MANY OPTIONS FOR NEUROMA SURGERY - PT II

Nerves are funny things. They have unique functions and a specialized metabolism. Because they are able to carry information rapidly, we are able to walk and talk, write and read. But tough they are not, prone to all manner of problems in the face of physically stressful conditions. To put it bluntly, nerves are quite delicate and heal poorly, if at all. Protect your nerves; they need it.

The nerves that run between our metatarsal bones are prone to pressure, stimulating a scarring process of the nerve covering and pain results. As discussed previously, this is not an uncommon problem. It is believed one out of three individuals will experience these symptoms at some point in their lives. For many, the pain demands treatment. However, the form of care is tremendously variable. Typically, conservative measures are sufficient. The need for, and timing of, surgical intervention will vary depending on the individual, their foot type, as well as the physician providing aid.

Readers have recently learned of the traditional surgical procedure for treatment of a painful neuroma in which the nerve is cut and the neuroma removed. However, certain changes take place when a nerve is transected, meaning it is cut through. The many tiny fibers composing a typical nerve will grow but do so in an unguided, chaotic fashion. A disorganized mass of nerve fibers often results, tending to produce as much pain as preoperatively, if not more.

This unfortunate complication of the conventional surgical technique for a trapped intermetatarsal nerve is called a stump neuroma and it occurs nearly a third of the time according to some studies. Unfortunately, this is not the only complication following the traditional method of nerve excision. Blood may pool in this loose space between the bones following the operation, creating a hematoma which is a hard mass of coagulated blood. This lump puts pressure on the surrounding structures leading to healing difficulties.

Alternative procedures have been sought in an effort to lower the frequency of problems. Approaching the nerve through the bottom of the foot allows significantly better access to the site. An attempt is made to bury the cut end of the nerve in a nearby muscle, a tissue type reducing the usual nerve fiber disorganization. Because of the location of the incision, we are able to transect the nerve farther from the pressures and trauma of weight bearing, a damaging force.

One of the latest developments is a technique which spares the nerve, instead attempting to minimize the physical pressure on the nerve. This method is associated with an extremely low complication rate in the small studies to date. This is not surprising since the incision is quite small and the nerve isn’t traumatized. The ligament which connects the two metatarsal bones is cut, removing one of the three structures trapping the nerve.

Other concepts and methods are being investigated in an effort to make neuroma surgery safer. One such concept involves destruction of the nerve through the application of high intensity radio waves. These have the ability to shrink up soft tissues. This again does not need a large incision, minimizing the degree of trauma, easing post-operative pain. Further studies are needed to better define the success rate and possible complications.

Unfortunately, the old method is still performed regularly in clinics and facilities throughout the nation. The reasons for this are many, one being the level of comfort attained with some procedure. Additionally, it can be difficult for a physician to gain experience with a new technique. There aren’t many opportunities to train in some new method. Also a factor, doctors are creatures of habit. Once they become practiced at some method, there is a certain familiarity, making it easy to fall back on.

But it seems obvious that a change is necessary. Conservative measures need to be pursued with dedication and perseverance, especially important since this older option carries a high risk of complications. Properly prescribed foot orthotics should be required before any operative intervention. Perhaps some of the exciting new regenerative techniques will find success in the treatment of this common foot pathology but, until then, it is wise to be cautious in consenting to surgery. After all, there is no surgical procedure without some risk for complications. 

Dr. Conway McLean, a board certified podiatric physician, is the Director of Superior Foot and Ankle Centers in Marquette Michigan.