Neuroma
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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. Neuromas form part of the peripheral nerve sheath tumors.Neuroma was first described by Thomas Morton in 1876
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
- The image below demonstrates microscopic histopathological analysis of traumatic neuroma
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Traumatic neuroma
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:
- Unproper footwear
- High impact sports (eg. rock-climbing, ballet dancing)
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
- Dysesthetic pain
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 ultrasound, traumatic neuroma is characterized by the following findings:
- Swollen nerve (mass-like)
- Hypoechoic
- Loss of normal fibrillar pattern
- Usually small, but may be as large as 5 cm.
- 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:
- 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
Treatment
Medical Therapy
- Medical therapy for neuroma, include:
- 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 with a relatively good success rate, around 80%.
- The recurrence rate after surgery is as high as 50%
Prevention
- There are no primary preventive measures available for neuroma.
- Secondary prevention measures, include: personal hygiene measures, such as wearing ergonomic shoes.