The recurrent pain of a neuroma following surgical excision and burial of nerve endings can be clinically challenging to manage. Cryoanalgesia in conjunction with ultrasound guidance was used successfully to manage this type of pain. Furthermore, ultrasound provided visualization of the cryolesions, as well as the relationships of the ice ball to the surrounding tissue. Following the completion of the freeze cycle, the tissue can be monitored for return to its usual morphology during the thaw period

DeBonet, Alexander F.

Rhame, Ellen E.

Simopoulos, Thomas T.

English

PubMed

Harvard University - DASH 

 Ultrasonographic Guidance and Characterization ofCryoanalgesic Lesions in Treating a Case of Refractory SuralNeuroma  (Article begins on next page)The Harvard community has made this article openly available.Please share how this access benefits you. Your story matters.Citation Rhame, Ellen E., Alexander F. DeBonet, and Thomas T.Simopoulos. 2011. Ultrasonographic guidance andcharacterization of cryoanalgesic lesions in treating a case ofrefractory sural neuroma. Case Reports in Anesthesiology2011:691478.Published Version doi:10.1155/2011/691478Accessed February 19, 2015 10:32:50 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:10381370Terms of Use This article was downloaded from Harvard University's DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAAHindawi Publishing CorporationCase Reports in AnesthesiologyVolume 2011, Article ID 691478, 4 pagesdoi:10.1155/2011/691478Case ReportUltrasonographic Guidanceand Characterization ofCryoanalgesic Lesionsin Treating a Case of RefractorySural NeuromaEllen E. Rhame, AlexanderF. DeBonet, and Thomas T. SimopoulosInterventional Pain Management, Arnold Pain Management Center, Harvard Medical School, Beth Israel Deaconess Medical Center,Brookline, MA 02445, USACorrespondence should be addressed to Thomas T. Simopoulos, tsimopou@bidmc.harvard.eduReceived 29 August 2011; Accepted 25 September 2011Academic Editors: P. Michalek, S. Osada, and J. YangCopyright © 2011 Ellen E. Rhame et al.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The recurrent pain of a neuroma following surgical excision and burial of nerve endings can be clinically challenging tomanage. Cryoanalgesia in conjunction with ultrasound guidance was used successfully to manage this type of pain. Furthermore,ultrasound provided visualization of the cryolesions, as well as the relationships of the ice ball to the surrounding tissue. Followingthe completion of the freeze cycle, the tissue can be monitored for return to its usual morphology during the thaw period.1.IntroductionCryoanalgesia is a technique intended to provide pain reliefin which low temperatures are used to generate soft tissuelesions [1]. It was ﬁrst executed by Cooper et al. in 1962 withan early method that involved a hollow tube with an insu-lated tip, utilized liquid nitrogen as a coolant and achieveda temperature of –190◦C[ 2]. Lloyd et al. ﬁrst used the term“cryoanalgesia” for pain relief in 1976 [3]. They described atechnique in which the exposure of painful tissue to locallysubphysiologic temperatures could produce an eﬀective re-versible conduction block of peripheral nerves without thesubsequent development of neuralgia. A major limitation inthecharacterizationofapercutaneouslygeneratedcryolesionis that the lesion itself cannot be visualized in the closed ap-plication, and the only means of conﬁrmation of appropriateprobe function is by the use of a thermocouple to monitortemperature. However, use of the thermocouple does notprovide details of ice ball formation. Modern ultrasoundtechnique may allow this visual limitation to be overcomeand provide greater ability to assess and even quantify thedimensionsofacryolesioninrealtimeasitisbeingproducedto provide a therapeutic endpoint during the cryoablationprocedure.Conventionally, pain physicians have used anatomicaland ﬂuoroscopic landmarks as well as sensory and motorstimulation to conﬁrm the proximity of the cryoprobe to atarget nerve. In a consideration of safety, this provides only acrude avoidance of potentially critical structures such as ad-jacent critical blood vessels, which may be avoided with ul-trasonographic guidance. From a therapeutic standpoint, ul-trasound allows imaging of many peripheral nerves and thuscanprovidevisualconﬁrmationthatacryolesionhasencom-passed the target nerve and enables spacial adjustments tobe made as necessary. Ultimately, the employment of ultra-sound guidance will likely increase the therapeutic successand reduce patient morbidity involved in cryotherapy.Wedescribeacaseofsuralneuroma,inwhichultrasoundguidance was used to visualize in real time the lesion