Cryosurgery for neuroma
Cryosurgery is an excellent alternative to open surgery for neuroma when traditional conservative therapy has failed. Compared to open surgery, there is less down time and less chances of complications.
Who is a candidate for a cryosurgery for neuroma procedure?
Cryosurgery for neuromas is not a first line of treatment. It is reserved for when patients have failed more conservative treatments first. For a list and description of conservative treatments for neuromas, please see our page on nonsurgical neuroma treatments by clicking here.
What is a cryosurgery for neuroma?
Cryosurgery procedures have been performed in medicine for many years. Another name for cryosurgery for neuroma is cryogenic neuroablation. Cryosurgery involves using a cryoprobe that uses extremely cold temperature in order to destroy specific neuroma tissue. The cryosurgery machine uses compressed nitrous oxide (N2O) gas to achieve a temperature of -70°C (-94°F). This cold temperature is applied for 2 minutes. The tip of the cryosurgery probe creates an ice ball that measures 6-8 mm that causes a thermal injury to the neuroma and nerve.
At this extreme temperature, the cold causes an injury to the neuroma resulting in Wallerian degeneration of the nerve. This prevents sensation from traveling through the nerve to be perceived by the brain. If there is no perceived sensation, theoretically there will be no pain.
How cold does the cryosurgery probe get?
The cryosurgery probe reaches -70°C (-94°F).
What to expect during a cryosurgery procedure for neuroma
Cryosurgery for neuroma is performed in the surgical center. Patients have the option of remaining awake or being sedated with IV anesthesia by an anesthesiologist. All patients receive local anesthesia in the foot. We make a small incision between the toes to allow the entry of the cryosurgery probe. Obviously, if the patient is sedated, there is no discomfort during the procedure. If the patient chooses not to have sedation, they will feel a small injection to make the area numb. After local anesthesia is achieved, there should be no additional discomfort perceived.
How is a cryosurgery procedure for neuroma done?
Cryosurgery procedures are done in our outpatient surgery center. Patients have the option of being awake or choosing to have IV conscious sedation by an anesthesiologist. This is not general anesthesia. Patients remain breathing on their own, however, they are given IV sedation and they are monitored. This allows them to sleep comfortably during the short procedure.
The first step in performing this procedure is to localize the neuroma using diagnostic ultrasound. We visualize the nerve and neuroma under ultrasound and make multiple marks on the foot with a skin marker indicating where the anatomy is.
After we identify the exact position of the nerve and neuroma, the next step is to perform local anesthesia. Using a very small needle, we perform an injection in the skin over the nerve. This injection is very small and often patients tell us that there is little to no pain.
Cryosurgery probe insertion
We make a small incision between the toes that allows us to introduce the cryosurgery probe. The cryosurgery probe is introduced into the foot and placed right at the neuroma.
The intermetatarsal ligament
The anatomy of the foot is such that there is a ligament that connects the two adjacent metatarsal bones. This ligament resides just above the neuroma. It is this anatomy that allows us to place the probe in the exact correct position. While inserting the probe we are able to feel the intermetatarsal ligament above it. Once we feel this thick ligament, we know we are at the right position to find the neuroma.
Diagnostic ultrasound to confirm placement
Once we have identified the intermetatarsal ligament, we again use diagnostic ultrasound to confirm that we are in the perfect place.
Start the cryosurgery procedure
We start to decrease the temperature of the probe while asking the patient if they feel any pain. If they feel any pain, we immediately turn off the cold and allow the local some more time to work, or occasionally add more local anesthesia.
Once we are able to achieve the cold temperature of the probe without any pain, we are able to perform the cryosurgery procedure. Once the probe has reached -70°C (-94°F), we start a 2 minute timer. After the 2 minute timer has completed, we move the probe and reposition it in a slightly different direction.
After we perform two freezing cycles at the two different locations, we are now done. We remove the cryosurgery probe in place one suture in the incision. Patients leave the procedure with a small surgical dressing.
Postoperative instructions
Patients are given a surgical shoe that they should wear for 1 week. Patients are instructed to return to their normal shoes after 1 week, which we recommend that they wear sneakers. We recommend patient do not take mass transit such as trains or buses to get home after the procedure. We also prefer that they do not drive themselves. When patients choose to have IV sedation, they must have an adult with them to escort them home.
