Neuroma: Difference between revisions
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==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
*Neuroma is a uncommon disease | *Neuroma is a uncommon disease<ref name="pmid10597831">{{cite journal |vauthors=Wu J, Chiu DT |title=Painful neuromas: a review of treatment modalities |journal=Ann Plast Surg |volume=43 |issue=6 |pages=661–7 |year=1999 |pmid=10597831 |doi= |url=}}</ref> | ||
===Age=== | ===Age=== | ||
*Neuroma is more commonly observed among patients aged between 15 to 50 years old | *Neuroma is more commonly observed among patients aged between 15 to 50 years old<ref name="pmid10597831">{{cite journal |vauthors=Wu J, Chiu DT |title=Painful neuromas: a review of treatment modalities |journal=Ann Plast Surg |volume=43 |issue=6 |pages=661–7 |year=1999 |pmid=10597831 |doi= |url=}}</ref> | ||
*Neuroma is more commonly observed among middle aged adults | *Neuroma is more commonly observed among middle aged adults | ||
===Gender=== | ===Gender=== | ||
*Females are more commonly affected with neuroma than males | *Females are more commonly affected with neuroma than males | ||
*The female to male ratio is approximately 5:1 | *The female to male ratio is approximately 5:1<ref name="pmid10597831">{{cite journal |vauthors=Wu J, Chiu DT |title=Painful neuromas: a review of treatment modalities |journal=Ann Plast Surg |volume=43 |issue=6 |pages=661–7 |year=1999 |pmid=10597831 |doi= |url=}}</ref> | ||
===Race=== | ===Race=== | ||
*There is no racial predilection for neuroma | *There is no racial predilection for neuroma | ||
==Risk Factors== | ==Risk Factors== | ||
| Line 107: | Line 107: | ||
== Natural History, Complications and Prognosis== | == Natural History, Complications and Prognosis== | ||
*The majority of patients with neuroma are symptomatic at the time of diagnosis | *The majority of patients with neuroma are symptomatic at the time of diagnosis<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
*Early clinical features include neuropathic pain or local [[tenderness]] | *Early clinical features include neuropathic pain or local [[tenderness]] | ||
*If left untreated, the majority of patients with neuroma may progress to develop [[difficulty walking]] and [[limping]] | *If left untreated, the majority of patients with neuroma may progress to develop [[difficulty walking]] and [[limping]] | ||
*A significant complication of neuroma is chronic [[neuropathic pain]] | *A significant complication of neuroma is chronic [[neuropathic pain]] | ||
*Prognosis is generally good, and the survival rate of patients with neuroma is 99% | *Prognosis is generally good, and the survival rate of patients with neuroma is 99% | ||
== Diagnosis == | == Diagnosis == | ||
=== Symptoms === | === Symptoms === | ||
*Neuroma is usually asymptomatic | *Neuroma is usually asymptomatic | ||
*Symptoms of neuroma may include:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | *Symptoms of neuroma may include:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
**Focal area of [[Trauma|traumatic]] [[neuropathic]] [[pain]] with the presence of a [[Typical set|typical]] [[trigger point]] in the [[area]] of a [[neuroma]] (especially with the [[pressure]] application) [[Causality|causing]] the [[patient]] to feel burning, stabbing, [[raw]], gnawing or sickening [[sensations]] | **Focal area of [[Trauma|traumatic]] [[neuropathic]] [[pain]] with the presence of a [[Typical set|typical]] [[trigger point]] in the [[area]] of a [[neuroma]] (especially with the [[pressure]] application) [[Causality|causing]] the [[patient]] to feel burning, stabbing, [[raw]], gnawing or sickening [[sensations]] | ||
| Line 124: | Line 124: | ||
=== Physical Examination === | === Physical Examination === | ||
*Patients with neuroma usually appear with antalgic posture | *Patients with neuroma usually appear with antalgic posture<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
*Physical examination may be remarkable for: | *Physical examination may be remarkable for: | ||
:*[[Tenderness]] to palpation | :*[[Tenderness]] to palpation | ||
| Line 131: | Line 131: | ||
=== Laboratory Findings === | === Laboratory Findings === | ||
*There are no specific laboratory findings associated with neuroma | *There are no specific laboratory findings associated with neuroma<ref name="wiki">Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016</ref> | ||
===Imaging Findings=== | ===Imaging Findings=== | ||
| Line 165: | Line 165: | ||
:*Anticonvulsants (more effective) | :*Anticonvulsants (more effective) | ||
:*Serotonin-norepinephrine reuptake inhibitors | :*Serotonin-norepinephrine reuptake inhibitors | ||
:*Ultrasound-guided interdigital injection of steroid and [[local anaesthetic]] | :*Ultrasound-guided interdigital injection of steroid and [[local anaesthetic]] | ||
=== Surgery === | === Surgery === | ||
*Surgery is the mainstay of therapy for neuroma | *Surgery is the mainstay of therapy for neuroma | ||
