Methylene Blue to Identify Nerve Pathology and Guide Surgery
In all cases, the preoperative ultrasonography easily identified the nerve (Fig. 2B) and region of interest (Fig. 2A). Indirect stimulation of the target nerve, while maintaining direct ultrasound visualization, was confirmed prior to the injection of MB in all cases. An MB-colored surgical corridor was created in all cases, which allowed the surgeon to dissect with confidence toward the target structures quickly and efficiently while minimizing collateral trauma to surrounding tissues. Examples of operative dissections with MB staining are shown in Fig. 2C and Fig. 3C and described below. Methylene blue dye injections were always extraneural and typically stained the epineurium.
(Enlarge Image)
Figure 3.
Case 7. A patient with a sciatic myxoma. A: The MR neurogram is shown; the arrow indicates the tumor. B: The ultrasound image that was used for administration of MB is shown with the tumor in view. C and D: Intraoperative photographs of the sciatic myxoma. Shown in C is the initial subcutaneous dissection demonstrating the MB tract. Immediately prior to removal of the tumor a photograph was taken to show the tumor and normal sciatic nerve (D). E: After the tumor was removed, the borders of the tumor are shown with peripheral staining of MB.
There were no cases in which patients experienced an allergic reaction to the MB injection. The needle used for nerve stimulation and for administration of the MB did not cause any complications, such as nerve injury or hematoma. In every surgery, the MB was present throughout the dissection, and it was useful for operative exposure. There were no patients that experienced permanent skin discoloration.
Results
In all cases, the preoperative ultrasonography easily identified the nerve (Fig. 2B) and region of interest (Fig. 2A). Indirect stimulation of the target nerve, while maintaining direct ultrasound visualization, was confirmed prior to the injection of MB in all cases. An MB-colored surgical corridor was created in all cases, which allowed the surgeon to dissect with confidence toward the target structures quickly and efficiently while minimizing collateral trauma to surrounding tissues. Examples of operative dissections with MB staining are shown in Fig. 2C and Fig. 3C and described below. Methylene blue dye injections were always extraneural and typically stained the epineurium.
(Enlarge Image)
Figure 3.
Case 7. A patient with a sciatic myxoma. A: The MR neurogram is shown; the arrow indicates the tumor. B: The ultrasound image that was used for administration of MB is shown with the tumor in view. C and D: Intraoperative photographs of the sciatic myxoma. Shown in C is the initial subcutaneous dissection demonstrating the MB tract. Immediately prior to removal of the tumor a photograph was taken to show the tumor and normal sciatic nerve (D). E: After the tumor was removed, the borders of the tumor are shown with peripheral staining of MB.
There were no cases in which patients experienced an allergic reaction to the MB injection. The needle used for nerve stimulation and for administration of the MB did not cause any complications, such as nerve injury or hematoma. In every surgery, the MB was present throughout the dissection, and it was useful for operative exposure. There were no patients that experienced permanent skin discoloration.
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