gen-erated during a cryotherapy procedure. Although the use ofultrasound guidance in cryoanalgesia has been described, tothe best of our knowledge the ultrasonographic image of acryolesion itself for use in treatment in peripheral nervecryotherapy has heretofore not been demonstrated in thepain medicine literature [4–6].2.CaseReportA ﬁfty-seven-year-old male with a past medical history sig-nificant for asthma and hypertension presented with a chiefcomplaint of distal left lower extremity pain. At the age of2 Case Reports in AnesthesiologyFigure 1: The blue skin marker demarcates the area of maximumpain in the hyperpigmented skin graft site of the left lower extrem-ity.twenty-one he was struck by a motor vehicle and sustainedmultiple fractures as well as a signiﬁcant degloving injury tohis distal left lower extremity. He underwent multiple exten-sive surgeries involving bone and skin grafts. Approximatelysix years prior to presentation at our clinic, he experienceda considerable exacerbation of his pain symptoms, was di-agnosed with a sural neuroma, and eventually underwentsurgical excision of the neuroma. The sural nerve endingswere buried deep into the muscle just above the periosteum.Unfortunately, his pain returned which he described asburning, shooting, and located over his left lateral leg distalto the knee extending down to the ankle. The pain was exac-erbated with palpation, eversion of the foot, and prolongedstanding. He was treated with physical therapy, gabapentin,amitriptyline, and TENS unit with minimal beneﬁt. At thetime of presentation, he was taking desipramine 25 milli-grams (mg) nightly and hydrocodone-acetaminophen 5mg/500mgasneeded,whichalleviatedonlyaportionofhispain.On examination, he was a well-appearing man in no appar-ent distress. His left lower extremity distal to the knee re-vealed skin grafts, scarring, and hyperpigmentation (Figure1). Hyperalgesia was present over the left lateral leg approxi-mately halfway between the knee and ankle. This region hadapositive Tinel’s sign overaportion ofthescar.Therewasnodistinct palpable mass. The rest of the standard neurologicalexamination was within normal limits.In March of 2007, the patient received an injection of thesuralneuromasitewithlocalanestheticandsteroid.Heexpe-rienced signiﬁcant relief for only the duration of the localanesthetic eﬀect. He was then scheduled for cryoneurolysisof the sural neuroma. Throughout a period of 3 years in ourclinic, he reported excellent relief from cryoneurolysis for 3months following each serial treatment. In fact, he reportsFigure 2: The cryoprobe was inserted via a 12-gauge angiocatheterintroducer proximal to the skin graft site of the left lower extremity.The ultrasound probe is being utilized to provide an in-planeview of the cryoprobe and ice ball location during cryoneurolysistreatment.that for a period of approximately 10 weeks following theprocedure, “I forget that I even have a pain in my leg.”Because of imaging limitations with ﬂuoroscopy, ultra-sound was used to better characterize the relationship of thecryoprobe in soft tissues relative to the ﬁbula. The patientwas placed in the right lateral decubitus position, and sterileprepanddrapewereperformedusingchlorhexidine/alcohol.Three milliliters (mL) of 1% lidocaine was inﬁltrated subcu-taneouslyusinga27-gaugeneedleattheentrysiteforthecry-oprobe located approximately 2 centimeters (cm) proximaltotheskingrafts(Figure 2).Usingan11blade,a3-millimeter(mm) stab skin incision was made through which a 12-gaugeangiocatherer was inserted into the subcutaneous tissue withthe aid of ultrasound guidance (General Electric Venue 40ultrasound system and 12L linear probe). Ultrasonographicexamination of the corresponding painful site did not allowvisualization of an apparent sural neuroma. A 14-gauge cry-oprobe (Wallach WA5000 Painblocker) was inserted throughthe 12-gauge angiocatheter upon removal of the needle. Pro-per sensory stimulation was used to conﬁrm proper place-ment of the cryoprobe at 125 Hertz (Hz) to reproduce par-esthesias over the patient’s typical location of pain. Thecryotherapy session consisted of 6 individual cryolesions,each of 4 minute duration, with a 40-second thaw periodbetween each lesion.During the beginning of the procedure, the cryolesionand cryoprobe were imaged using ultrasound both in-planeandout-of-planeview.Theproximityofthecryoprobetotheﬁbula was easily visualized prior to beginning cryotherapy(Figure 3). Any apparent vascular structures were readilyavoided during cryoprobe insertion under direct in-planeultrasonographic guidance and doppler examination. Thespacial magnitude of the cryolesion relative to the cryoprobewas easily visualized under real-time