Neuroma Surgical Care
Conservative measures aimed at providing relief of pain are success approximately 70% of the time. If painful symptoms continue despite adequate use of shoe and orthtoic therapy as well as the selective use of cortisone injections than surgical care is warranted.
The surgical procedure is performed in an outpatient surgical care center. An anesthesiologist administers light sedation called “twilight” anesthesia or Monitored Anesthesia Care (MAC) as well as the administration of local long acting anesthetics that are injected into the surgical region.
The general surgical approach for the relief of neuroma pain is to removed the nerve from typically the second or third innerspaces or between the second and third or third and fourth metatarsal bones. The third innerspace neuroma occurs more commonly than the second innerspace neuroma.
A thorough clinical exam during the conservative treatment period will help located the affected nerve location. The use of x-rays and MRI are rarely needed to make an accurate diagnosis. A surgical incision is placed over the affected innerspace that extends from the middle of the metatarsal bones and extends to the base of the toes to the webspace. The ligament called the deep transverse innermetatarsal ligament is then resected which helps to identify the abnormal nerve.
Normally the nerve will be quite thickened in between the metatarsal bones. The nerve is then traced to a point where it bifurcates extending braches to the involved toes. At this point the digital braches are cut and then the nerve is resected at a safe level behind the metatarsal heads. The wound is then closed with suture that typically dissolves and is buried under the skin layer. The wound is dressed with bandaid or steristrip closures with a dry surgical sterile dressing.
Pain is usually not noted for 12 hours after returning home after surgery. As the local anesthetic begins to wear off and early symptoms of pain begin this is a very important time to begin taking the pain medication. Generally the pain is mild to moderate with most of the acute pain subsiding after the first three to five days.
You will be able in most instances to walk with the use of a surgical shoe without the additional need for crutches. Walking is typically guarded by placing pressure on the outside region of the foot to take pressure off of the surgical area.
The wound is left in place and should never be changed at home unless instructed by your surgeon. Wound checks are performed one week after surgery with the surgical dressing and steri strip closures removed after ten to fourteen days post operatively.
Bathing and showering can then be done without any restrictions at this time with aggressive massage and soft tissue rehabilitation as directed by your surgeon. Activity will increase gradually with the discontinuation of the surgical shoe and advancement into normal shoeware beginning at three weeks post operatively.
Complete recovery is expected at three months after surgery at which time most shoes and activities that you want to wear or do will be relatively painfree. return to normal activity often will begin four weeks post operatively. The nerve that remains can stay painful over the first four weeks and then begins to calm down with marked pain relief noted around four to six weeks post operatively.
Complications including infection, excessive surgical bleeding are rare. The most common complication occurring approximately 10% of the time can include recurrent neuroma with painful scar tissue forming at the resected nerve site that can lead to similar symptoms as noted preoperatively. Continued conservative measures often helps with the pain but very occasional revisional surgery must be performed to provide long lasting pain relief.