Neuroma: Difference between revisions
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=== Prevention === | === Prevention === | ||
*There are no primary preventive measures available for neuroma . | *There are no primary preventive measures available for neuroma. | ||
*Secondary prevention measures, include: personal hygiene measures, such as wearing ergonomic shoes. | |||
==References== | ==References== |
Revision as of 15:52, 21 April 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 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.
- Common complications of neuroma include
- 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 1-2
- T2: typically low signal but can sometimes be intermediate in signal
- T1 C+ (Gd): tends to show intense enhancement
Other Diagnostic Studies
- Neuroma may also be diagnosed using [diagnostic study name].
- Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].
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.