ultrasound. The lesionappeared as an echo-opaque hemisphere with a hyperechoicrim with a posterior acoustic shadowing (Figure 4). The le-sion was easily appreciated as increasing in size radiallythroughoutthe4-minuteperiodaswellasdecreasingradiallyduring the 40-second thaw period between lesions. Thediameters (in cm) of the lesions were 0.80, 0.87, 1.01, andCase Reports in Anesthesiology 3GE12cmFigure 3: The in-plane view of the cryoprobe and ﬁbula prior tocryolesioning.2GE111 1Figure 4: Cryolesion (diameter = 0.80cm) at 1 minute and 30seconds into the freeze cycle. Note the hyperechoic rim withposterior acoustic shadowing emanating from the tip of the probe.1.12 at 1.5, 2, 3, and 4 minutes, respectively. The short axisview conﬁrmed the spherical nature of the lesion at thetip. The largest ultrasonographically measured cryolesionwas an area of 0.85cm2 and a circumference of 3.28cm, at4 minutes into freezing cycle (Figure 5). It must be takeninto consideration that because of the posterior acousticshadowing cast by the cryolesion, as its radius increases thedimensions of the posterior portion of the cryolesion mustbe approximated for measurement purposes. The cryoprobewaspositionedsothattheposteriorportionofthecryolesionwould include the periosteum of the lateral mid-ﬁbula wherethe symptomatic neuroma was believed to lay. After a 4-minute cryolesion, the tissue changes were visualized at 50seconds but then normalized at 2 minutes and 20 seconds(Figure 6). The patient tolerated the procedure well withoutapparent complications. Sequential freezing and thawingpictures as presented in Figures 3–6.3. DiscussionIncreased utilization of ultrasound is becoming more com-monplace in both acute and chronic pain therapies. Asidefrom oﬀering image guidance, other potential beneﬁts ofultrasound include decreased radiation exposure, increasedportability, and decreased costs [5]. In this case of recurrentpain after surgical excision of a neuroma, ultrasound allowedidentiﬁcation of the ice ball in relation to the deep mus-cle, fascia, and periosteum. Ultrasonographic imaging hasbeen shown to be an eﬀective means of monitoring ice ballGE1 11124min INFigure 5: Cryolesion (diameter = 1.12cm) at 4 minutes into thefreeze cycle.GE12130 AFTFigure 6: Cryolesion is barely visible at 1 minute and 30 secondsinto the thaw period.lesions during cryodestruction of liver tumors in the surgicalliterature [7]. It follows that the characteristics of an in vivosoft tissue cryolesion in the extremities can be determined aswell.The cryolesions of the liver and peripheral soft tissues,in this case mostly muscle/fascia, exhibited a similar mor-phology. The hyperechoic rim of the cryolesion has been de-scribed as a “freeze front” which advances during the freez-ing cycle and regresses during the thawing cycle [7]. Thesurgical literature also provides evidence that the ultrasoundimages of cryolesion and the gross macroscopic hepatic cry-olesion correlate closely in actual size [8]. Previously, theultrasonographic cryolesion has been described as a “hemi-spherical hyperechoic rim with posterior acoustic shadow-ing”, and this image was readily observed in this case study[9]. The hyperechoic rim is thought to be a result of in-creased acoustic impedence at the border between frozenand unfrozen tissues, which causes ultrasound waves to bereﬂected back towards the transducer [8]. The posterioracousticshadowresultsinpartfromthedecreasedportionofultrasoundwavesthatiscapableofpassingthoughthefrozencryolesion. Following complete thawing of the cryolesion,no ultrasonographic diﬀerences were appreciated betweentissues that had undergone cryotherapy and those that hadnot. This diﬀers from cryotherapy of the liver, where theliver tissue that had undergone cryotherapy for 22 minutesat –180◦C remained hypoechoic compared to surroundingtissues after complete thawing [7, 8].Several factors contribute to the dimensions of a lesiongenerated during cryotherapy. The overall volume of thecryolesion itself is a function of the duration of the lesioning4 Case Reports in Anesthesiologyapplication and the temperature achieved during lesioningthat may be hampered by the constant delivery of body heatby blood vessels or cerebrospinal ﬂuid [10]. In clinicalpractice, the upper limit freeze duration is empirically setat 4 minutes, because little beneﬁt is thought to be derivedfrom longer durations [11]. The present images do suggestthe majority of the lesion is established during the ﬁrst twominutes, but continue to expand an additional 2.5mm at theend of 4 minutes. On the other hand, repeated freeze-and-thaw cycles have been demonstrated to be associated withincreased volume of the cryolesion [12]. Repeat