Neuroma

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List of terms related to Neuroma

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and keywords: Traumatic neuroma; Morton neuroma; Joplin neuroma

Overview

Neuroma (Neuro- is from the Greek for nerve) is defined as a benign tumor of a nerve. However, neuroma commonly refers to any tumor of cells of the nervous system and forms a part of peripheral nerve sheath tumors.

Historical Perspective

• Neuroma was first described by Thomas Morton in 1876

Classification

• Neuroma may be classified according to histopathological features into 3 groups:

• Morton neuroma

• Symptomatic perineural fibrosis around a plantar digital nerve of the foot
• Also known as Morton’s metatarsalgia

• Traumatic neuroma

• Arises from nerve injury (often as a result of surgery).
• They occur at the end of injured nerve fibres as a form of uneffective, unregulated nerve regeneration
• Subtype of traumatic neuroma, called "Joplin neuroma" (a compression traumatic neuroma)
• Occurs most commonly near a scar
• Often very painful

• Neoplasic neuroma

• Solid nodular mass
• Usually, separate from nerve fibers

Pathophysiology

• The pathogenesis of neuroma is characterised by neural degeneration with epineural and endoneural vascular hyalinization, and perineural fibrosis.
• The pathogenesis of traumatic neuroma is characterised by a chronic reactive fibroinflammatory disorganised regeneration around a nerve after an injury (such as traction injury or chronic repetitive stress)
• Morton neuroma is characterized by being located in the 3rd web-space, between 3rd and 4th metatarsal heads.
• Another subtype of traumatic neuroma is terminal neuroma (also known as "stump neuroma") which can occur after transection of the nerve (e.g. limb amputation).
• The are no genetic mutations associated with the development of neuroma.
• On gross pathology, characteristic findings of neuroma, include:

• Adherent fibrofatty tissue
• Yellowish small mass

• On microscopic histopathological analysis, characteristic findings of neuroma, include:

• Extensive fibrosis around and within the nerve
• Digital artery
• Thrombosis
• Arterial thickening

Causes

• Common causes of neuroma, include:

• Indirect nerve trauma

• Traction injury
• Chronic repetitive stress

Differentiating Neuroma from other Diseases

• Neuroma must be differentiated from other diseases that cause forefoot pain, and numbness, such as:

• Stress fracture (neck of the metatarsal)
• Rheumatoid arthritis
• Plexiform neurofibroma
• Hammertoe

Epidemiology and Demographics

• Neuroma is a uncommon disease.

Age

• Neuroma is more commonly observed among patients aged between 15 to 50 years old.
• Neuroma is more commonly observed among middle aged adults.

Gender

• Females are more commonly affected with neuroma than males.
• The female to male ratio is approximately 5:1.

Race

• There is no racial predilection for neuroma.

Risk Factors

• Common risk factors in the development of neuroma, include:

Natural History, Complications and Prognosis

• The majority of patients with neuroma are symptomatic at the time of diagnosis.
• Early clinical features include neuropathic pain, or local tenderness.
• If left untreated, the majority of patients with neuroma may progress to develop walking difficulty, and limping.
• The most important complication of neuroma is chronic neuropathic pain.
• Prognosis is generally good, and the survival rate of patients with neuroma is 99%.

Diagnosis

Symptoms

• Neuroma is usually asymptomatic.
• Symptoms of neuroma may include the following:

• Focal area of pain

Physical Examination

• Patients with neuroma usually appear with antalgic posture.
• Physical examination may be remarkable for:

• Tenderness to palpation

Laboratory Findings

• There are no specific laboratory findings associated with neuroma.

Imaging Findings

• On ultrasound, neuroma is characterized by the following findings:

• Round to ovoid
• Well-defined, hypoechoic lesion
• Located in the intermetatarsal space proximal to the metatarsal head

• On MRI, characteristic findings of neuroma, include:

• Dumbbell/ovoid-shaped lesion at a similar position to that described on ultrasound
• T1: typically low-to-iso signal
• T2: typically low signal but can sometimes be intermediate in signal
• T1 C+ (Gd): tends to show intense enhancement

Treatment

Medical Therapy

• Medical therapy for neuroma, include:

• Ultrasound-guided interdigital injection of steroid and local anaesthetic.

Surgery

• Surgery is the mainstay of therapy for neuroma .
• Surgical excision is the treatment of choice for patients with neuroma with a relatively good success rate, around 80%.

Prevention

• There are no primary preventive measures available for neuroma.
• Secondary prevention measures, include: personal hygiene measures, such as wearing ergonomic shoes.