*Surgical excision is the treatment of choice for patients with neuroma; this surgical intervention is associated with a relatively favorable success rate, approximately 80% | *Surgical excision is the treatment of choice for patients with neuroma; this surgical intervention is associated with a relatively favorable success rate, approximately 80% | ||
*The recurrence rate after surgery is as high as 50% | *The recurrence rate after surgery is as high as 50% | ||
=== Prevention === | === Prevention === | ||
*There are no primary preventive measures available for neuroma | *There are no primary preventive measures available for neuroma<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
*Secondary prevention measures include: personal hygiene measures, such as wearing ergonomic shoes | *Secondary prevention measures include: personal hygiene measures, such as wearing ergonomic shoes | ||
==References== | ==References== | ||
Revision as of 15:20, 23 May 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mohsin, M.D.[2] Maria Fernanda Villarreal, M.D. [3]
Synonyms and keywords: Traumatic neuroma; Morton neuroma; Joplin neuroma; Amputation neuroma; Pseudoneuroma; Morton’s metatarsalgia; Plantar interdigital 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.[1] Neuromas form part of the peripheral nerve sheath tumors. Neuroma was first described by Thomas Morton in 1876. Neuromas may be classified according to histopathological features into 3 groups: Morton's neuroma, traumatic neuroma, and neoplasic neuromas. The pathogenesis of neuroma is characterized by neural degeneration with epineural and endoneural vascular hyalinization, and perineural fibrosis. Neuroma is more commonly observed among patients aged between 15 to 50 years old. Neuroma is more commonly observed among middle aged adults. Females are more commonly affected with neuroma than males. The female to male ratio is approximately 5:1. Common risk factors in the development of neuroma include improper footwear and high impact sports (e.g., rock-climbing, ballet dancing). A major complication of neuroma is chronic neuropathic pain. On ultrasound, neuroma is characterized as a well-defined, hypoechoic lesion located in the intermetatarsal space proximal to the metatarsal head. Patients with neuroma usually appear with antalgic posture. Physical examination may be remarkable for tenderness to palpation and dysesthetic pain. Surgical excision is the treatment of choice for patients with neuroma; this surgical intervention is associated with a relatively favorable success rate, approximately 80%. The recurrence rate after surgery is as high as 50%.
Historical Perspective
- In 1876, Neuroma was first described by Thomas Morton
Classification
- Neuroma may be classified according to histopathological features into 3 groups:[2]
- Morton neuroma
- Symptomatic perineural fibrosis around a plantar digital nerve of the foot due to chronic nerve compression
- Also known as:
- Morton’s metatarsalgia
- Plantar interdigital neuroma
- Traumatic neuroma[3][4]
- Arises from nerve injury (often as a result of surgery)
- They occur at the end of injured nerve fibers as a form of unregulated nerve regeneration
- Subtype of traumatic neuroma, called "Joplin neuroma" (a compression traumatic neuroma)
- Occurs most commonly near a scar
- Often very painful
- Also known as:
- Amputation neuroma
- Pseudoneuroma
- Neoplasic neuroma
- Solid nodular mass
- Usually, separate from nerve fibers
- Acoustic neuroma - this is misnomer; it is actually a Schwannoma
- Palisaded encapsulated neuroma
- Morton neuroma
Pathophysiology
- The pathogenesis of neuroma is characterized by neural degeneration with epineural and endoneural vascular hyalinization, and perineural fibrosis[2]
- The pathogenesis of traumatic neuroma is characterized by:[5][6][7]
- Tangle of neural fibers and connective tissue that develops following a peripheral nerve injury
- Interruption in continuity of nerve causing wallerian degeneration (loss of axons in proximal stump and retraction of axons in distal segment), followed by exuberant regeneration of nerve and formation of mass of Schwann cells, axons and fibrous cells
- Chronic reactive fibroinflammatory disorganized 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[8]
- 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)
- There are no genetic mutations associated with the development of neuroma
- On gross pathology, characteristic findings of neuroma, include:[9][10]
- On microscopic histopathological analysis, characteristic findings of neuroma, include:[9][10]
- Extensive fibrosis around and within the nerve
- Digital artery
- Thrombosis
- Arterial thickening
Histopathology of traumatic neuroma
- Numerous well formed small nerve twigs
- Limited soft tissue infiltration
- Contains axons in haphazardly arranged nerves within mature collagenous scar with entrapped smooth muscle
 |
Common sites of involvement by traumatic neuroma