freeze/thawlesions were not evaluated in this report. Moreover, the ther-apeutic eﬃcacy of the treatment improves as the placementof the cryoprobe targets more closely the peripheral nerve[10] .T h i sa l l o w sf o rag r e a t e rl e n g t ho fap e r i p h e r a ln e r v eto be lesioned, thereby impairing saltatory conduction so asto prevent pain transmission [13]. In cats it has been de-termined that a cryolesion of 3–6mm in diameter was neces-sary to prevent saltatory conduction [13]. While this agreeswith prior clinical reports [14], the estimations in this studyare nearly twice as large in diameter. This disparity may bebasedonthesizeoftheprobe,diﬀerencesincryodevices,andthe surrounding tissue milieu. In any event, a larger lesionwould be preferable for ensuring an ice ball has interactedwith suﬃcient length of the target nerve. This feature is par-ticularly useful when target nerves are not readily visualizedas in this case.In usual clinical practice, an adequate thawing intervalfollowing a cryolesion is desirable. This is because if thecryoprobe is moved before complete thawing has occurred,damage may transpire to surrounding tissues that remainadherent to the cryoprobe while frozen. A time periodranging from 20th–40 seconds for a thaw interval prior torepositioning the cryoprobe before starting the next freezecycle has been used clinically for years without reported ad-verse events [10]. After a 4-minute cryolesion, tissue changeswere very apparent at 50 seconds and did not normalize until140 seconds later. Though ultrasonographic data wouldsuggest a 140-second thaw interval after a 4-minute cryol-esion, there have been no adverse reports using the shorteraforementioned intervals. Therefore it is diﬃcult to recom-mend increasing the time for thawing, but warrants furtherinvestigation.4. ConclusionsUltrasoundtechniques oﬀervaluable guidance of cryoprobesinto deep soft tissue that is in close proximity to periosteumwhere transposed nerve endings lie. Furthermore, ultra-sound can be useful in characterizing the dimensions of ul-trasound lesions and their relationships to surroundingtissues. Lastly, this imaging modality can also be used todetermine when the tissue following a cryolesion returns toits usual morphology.AcknowledgmentsRobert Trainer, MD, and Linda May, RN, are acknowledgedfor their assistance in performing the procedure.References[1] M. Day and S. Anderson, “Cryoanalgesia and radiofrequency,”in Principles and Practice of Pain Management,C .A .W a r ﬁ e l dand Z. H. Bajwa, Eds., pp. 751–764, Mc-Graw-Hill, New York,NY, USA, 2nd edition, 2004.[2] I.S.Cooper,F.Grissman,andR.Johnston,“Acompletesystemfor cytogenic surgery,” St. Barnabas Hospital Medical Bulletin,vol. 1, pp. 11–16, 1962.[3] J. W. Lloyd, J. D. W. Barnard, and C. J. Glynn, “Cryoanalgesia.A new approach to pain relief,” Lancet, vol. 2, no. 7992, pp.932–934, 1976.[4] N. A. Campos, J. H. Chiles, and A. R. Plunkett, “Ultrasound-guided cryoablation of genitofemoral nerve for chronic ingui-nal pain,” Pain Physician, vol. 12, no. 6, pp. 997–1000, 2009.[5] M. G. Byas-Smith and A. Gulati, “Ultrasound-guided inter-costal nerve cryoablation,” Anesthesia and Analgesia, vol. 103,no. 4, pp. 1033–1035, 2006.[ 6 ]R .H .O v e r b a u g h ,Ultrasound Guided Cryoablation for Treat-mentofOccipitalNeuralgia,MedicallyChallengingCase,Ame-rican Society of Regional Anesthesia, 2010.[7] T. S. Ravikumar, R. Kane, and B. Cady, “Hepatic cryosurgerywith intraoperative ultrasound monitoring for metastaticcolon carcinoma,” Archives of Surgery, vol. 122, no. 4, pp. 403–409, 1987.[8] C. M. Lam, S. M. Shimi, and A. Cuschieri, “Ultrasonographiccharacterization of hepatic cryolesions: an ex vivo study,” Ar-chives of Surgery, vol. 130, no. 10, pp. 1068–1072, 1995.[9] G. Onik, B. Rubinsky, R. Zemel et al., “Ultrasound-guidedhepatic cryosurgeryin thetreatment of metastatic colon carci-noma.Preliminaryresults,”Cancer,vol.67,no.4,pp.901–907,1991.[10] A. M. Trescot, “Cryoanalgesia in interventional pain manage-ment,” Pain Physician, vol. 6, no. 3, pp. 345–360, 2003.[11] L. R. Saberski, “Cryoneurolysis in clinical practice,” in Inter-ventional Pain Management, S. D. Waldman, Ed., pp. 226–242,W.B. Saunders, Philadelphia, Pa, USA, 2nd edition, 2001.[12] W. Gill, J. Fraser, and D. C. Carter, “Repeated freeze-thawcycles in cryosurgery,” Nature, vol. 219, no. 5152, pp. 410–413,1968.[13] W. W. Douglas and J. L. Malcolm, “The eﬀect of localizedcooling on conduction in cat nerves,” Journal of Physiology,vol. 130, pp. 63–71, 1955.[14] P. J. D. Evans, “Cryoanalgesia. The application of low temper-atures to nerves to produce anaesthesia or analgesia,” Anaes-thesia, vol. 36, no. 11, pp. 1003–1013, 1981.

