Síndrome Del Túnel Del Tarso
Pacientes tratados
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0
Intervenciones de cirugía ecoguiada
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Años de experiencia
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El síndrome del túnel del tarso es una enfermedad con una alta prevalencia en la población general pero muy infradiagnosticado. Se estima que el 10% de la población va a sufrir una fascitis plantar en su vida, y de este número de fascitis, al menos la mitad pueden ser en realidad alteraciones compresivas en el nervio tibial posterior.
El nervio tibial posterior es el que da la sensibilidad a la planta del pie, con sus dos ramas, nervio plantar medial y nervio plantar lateral. A su paso por el tobillo, discurre por un túnel fibroso llamado túnel del tarso, y al dividirse en dos, el tabique que lo separa es muy duro y rígido. Así mismo, sobre el nervio hay un músculo, abductor del primer dedo, cuya fascia profunda es terriblemente firme, tanto que cortarla con bisturí es difícil. Por toda esta anatomía que lo rodea, es fácil que el nervio sufra una compresión en algún momento de la vida, dando sintomatología dolorosa, a menudo poco específica: alodinia o dolor exagerado, dolor excesivo al hacer algún gesto, dolor en la planta del pie o en los dedos, acorchamiento…
Normalmente este dolor es confundido o metido en el mismo saco que la fascitis plantar, arrastrando las pacientes molestias durante años sin encontrar una solución.
El diagnóstico es clínico, simplemente apretar el recorrido del nervio y sus ramas es doloroso (signo de Tinel). Se suele comparar con el otro pie si está asintomático. Se suele realizar la misma prueba tras localizar el nervio y sus ramas con el ecógrafo de alta definición, para aumentar la sensibilidad de esta sencilla prueba. Se puede también inyectar una mínima cantidad de anestésico local para comprobar que el nervio analgesiado es el causante del dolor, y en ocasiones, tras comprobarlo, realizar una inyección de suero salino peri – nervio para dilatar el espacio que tiene el nervio y ver si mejora la sintomatología en los siguientes días. También es posible realizar un estudio neurofisiológico por parte de un médico especialista, pero la sensibilidad de esta prueba es baja si el clínico no está superespecializado en nervio periférico del pie y tobillo y sin la ayuda de un ecografista que le guie con un ecógrafo de alta gama para localizar las pequeñas ramas nerviosas.
Nervio tibial y sus ramas a su paso por el túnel del tarso, diseccionado.
TN: nervio tibial posteriorMCN: nervio calcáneo medial, sensitivo del talón
MPN: nervio plantar medial, rama medial del nervio tibial posterior
LPN: nervio plantar lateral, rama lateral del nervio tibial posterior
BN: nervio de baxter o primera rama del nervio plantar lateral, cuya compresión da un dolor similar a la fascitis o fasciopatía planta
Anestesia y tratamiento del nervio tibial posterior a su paso retromaleolar previo a su descompresión quirúrgica bajo ecoguía
Una vez hecho el diagnóstico, el tratamiento es quirúrgico, liberando el nervio de las estructuras que lo comprimen: fascia profunda del músculo abductor, tabique internervioso, ligamento lacinado y en ocasiones fascia plantar. En nervios con daños permanentes la técnica puede incluir la radiofrecuencia ecoguiada. El equipo de VITRUVIO es pionero en describir y publicar la técnica ecoguiada de cirugía del túnel del tarso, que tiene la gran ventaja frente a la cirugía abierta de que esta, al tener que hacer una gran incisión, y el tejido de cicatriz es duro e inelástico, cuando se cierra la herida la propia cicatriz suele volver a comprimir el nervio, resultando de esto una recidiva de la enfermedad en poco tiempo. Sí que puede estar indicada la técnica abierta en caso de tumores nerviosos o lesiones ocupantes del espacio.
Sin duda la cirugía ecoguiada para el síndrome del túnel del tarso ha supuesto un antes y un después para el tratamiento de esta desconocida enfermedad.
Incisión y disección necesaria para cirugía abierta del túnel del tarso
Cirugía ecoguiada del túnel del tarso, poniendo el vendaje antes de que el paciente se marche caminando a su domicilio
Síntomas
Dolor en el talón, en la cara interna del tobillo o en la planta del pie, principalmente cuando estamos de pie o tumbados en la cama. En ocasiones, adormecimiento del pie y otra sintomatología difusa.
Diagnóstico
Exploración física, ecografía de alta definición del nervio, en ocasiones una pequeña inyección de anestésico local, en otras inyectar suero salino en los puntos de compresión del nervio para comprobar la mejoría del paciente y el estudio neurofisiológico con guía ecográfica.
Tratamiento
Principalmente quirúrgico, con cirugía ecoguiada ultramínimamente invasiva. En casos concretos, hidrodisección ecoguiada del nervio o radiofrecuencia pulsada sobre él.
Más sobre el síndrome del túnel del tarso
Esta patología es de gran interés para mí por su gran prevalencia en la población general y su pobre tratamiento en la actualidad, lo que me lleva, junto a mi equipo, tras una larga investigación en laborarios de anatomía de la Universidad Complutense de Madrid, junto a prestigiosos investigadores – anatomistas de este centro y expertos de anatomía de universidades extranjeras, a describir y publicar por primera vez la técnica de cirugía del túnel del tarso.
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