Neuroma: Difference between revisions
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==Overview== | ==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]].<ref name="Dorlands">{{cite encyclopedia|editor= |encyclopedia=Dorland's Illustrated Medical Dictionary| edition=32nd| title=Neuroma | url=http://books.google.com/books?id=mNACisYwbZoC&pg=PT5287|accessdate=25 August 2013| year=2011| publisher=Oxford University Press| isbn=978-1-4557-0985-4 |page=5287}}</ref> 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''' (''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]].<ref name="Dorlands">{{cite encyclopedia|editor= |encyclopedia=Dorland's Illustrated Medical Dictionary| edition=32nd| title=Neuroma | url=http://books.google.com/books?id=mNACisYwbZoC&pg=PT5287|accessdate=25 August 2013| year=2011| publisher=Oxford University Press| isbn=978-1-4557-0985-4 |page=5287}}</ref> 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 [[hyaline|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== | ==Historical Perspective== | ||
Neuroma was first described by Thomas Morton in 1876. | |||
==Classification== | ==Classification== | ||
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::*Also known as Morton’s metatarsalgia | ::*Also known as Morton’s metatarsalgia | ||
:*'''Traumatic neuroma''' | :*'''Traumatic neuroma''' | ||
::*Arises from nerve injury (often as a result of surgery) | ::*Arises from nerve injury (often as a result of surgery) | ||
::*They occur at the end of injured nerve | ::*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) | ::*Subtype of traumatic neuroma, called "Joplin neuroma" (a compression traumatic neuroma) | ||
::*Occurs most commonly near a [[scar]] | ::*Occurs most commonly near a [[scar]] | ||
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==Pathophysiology== | ==Pathophysiology== | ||
*The pathogenesis of neuroma is | *The pathogenesis of neuroma is characterized by neural degeneration with epineural and endoneural vascular hyalinization, and perineural fibrosis.<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
*The pathogenesis of traumatic neuroma is | *The pathogenesis of traumatic neuroma is characterized by a 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 [[Metatarsals|metatarsal]] heads. | *Morton neuroma is characterized by being located in the 3rd web-space, between 3rd and 4th [[Metatarsals|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). | *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. | *The are no genetic mutations associated with the development of neuroma. | ||
*On gross pathology, characteristic findings of neuroma, include:<ref name="wiki">Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016</ref><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> | *On gross pathology, characteristic findings of neuroma, include:<ref name="wiki">Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016</ref><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> | ||
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:*[[Thrombosis]] | :*[[Thrombosis]] | ||
:*Arterial thickening | :*Arterial thickening | ||
*The image below demonstrates microscopic histopathological analysis of traumatic neuroma | *The image below demonstrates microscopic histopathological analysis of traumatic neuroma: | ||
<gallery> | <gallery> | ||
Image:Traumatic neuroma.jpg| Traumatic neuroma | Image:Traumatic neuroma.jpg|Traumatic neuroma. Courtesy of Libre Pathology | ||
</gallery> | </gallery> | ||
==Causes== | ==Causes== | ||
*Common causes of neuroma | *Common causes of neuroma include:<ref name="wiki">Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016</ref><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> | ||
:*Indirect nerve trauma | :*Indirect nerve trauma | ||
::*Traction injury | ::*Traction injury | ||
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==Differentiating Neuroma from other Diseases== | ==Differentiating Neuroma from other Diseases== | ||
*Neuroma must be differentiated from other diseases that cause forefoot pain | *Neuroma must be differentiated from other diseases that cause forefoot pain and numbness such as:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref><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> | ||
:*[[Stress fracture]] (neck of the metatarsal) | :*[[Stress fracture]] (neck of the metatarsal) | ||
:*[[Rheumatoid arthritis]] | :*[[Rheumatoid arthritis]] | ||
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==Risk Factors== | ==Risk Factors== | ||
*Common risk factors in the development of neuroma | *Common risk factors in the development of neuroma include:<ref name="wiki">Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016</ref> | ||
:* | :*Improper footwear | ||
:*High impact sports ( | :*High-impact sports (e.g., rock-climbing, ballet dancing) | ||
== Natural History, Complications and Prognosis== | == Natural History, Complications and Prognosis== | ||
*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> | *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 | *Early clinical features include neuropathic pain or local [[tenderness]]. | ||
*If left untreated, the majority of patients with neuroma may progress to develop walking | *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%. | *Prognosis is generally good, and the survival rate of patients with neuroma is 99%. | ||
