression of the tibial nerve and its associated branches. Various techniques have been described in literature to address tarsal tunnel syndrome, including a release of the flexor retinaculum, an endoscopic approach, and a decompression of multiple sites concomitantly in a single lower extremity. This article describes a minimally invasive approach to releasing the tarsal tunnel without sedation, therefore allowing the surgeon to confirm adequate decompression intraoperatively.
Methods: Sixty-nine patients, totaling 116 feet were operated on by the senior author (T.I.). All patients presented with idiopathic tarsal tunnel syndrome and patients with tarsal tunnel syndrome secondary to a soft tissue mass, lumbar degenerative disease, or arteriosclerosis obliterans were excluded. Diagnosis was primarily made on clinical symptoms, including a positive Tinel’s sign, paresthesia, foreign-body sensations in the foot, cold sensations, and burning or tingling sensations. None of the symptoms were present in the heel. A skin incision is made distal to the medial malleolus over the point of Tinel’s sign and under local anesthesia with 1 percent Lidocaine. No tourniquet is used for the procedure. The abductor hallucis muscle is left intact, flexor retinaculum released, and the surrounding soft tissue dissected. When the patient reports >50 percent reduction of symptoms, Tinel’s sign is no longer present, and arterial pulsation adequate, the decompression is deemed to be complete. Only when insufficient intraoperative relief was encountered was the neurovascular bundle dissected to separate the nerve and the vessels. Post-operatively the patients were allowed to immediately weight bear without cast immobilization.
Results: Patient self-assessments were used to evaluate patients’ degree of satisfaction. Ninety percent of patients indicated satisfactory to acceptable results while 10 percent of patients were not satisfied. All dissatisfied patients underwent further operative decompression of the tarsal tunnel and reported improvement of symptoms postoperatively.
Conclusion: The minimally invasive approach to the tarsal tunnel release under local anesthesia without sedation yielded good results. The key innovation in this technique is the absence of patient sedation. By avoiding sedation, the surgeon is able to intraoperatively evaluate the success of the decompression in real time, thereby reducing unnecessary dissection. This technique is a novel approach to limiting excessive dissection and soft tissue damage when surgically addressing tarsal tunnel syndrome and provides us with another option to consider when planning for a tarsal tunnel release.