Case Reports in Anesthesiology

Ultrasonographic Guidance and Characterization of Cryoanalgesic Lesions in Treating a Case of Refractory Sural Neuroma

Ellen E. Rhame

Alexander F. DeBonet

Thomas T. Simopoulos

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The recurrent pain of a neuroma following surgical excision and burial of nerve endings can be clinically challenging to manage. Cryoanalgesia in conjunction with ultrasound guidance was used successfully to manage this type of pain. Furthermore, ultrasound provided visualization of the cryolesions, as well as the relationships of the ice ball to the surrounding tissue. Following the completion of the freeze cycle, the tissue can be monitored for return to its usual morphology during the thaw period.</jats:p

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Hindawi Publishing CorporationCase Reports in AnesthesiologyVolume 2011, Article ID 691478, 4 pagesdoi:10.1155/2011/691478Case ReportUltrasonographic Guidance and Characterization ofCryoanalgesic Lesions in Treating a Case of RefractorySural NeuromaEllen E. Rhame, Alexander F. DeBonet, and Thomas T. SimopoulosInterventional Pain Management, Arnold Pain Management Center, Harvard Medical School, Beth Israel Deaconess Medical Center,Brookline, MA 02445, USACorrespondence should be addressed to Thomas T. Simopoulos, tsimopou@bidmc.harvard.eduReceived 29 August 2011; Accepted 25 September 2011Academic Editors: P. Michalek, S. Osada, and J. YangCopyright © 2011 Ellen E. Rhame et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The recurrent pain of a neuroma following surgical excision and burial of nerve endings can be clinically challenging tomanage. Cryoanalgesia in conjunction with ultrasound guidance was used successfully to manage this type of pain. Furthermore,ultrasound provided visualization of the cryolesions, as well as the relationships of the ice ball to the surrounding tissue. Followingthe completion of the freeze cycle, the tissue can be monitored for return to its usual morphology during the thaw period.1. IntroductionCryoanalgesia is a technique intended to provide pain reliefin which low temperatures are used to generate soft tissuelesions [1]. It was first executed by Cooper et al. in 1962 withan early method that involved a hollow tube with an insu-lated tip, utilized liquid nitrogen as a coolant and achieveda temperature of –190◦C [2]. Lloyd et al. first used the term“cryoanalgesia” for pain relief in 1976 [3]. They described atechnique in which the exposure of painful tissue to locallysubphysiologic temperatures could produce an eﬀective re-versible conduction block of peripheral nerves without thesubsequent development of neuralgia. A major limitation inthe characterization of a percutaneously generated cryolesionis that the lesion itself cannot be visualized in the closed ap-plication, and the only means of confirmation of appropriateprobe function is by the use of a thermocouple to monitortemperature. However, use of the thermocouple does notprovide details of ice ball formation. Modern ultrasoundtechnique may allow this visual limitation to be overcomeand provide greater ability to assess and even quantify thedimensions of a cryolesion in real time as it is being producedto provide a therapeutic endpoint during the cryoablationprocedure.Conventionally, pain physicians have used anatomicaland fluoroscopic landmarks as well as sensory and motorstimulation to confirm the proximity of the cryoprobe to atarget nerve. In a consideration of safety, this provides only acrude avoidance of potentially critical structures such as ad-jacent critical blood vessels, which may be avoided with ul-trasonographic guidance. From a therapeutic standpoint, ul-trasound allows imaging of many peripheral nerves and thuscan provide visual confirmation that a cryolesion has encom-passed the target nerve and enables spacial adjustments tobe made as necessary. Ultimately, the employment of ultra-sound guidance will likely increase the therapeutic successand reduce patient morbidity involved in cryotherapy.We describe a case of sural neuroma, in which ultrasoundguidance was used to visualize in real time the lesion gen-erated during a cryotherapy procedure. Although the use ofultrasound guidance in cryoanalgesia has been described, tothe best of our knowledge the ultrasonographic