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=== Symptoms === | === Symptoms === | ||
*Neuroma is usually asymptomatic. | *Neuroma is usually asymptomatic. | ||
*Symptoms of neuroma | *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 neuropathic pain | :*Focal area of neuropathic pain | ||
::*No alleviating factors | ::*No alleviating factors | ||
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*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> | *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 | ||
:*Limitation of range of motion | :*Limitation of range of motion | ||
:*[[Pain|Dysesthetic pain]] | :*[[Pain|Dysesthetic pain]] | ||
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===Imaging Findings=== | ===Imaging Findings=== | ||
*On MRI, characteristic findings of neuroma include: | |||
*On MRI, characteristic findings of neuroma | |||
:*Dumbbell/ovoid-shaped lesion at a similar position to that described on ultrasound | :*Dumbbell/ovoid-shaped lesion at a similar position to that described on ultrasound | ||
:*T1: typically low-to-iso signal | :*T1: typically low-to-iso signal | ||
:*T2: typically low signal but can sometimes be intermediate in signal | :*T2: typically low signal but can sometimes be intermediate in signal | ||
:*T1 C+ (Gd): tends to show intense enhancement | :*T1 C+ (Gd): tends to show intense enhancement | ||
*On MRI, characteristic findings of traumatic neuroma | *On MRI, characteristic findings of traumatic neuroma include:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
:*Fusiform swelling of a nerve or a bulbous mass at a nerve end | :*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 | :*The parent nerve of some small nerve may difficult or impossible to discern | ||
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Image:Morton-neuroma-2.png| Morton neuroma MRI<SMALL>Courtesy of Radiopedia</SMALL> | Image:Morton-neuroma-2.png| Morton neuroma MRI<SMALL>Courtesy of Radiopedia</SMALL> | ||
</gallery> | </gallery> | ||
*On ultrasound, neuroma is characterized by the following findings:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | |||
:*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:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | |||
:*Swollen nerve (mass-like) | |||
:*Hypoechoic | |||
:*Loss of normal fibrillar pattern | |||
:*Usually small, but may be as large as 5 cm. | |||
== Treatment == | == Treatment == | ||
=== Medical Therapy === | === Medical Therapy === | ||
*Medical therapy for neuroma | *Medical therapy for neuroma may include:<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | ||
:*[[Tricyclic antidepressant|Tricyclic antidepressants]] | :*[[Tricyclic antidepressant|Tricyclic antidepressants]] | ||
:*Anticonvulsants (more effective) | :*Anticonvulsants (more effective) | ||
Line 137: | Line 138: | ||
=== 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 with a relatively | *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.<ref name="morton">Neuroma. Radiopedia http://radiopaedia.org/cases/morton-neuroma-2 Accessed on April 21, 2016</ref> | *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 | *Secondary prevention measures include: personal hygiene measures, such as wearing ergonomic shoes. | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category: Oncology]] | [[Category:Oncology]] | ||
[[Category:FinalQCRequired]] |
Revision as of 13:42, 2 August 2016
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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.[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
Neuroma was first described by Thomas Morton in 1876.
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
- 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 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
- Neoplasic neuroma
- Solid nodular mass
- Usually, separate from nerve fibers
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 a 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.
- 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:[3][4]
- Adherent fibrofatty tissue
- Yellowish small mass
- Extensive fibrosis around and within the nerve
- Digital artery
- Thrombosis
- Arterial thickening
- The image below demonstrates microscopic histopathological analysis of traumatic neuroma:
-
Traumatic neuroma. Courtesy of Libre Pathology
Causes
- 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:[2][4]
- Stress fracture (neck of the metatarsal)
- Rheumatoid arthritis
- Plexiform neurofibroma
- Hammertoe
Epidemiology and Demographics
- Neuroma is a uncommon disease.[4]
Age
- Neuroma is more commonly observed among patients aged between 15 to 50 years old.[4]
- 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.[4]
Race
- There is no racial predilection for neuroma.
Risk Factors
- Common risk factors in the development of neuroma include:[3]
- 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 neuropathic pain
- No alleviating factors
- Aggravating with movement
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.[3]
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
- ↑ 3.0 3.1 3.2 3.3 3.4 Neuroma. Wikipedia. https://en.wikipedia.org/wiki/Neuroma Accessed on April 21, 2016
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Wu J, Chiu DT (1999). "Painful neuromas: a review of treatment modalities". Ann Plast Surg. 43 (6): 661–7. PMID 10597831.