What to expect after a cryosurgery procedure for neuroma
We advise patients that the anesthesia will wear off in between 6 and 24 hours. When the anesthesia has worn off, most patients describe the pain as mild burning sensations. We instruct patients to take Tylenol as needed for pain. We instruct patients to elevate the foot and use ice to reduce inflammation. Patients are instructed to rest and not return to activity until after 1-2 weeks. Many commute to work as normal after 1 week postoperatively. Most patients feel better using a comfortable shoe or sneaker for 2-3 weeks after the procedure.
Some patients will notice bruising and swelling at the procedure site. This is completely normal and expected. This only lasts a few days to a few weeks. The procedural pain may last a couple of days to a couple of weeks. Most patients describe the postoperative recovery in a similar fashion. They report that the original neuroma pain has been replaced by procedural pain. The typical nerve pain with numbness, tingling and shooting is replaced by a dull aching sensation. Rarely, the pain may be more severe in the area from the procedure but only lasts a week or two.
Follow-up after cryosurgery for neuroma
We instruct patients to return to our office 2 weeks after their procedure. At this visit, we will remove the suture between the toes. At this visit, the patient will inform us on how they are feeling. This may range from completely pain-free, to decreased pain, to the pain has stayed exactly the same. On rare occasions, patients have informed us that there is more pain than before the procedure.
Repeat cryosurgery procedure for neuroma, second time
We have patients follow-up 2 months after their cryosurgery procedure. About 75% of people achieve enough relief that they do not require additional procedures. If they are completely pain-free, we advise them to only follow-up if necessary. If the pain has decreased but is still present, we advise them to return in another two months to determine if they require another cryosurgery procedure or not.
The other 25% of people who are still experiencing pain, undergo a second cryosurgery procedure that we schedule at the surgery center again. The repeat cryosurgery procedure is performed in exactly the same manner as described above for the first one.
It is very rare that we will perform any more than two procedures. Although I have performed a third procedure on a very small number of patients, if the procedure fails after two, I usually instruct them to move on to a more invasive procedure. These more invasive procedures will be described on another page of this website.
What is the success rate of cryosurgery procedures for neuroma?
About 75% of people that have cryosurgery procedure for neuroma achieve enough relief of pain and they do not require additional treatments. Many patients have complete 100% resolution of the pain, and some have significant enough resolution that they do not require additional treatments.
Of the 25% that go on to repeat the cryosurgery procedure two times, an additional 80-90% of them have enough relief of symptoms that they do not need additional treatments. The remaining small percent of people go on to additional, usually more invasive, procedures.
What to expect long-term after cryosurgery for neuroma procedures
After the pain has resolved and a few months have elapsed from your procedure, you can expect to have some numbness in the area. A majority of patients report numbness in the adjacent toes, just distal to where the neuroma was. Virtually all of these patients report that this numbness is acceptable, and minor compared to the pain that they had before the procedure. In my experience, I have had no patients complain that the numbness bothered them a lot, nor regretted performing this procedure due to numbness.
What are the possible complications that can occur after cryosurgery procedure for neuroma
Although I have never seen an infection after a cryosurgery procedure, it is a possible complication. It is possible to track bacteria through the skin when performing any invasive procedure such as an injection. Obviously, we use sterile technique by wiping the skin with alcohol prior to performing any injection or procedure.
It is possible to experience increased pain after a cryosurgery procedure for neuroma than before the procedure. Although this is rare, can happen. In my experience, patients have had increased pain after this procedure, they all went on to more invasive procedures to remove the neuroma which alleviated the pain.
Is cryosurgery for neuroma procedure covered by insurance?
Cryosurgery procedure for neuroma is a covered service by virtually all insurance companies. In my experience, I have not seen any insurances that do not reimburse for the cost. With that said, we are out of network with all insurances which may result in some out-of-pocket costs. A majority of PPO insurances will reimburse 100% of our fees. Please see the “insurance and financial” page of our website. We have expertly trained staff in our office that we will gladly discuss financial obligations prior to any procedure.
Summary
Cryosurgery procedure for neuroma is an excellent alternative to performing open neuroma surgery when conservative therapy fails. This extremely safe procedure allows for a very high success rate, and a very low complication rate. It requires very little down time postoperatively. It is cost effective and covered by most insurances. We invite you to come in for a consultation to discuss this procedure with our doctors.