image of acryolesion itself for use in treatment in peripheral nervecryotherapy has heretofore not been demonstrated in thepain medicine literature [4–6].2. Case ReportA fifty-seven-year-old male with a past medical history sig-nificant for asthma and hypertension presented with a chiefcomplaint of distal left lower extremity pain. At the age of2 Case Reports in AnesthesiologyFigure 1: The blue skin marker demarcates the area of maximumpain in the hyperpigmented skin graft site of the left lower extrem-ity.twenty-one he was struck by a motor vehicle and sustainedmultiple fractures as well as a significant degloving injury tohis distal left lower extremity. He underwent multiple exten-sive surgeries involving bone and skin grafts. Approximatelysix years prior to presentation at our clinic, he experienceda considerable exacerbation of his pain symptoms, was di-agnosed with a sural neuroma, and eventually underwentsurgical excision of the neuroma. The sural nerve endingswere buried deep into the muscle just above the periosteum.Unfortunately, his pain returned which he described asburning, shooting, and located over his left lateral leg distalto the knee extending down to the ankle. The pain was exac-erbated with palpation, eversion of the foot, and prolongedstanding. He was treated with physical therapy, gabapentin,amitriptyline, and TENS unit with minimal benefit. At thetime of presentation, he was taking desipramine 25 milli-grams (mg) nightly and hydrocodone-acetaminophen 5mg/500mg as needed, which alleviated only a portion of his pain.On examination, he was a well-appearing man in no appar-ent distress. His left lower extremity distal to the knee re-vealed skin grafts, scarring, and hyperpigmentation (Figure1). Hyperalgesia was present over the left lateral leg approxi-mately halfway between the knee and ankle. This region hada positive Tinel’s sign over a portion of the scar. There was nodistinct palpable mass. The rest of the standard neurologicalexamination was within normal limits.In March of 2007, the patient received an injection of thesural neuroma site with local anesthetic and steroid. He expe-rienced significant relief for only the duration of the localanesthetic eﬀect. He was then scheduled for cryoneurolysisof the sural neuroma. Throughout a period of 3 years in ourclinic, he reported excellent relief from cryoneurolysis for 3months following each serial treatment. In fact, he reportsFigure 2: The cryoprobe was inserted via a 12-gauge angiocatheterintroducer proximal to the skin graft site of the left lower extremity.The ultrasound probe is being utilized to provide an in-planeview of the cryoprobe and ice ball location during cryoneurolysistreatment.that for a period of approximately 10 weeks following theprocedure, “I forget that I even have a pain in my leg.”Because of imaging limitations with fluoroscopy, ultra-sound was used to better characterize the relationship of thecryoprobe in soft tissues relative to the fibula. The patientwas placed in the right lateral decubitus position, and sterileprep and drape were performed using chlorhexidine/alcohol.Three milliliters (mL) of 1% lidocaine was infiltrated subcu-taneously using a 27-gauge needle at the entry site for the cry-oprobe located approximately 2 centimeters (cm) proximalto the skin grafts (Figure 2). Using an 11 blade, a 3-millimeter(mm) stab skin incision was made through which a 12-gaugeangiocatherer was inserted into the subcutaneous tissue withthe aid of ultrasound guidance (General Electric Venue 40ultrasound system and 12 L linear probe). Ultrasonographicexamination of the corresponding painful site did not allowvisualization of an apparent sural neuroma. A 14-gauge cry-oprobe (Wallach WA5000 Painblocker) was inserted throughthe 12-gauge angiocatheter upon removal of the needle. Pro-per sensory stimulation was used to confirm proper place-ment of the cryoprobe at 125 Hertz (Hz) to reproduce par-esthesias over the patient’s typical location of pain. Thecryotherapy session consisted of 6 individual cryolesions,each of 4 minute duration, with a 40-second thaw periodbetween each lesion.During the beginning of the procedure, the cryolesionand cryoprobe were imaged using ultrasound both in-planeand out-of-plane view. The proximity of the cryoprobe to thefibula was easily visualized prior to beginning