- Most common oral locations are:
- Tongue
- Near mental foramen of mouth
- Rarely involves:
- Head
- Neck
Causes
- Indirect nerve trauma
- Especially during a surgery
- Cone biopsy (rare complication)
- 55% of hysterectomy patients have microneuromas, associated with childbirth
- 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:[2][10]
- Stress fracture (neck of the metatarsal)
- Rheumatoid arthritis
- Plexiform neurofibroma
- Hammertoe
- Neurofibroma
Epidemiology and Demographics
- Neuroma is a uncommon disease[10]
Age
- Neuroma is more commonly observed among patients aged between 15 to 50 years old[10]
- 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[10]
Race
- There is no racial predilection for neuroma
Risk Factors
- Common risk factors in the development of neuroma include:[9]
- Improper footwear
- High-impact sports (e.g., rock-climbing, ballet dancing)
Natural History, Complications and Prognosis
- The majority of patients with neuroma are symptomatic at the time of diagnosis[2]
- Early clinical features include neuropathic pain or local tenderness
- If left untreated, the majority of patients with neuroma may progress to develop difficulty walking and limping
- A significant 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:[2]
- Focal area of traumatic neuropathic pain with the presence of a typical trigger point in the area of a neuroma (especially with the pressure application) causing the patient to feel burning, stabbing, raw, gnawing or sickening sensations
- Paresthesia over the injured area
- Dysesthesia (painfulhypersensitivity to normal lighttactile stimuli)
- Functional impairment
- Psychological distress (severely decreasing the quality of life)
Physical Examination
- Patients with neuroma usually appear with antalgic posture[2]
- Physical examination may be remarkable for:
- Tenderness to palpation
- Limitation of range of motion
- Dysesthetic pain
Laboratory Findings
- There are no specific laboratory findings associated with neuroma[9]
Imaging Findings
- 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
- On MRI, characteristic findings of traumatic neuroma include:[2]
- Fusiform swelling of a nerve or a bulbous mass at a nerve end
- The parent nerve of some small nerve may difficult or impossible to discern
- T2/STIR:inhomogeneous hyperintensity (may have a hypointense rim)
- T1 C+ (Gd): variable contrast enhancement
- The image below demonstrates MRI findings of traumatic neuroma.
-
Morton neuroma MRICourtesy of Radiopedia
- On ultrasound, neuroma is characterized by the following findings:[2]
- Round to ovoid
- Well-defined, hypoechoic lesion
- Located in the intermetatarsal space proximal to the metatarsal head
- On ultrasound, traumatic neuroma is characterized by the following findings:[2]
- Swollen nerve (mass-like)
- Hypoechoic
- Loss of normal fibrillar pattern
- Usually small, but may be as large as 5 cm.
Treatment
Medical Therapy
- Medical therapy for neuroma may include:[2]
- Tricyclic antidepressants
- Anticonvulsants (more effective)
- Serotonin-norepinephrine reuptake inhibitors
- 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; this surgical intervention is associated with a relatively favorable success rate, approximately 80%
- The recurrence rate after surgery is as high as 50%
Prevention
- There are no primary preventive measures available for neuroma[2]
- Secondary prevention measures include: personal hygiene measures, such as wearing ergonomic shoes
References
- ↑ "Neuroma". Dorland's Illustrated Medical Dictionary (32nd ed.). Oxford University Press. 2011. p. 5287. ISBN 978-1-4557-0985-4. Retrieved 25 August 2013.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016
- ↑ Foltán R, Klíma K, Spacková J, Sedý J (2008). "Mechanism of traumatic neuroma development". Med Hypotheses. 71 (4): 572–6. doi:10.1016/j.mehy.2008.05.010. PMID 18599222.
- ↑ Yao C, Zhou X, Zhao B, Sun C, Poonit K, Yan H (2017). "Treatments of traumatic neuropathic pain: a systematic review". Oncotarget. 8 (34): 57670–57679. doi:10.18632/oncotarget.16917. PMC 5593675. PMID 28915703.
- ↑ Kitcat M, Hunter JE, Malata CM (2009). "Sciatic neuroma presenting forty years after above-knee amputation". Open Orthop J. 3: 125–7. doi:10.2174/1874325000903010125. PMC 2835865. PMID 20224738.
- ↑ Lee EJ, Calcaterra TC, Zuckerbraun L (1998). "Traumatic neuromas of the head and neck". Ear Nose Throat J. 77 (8): 670–4, 676. PMID 9745184.
- ↑ Hanna SA, Catapano J, Borschel GH (2016). "Painful pediatric traumatic neuroma: surgical management and clinical outcomes". Childs Nerv Syst. 32 (7): 1191–4. doi:10.1007/s00381-016-3109-z. PMID 27179535.
- ↑ Perry, Arie (2010). Practical surgical neuropathology : a diagnostic approach. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0443069826.
- ↑ 9.0 9.1 9.2 9.3 9.4 Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 Wu J, Chiu DT (1999). "Painful neuromas: a review of treatment modalities". Ann Plast Surg. 43 (6): 661–7. PMID 10597831.