Anesthesia & Analgesia Practice: Ultrasound-guided Hydro Dissection of Baxter’s Nerve (With impact factor of 2.95)

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By Dr. Rajendra Sahoo, MBBS, MD, CIPS, ASRA-PMUC, FIPM; Pain Fellowship (Canada), Consultant Pain Management, KIMS

Heel pain is a common presentation in clinical practice. Common causes include plantar fasciitis, calcaneal spur, fat pad atrophy, trauma, tumour, calcaneal stress fracture and entrapment neuropathy. Many a times the pain decreases with conservative treatment; however, in some cases, the symptoms persist and become chronic heel pain. Entrapment neuropathy of small nerves like Baxter’s neuropathy is another overlooked cause of heel pain.

Baxter’s nerve, also known as the first branch of lateral plantar nerve, takes an acute 90 degrees course after traversing vertically and often gets entrapped at the deep taut fascia of abductor hallucis and quadratus plante muscle in the foot. This entrapment has been implicated in up to 20% cases of chronic heel pain of neuropathic origin. This condition is very well described in Orthopedic literature and treatment for recalcitrant cases included surgical release. Subsequently, radiofrequency ablation had been used with good results. 

Typical clinical features include heel pain with radiation to lateral foot on weight bearing and in MRI foot. This patient showed complete fatty atrophy of the abductor digiti minimi muscle (innervated by Baxter’s nerve) suggesting nerve entrapment. In this patient, the authors utilized Ultrasound-guided hydro dissection of the Baxter’s nerve in the plane of entrapment between the muscles described above using 40mg depo medrol and bupivacaine 1ml. The patient reported complete and long-lasting pain relief. 

This case description is the “First such described case in the literature” on the utility of percutaneous ultrasonography guided hydro dissection for Baxter’s neuropathy. Ultrasound and hydro dissection has been found to be effective in other common entrapment neuropathy like carpal tunnel syndrome and meralgia paresthetica.

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