cryotherapy(Figure 3). Any apparent vascular structures were readilyavoided during cryoprobe insertion under direct in-planeultrasonographic guidance and doppler examination. Thespacial magnitude of the cryolesion relative to the cryoprobewas easily visualized under real-time ultrasound. The lesionappeared as an echo-opaque hemisphere with a hyperechoicrim with a posterior acoustic shadowing (Figure 4). The le-sion was easily appreciated as increasing in size radiallythroughout the 4-minute period as well as decreasing radiallyduring the 40-second thaw period between lesions. Thediameters (in cm) of the lesions were 0.80, 0.87, 1.01, andCase Reports in Anesthesiology 3GE12 cmFigure 3: The in-plane view of the cryoprobe and fibula prior tocryolesioning.2GE1111Figure 4: Cryolesion (diameter = 0.80 cm) at 1 minute and 30seconds into the freeze cycle. Note the hyperechoic rim withposterior acoustic shadowing emanating from the tip of the probe.1.12 at 1.5, 2, 3, and 4 minutes, respectively. The short axisview confirmed the spherical nature of the lesion at thetip. The largest ultrasonographically measured cryolesionwas an area of 0.85 cm2 and a circumference of 3.28 cm, at4 minutes into freezing cycle (Figure 5). It must be takeninto consideration that because of the posterior acousticshadowing cast by the cryolesion, as its radius increases thedimensions of the posterior portion of the cryolesion mustbe approximated for measurement purposes. The cryoprobewas positioned so that the posterior portion of the cryolesionwould include the periosteum of the lateral mid-fibula wherethe symptomatic neuroma was believed to lay. After a 4-minute cryolesion, the tissue changes were visualized at 50seconds but then normalized at 2 minutes and 20 seconds(Figure 6). The patient tolerated the procedure well withoutapparent complications. Sequential freezing and thawingpictures as presented in Figures 3–6.3. DiscussionIncreased utilization of ultrasound is becoming more com-monplace in both acute and chronic pain therapies. Asidefrom oﬀering image guidance, other potential benefits ofultrasound include decreased radiation exposure, increasedportability, and decreased costs [5]. In this case of recurrentpain after surgical excision of a neuroma, ultrasound allowedidentification of the ice ball in relation to the deep mus-cle, fascia, and periosteum. Ultrasonographic imaging hasbeen shown to be an eﬀective means of monitoring ice ballGE1 11124min INFigure 5: Cryolesion (diameter = 1.12 cm) at 4 minutes into thefreeze cycle.GE12130 AFTFigure 6: Cryolesion is barely visible at 1 minute and 30 secondsinto the thaw period.lesions during cryodestruction of liver tumors in the surgicalliterature [7]. It follows that the characteristics of an in vivosoft tissue cryolesion in the extremities can be determined aswell.The cryolesions of the liver and peripheral soft tissues,in this case mostly muscle/fascia, exhibited a similar mor-phology. The hyperechoic rim of the cryolesion has been de-scribed as a “freeze front” which advances during the freez-ing cycle and regresses during the thawing cycle [7]. Thesurgical literature also provides evidence that the ultrasoundimages of cryolesion and the gross macroscopic hepatic cry-olesion correlate closely in actual size [8]. Previously, theultrasonographic cryolesion has been described as a “hemi-spherical hyperechoic rim with posterior acoustic shadow-ing”, and this image was readily observed in this case study[9]. The hyperechoic rim is thought to be a result of in-creased acoustic impedence at the border between frozenand unfrozen tissues, which causes ultrasound waves to bereflected back towards the transducer [8]. The posterioracoustic shadow results in part from the decreased portion ofultrasound waves that is capable of passing though the frozencryolesion. Following complete thawing of the cryolesion,no ultrasonographic diﬀerences were appreciated betweentissues that had undergone cryotherapy and those that hadnot. This diﬀers from cryotherapy of the liver, where theliver tissue that had undergone cryotherapy for 22 minutesat –180◦C remained hypoechoic compared to surroundingtissues after complete thawing [7, 8].Several factors contribute to the dimensions of a lesiongenerated during cryotherapy. The overall volume of thecryolesion itself is a function of the duration of