R F Ghaly1. 1. Chicago Institute of Neurosurgery and Neuroresearch, and Department of Anesthesiology and Pain Management, Cook County Hospital, Illinois 60614, USA. rfghaly@aol.com
Abstract
OBJECTIVE AND IMPORTANCE: Neoplasms of peripheral nerves can be obscured, especially during the early phase. The author reports a patient with a posterior tibial nerve neurilemoma (schwannoma). For a decade, the tumor was misdiagnosed as nonspecific S1 radiculopathy and psychogenic chronic pain syndrome. The patient's presentation and initial management are unique. CLINICAL PRESENTATION: A 40-year-old woman reported severe left foot and calf pain, numbness, and weakness. The symptoms were evident during three pregnancies, and they gradually progressed. The neuropathic pain was protracted, despite implantation of a dorsal column stimulator and administration of a wide variety of medications and therapies. The symptoms were unresponsive to both inpatient and outpatient treatments, which resulted in a misdiagnosis of psychogenic pain for more than a decade. Diagnostic scans obtained by computed tomography, ultrasonography, and nuclear scintigraphy confirmed a popliteal fossa mass. INTERVENTION: A high, large posterior tibial nerve neurilemoma was found intraoperatively, positioned just below the sciatic nerve bifurcation with extensive degenerative features and hemorrhages. Surgical resection provided immediate recovery. CONCLUSION: Peripheral nerve tumors are rarely acknowledged clinical entities. Chronic unexplained foot and calf pain and a positive Tinel's sign should raise suspicion of posterior tibial nerve neurilemoma. Even in patients who have had such tumors for a decade, surgical resection remains the treatment of choice.
OBJECTIVE AND IMPORTANCE: Neoplasms of peripheral nerves can be obscured, especially during the early phase. The author reports a patient with a posterior tibial nerve neurilemoma (schwannoma). For a decade, the tumor was misdiagnosed as nonspecific S1 radiculopathy and psychogenic chronic pain syndrome. The patient's presentation and initial management are unique. CLINICAL PRESENTATION: A 40-year-old woman reported severe left foot and calfpain, numbness, and weakness. The symptoms were evident during three pregnancies, and they gradually progressed. The neuropathic pain was protracted, despite implantation of a dorsal column stimulator and administration of a wide variety of medications and therapies. The symptoms were unresponsive to both inpatient and outpatient treatments, which resulted in a misdiagnosis of psychogenic pain for more than a decade. Diagnostic scans obtained by computed tomography, ultrasonography, and nuclear scintigraphy confirmed a popliteal fossa mass. INTERVENTION: A high, large posterior tibial nerve neurilemoma was found intraoperatively, positioned just below the sciatic nerve bifurcation with extensive degenerative features and hemorrhages. Surgical resection provided immediate recovery. CONCLUSION: Peripheral nerve tumors are rarely acknowledged clinical entities. Chronic unexplained foot and calfpain and a positive Tinel's sign should raise suspicion of posterior tibial nerve neurilemoma. Even in patients who have had such tumors for a decade, surgical resection remains the treatment of choice.