the lesioning4 Case Reports in Anesthesiologyapplication and the temperature achieved during lesioningthat may be hampered by the constant delivery of body heatby blood vessels or cerebrospinal fluid [10]. In clinicalpractice, the upper limit freeze duration is empirically setat 4 minutes, because little benefit is thought to be derivedfrom longer durations [11]. The present images do suggestthe majority of the lesion is established during the first twominutes, but continue to expand an additional 2.5mm at theend of 4 minutes. On the other hand, repeated freeze-and-thaw cycles have been demonstrated to be associated withincreased volume of the cryolesion [12]. Repeat freeze/thawlesions were not evaluated in this report. Moreover, the ther-apeutic eﬃcacy of the treatment improves as the placementof the cryoprobe targets more closely the peripheral nerve[10]. This allows for a greater length of a peripheral nerveto be lesioned, thereby impairing saltatory conduction so asto prevent pain transmission [13]. In cats it has been de-termined that a cryolesion of 3–6mm in diameter was neces-sary to prevent saltatory conduction [13]. While this agreeswith prior clinical reports [14], the estimations in this studyare nearly twice as large in diameter. This disparity may bebased on the size of the probe, diﬀerences in cryodevices, andthe surrounding tissue milieu. In any event, a larger lesionwould be preferable for ensuring an ice ball has interactedwith suﬃcient length of the target nerve. This feature is par-ticularly useful when target nerves are not readily visualizedas in this case.In usual clinical practice, an adequate thawing intervalfollowing a cryolesion is desirable. This is because if thecryoprobe is moved before complete thawing has occurred,damage may transpire to surrounding tissues that remainadherent to the cryoprobe while frozen. A time periodranging from 20th–40 seconds for a thaw interval prior torepositioning the cryoprobe before starting the next freezecycle has been used clinically for years without reported ad-verse events [10]. After a 4-minute cryolesion, tissue changeswere very apparent at 50 seconds and did not normalize until140 seconds later. Though ultrasonographic data wouldsuggest a 140-second thaw interval after a 4-minute cryol-esion, there have been no adverse reports using the shorteraforementioned intervals. Therefore it is diﬃcult to recom-mend increasing the time for thawing, but warrants furtherinvestigation.4. ConclusionsUltrasound techniques oﬀer valuable guidance of cryoprobesinto deep soft tissue that is in close proximity to periosteumwhere transposed nerve endings lie. Furthermore, ultra-sound can be useful in characterizing the dimensions of ul-trasound lesions and their relationships to surroundingtissues. Lastly, this imaging modality can also be used todetermine when the tissue following a cryolesion returns toits usual morphology.AcknowledgmentsRobert Trainer, MD, and Linda May, RN, are acknowledgedfor their assistance in performing the procedure.References[1] M. Day and S. Anderson, “Cryoanalgesia and radiofrequency,”in Principles and Practice of Pain Management, C. A. Warfieldand Z. H. Bajwa, Eds., pp. 751–764, Mc-Graw-Hill, New York,NY, USA, 2nd edition, 2004.[2] I. S. Cooper, F. Grissman, and R. Johnston, “A complete systemfor cytogenic surgery,” St. Barnabas Hospital Medical Bulletin,vol. 1, pp. 11–16, 1962.[3] J. W. Lloyd, J. D. W. Barnard, and C. J. 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The application of low temper-atures to nerves to produce anaesthesia or analgesia,” Anaes-thesia, vol. 36, no. 11, pp. 1003–1013, 1981.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

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The eﬀect of localized cooling on conduction in cat nerves,”

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Ultrasound-guided hepatic cryosurgeryin thetreatment of metastatic colon carcinoma.Preliminaryresults,”Cancer,vol.67,no.4,pp.901–907,

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Ultrasoundguided cryoablation of genitofemoral nerve for chronic inguinal pain,”

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Ultrasonographic Guidance and Characterization of Cryoanalgesic Lesions in Treating a Case of Refractory Sural Neuroma

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