Neuroma excision surgery
There are two types of open surgery for neuroma. The one discussed on this page is neuroma excision surgery, also called neurectomy.
Who is a candidate for neuroma excision surgery?
Patients who have failed nonsurgical treatments for neuroma, as well as have failed minimally invasive surgical procedures for neuroma, are candidates for open neuroma excision surgery.
What is neuroma excision surgery?
This type of neuroma surgery involves removing the entire neuroma and a small part of the surrounding healthy nerve. The neuroma is an enlargement of the intermetatarsal nerve between the metatarsal bones. Once this neuroma has been removed, theoretically the pain should completely go away.
Anatomy related to a neuroma excision surgery
The intermetatarsal nerve that becomes a neuroma is a nerve that runs between the metatarsal bones and splits into two branches. The branches continue after they split into each side of the adjacent toes. Their function is to allow one to feel sensation on one side of each toe that it goes into.
The nerve runs in a small tunnel that has borders on all four sides. The deep transverse intermetatarsal ligament forms the top of the tunnel. This ligament holds the metatarsal bones together and stabilizes the forefoot. On either side of the nerve, are the metatarsal bones. On the bottom of the nerve is the plantar foot skin and thickened connective tissue that makes up the ball of the foot.
How does a neuroma form?
When one walks, there is pressure on the nerve from weightbearing. Additionally, when ones arch pronates, or flattens out, there are lateral forces that push sideways on the nerve. When one wears a high-heeled shoes, or tight shoes, this increases the amount of forces on the nerve as well. Additionally, increased strenuous activity can also increase these forces on the nerve.
These forces can cause the nerve to become irritated, enlarged and inflamed. Ironically, when the nerve becomes enlarged and inflamed, it takes up more space and therefore causes even more irritation from the surrounding structures. The cycle continues until the nerve is enlarged and inflamed and turns into a neuroma.
Where is neuroma excision surgery performed?
Neuroma excision surgery is performed in the surgical center and usually requires an anesthesiologist in order to sedate patients. Patient receive IV sedation in order to sleep and remain comfortable during this short procedure. The procedure only takes approximately thirty to forty-five minutes. During this time, patients are sedated so that they do not feel the local anesthesia injection or the tourniquet around the ankle.
We place a tourniquet around the ankle to stop any bleeding during the surgery. A tourniquet is similar to a blood pressure cuff, however, it inflates much tighter. Patients that are awake with a tourniquet inflated often complain that it is painful and is often described as the worst part of the procedure. For this reason, we prefer to have patient sedated during the surgery.
The neuroma excision procedure
A small incision is made on the top of the foot between the metatarsal bones over the neuroma site. This incision is carried down until to the deep transverse intermetatarsal ligament is visualized. Incision is made through the deep transverse intermetatarsal ligament. At this stage, the neuroma is visualized between the bones.
The neuroma is an enlargement of the intermetatarsal nerve between its three branches. The three branches from the nerve proximally, and to the two distal branches that go to the adjacent toes, are visualized prior to being cut. After the neuroma is freed up from soft tissue attachments to these three branches of the nerve, they are cut, and the neuroma is removed from the foot. On removing the neuroma, we also take a small portion of the healthy nerve of the three branches. This ensures that we do not miss removing any neuroma tissue.
The proximal branch of the nerve is identified and sutured into the adjacent muscle tissue in order to prevent a stump neuroma from forming. A stump neuroma is a new neuroma that can form after surgery at the proximal nerve stump. While it is not a very common complication of neuroma surgery, by implanting the nerve into the adjacent muscle tissue, it drastically reduces the possibility of this complication.
After the neuroma is removed, closure is performed of the deep tissues, subcutaneous tissues and skin. Usually, we use absorbable sutures that do not need be removed at a future date.
What to expect immediately after neuroma excision surgery
After neuroma excision surgery, patients leave the surgery center with a bandage on the foot and in a surgical shoe or brace. Whenever patients have anesthesia, it is mandatory to have a chaperone take them home from the surgery center. We ask that patient do not take public transportation including trains or buses to get home after surgery.
Postoperative instructions after neuroma excision surgery
Patients are instructed to keep their bandages dry by using a shower bag for about two weeks after surgery. They are also instructed to continue wearing the surgical shoe or brace for two to four weeks after surgery. The exact time depends on the skin healing as well as the amount of inflammation.
Is neuroma excision surgery painful?
Most patients have little to no pain after neuroma excision surgery, however, a small number of patients do report having more pain. We prescribe prescription painkillers such as Vicodin. Most patients only take this for a couple of days after surgery. Patient are instructed to remain at rest and off their feet as much as possible for the first one to two weeks. We also recommend icing and elevation to prevent pain and inflammation.
Activity level after neuroma excision surgery?
Normally, we perform our surgeries on Fridays. We ask patients to stay at home and off their feet on Friday, Saturday and Sunday. For the first three days we recommended ice and elevation and remaining at rest. We prefer if the foot is elevated above the hip such that gravity runs downward from the foot into the larger vessels of the thigh. This helps to prevent inflammation and edema. Many patients are able to return to work on Monday. If patients are able to work from home, or remain out of work for a week, it is recommended, however, it is not mandatory.
Postoperative follow-up for neuroma excision surgery
We have patients follow up with us in five to seven days after surgery to evaluate the surgical site and make sure there is no infection or problems with wound healing. On this first visit, we will change the bandage and apply a new one.
We ask patients to follow-up one week later. At this second postoperative visit, we will allow patients to get their foot wet and shower, but they may not soak it. Most times, we use absorbable sutures that do not be to be removed. However, if for some reason we use non-absorbable sutures, they will often be removed at this visit. We also allow patients to slowly increase their activity to tolerance. Most patients return to sneakers at four weeks, depending on the amount of inflammation present.
Patients will then follow-up at week four. At this time, we allow them to return to sneakers and increased their activity to tolerance.
What to expect intermediate-term after neuroma excision surgery
Normally, it takes between two and four weeks for the initial discomfort from the surgery to go away. At this time, patients often report that the pain is different than before the surgery. Instead of experiencing numbness, tingling and nerve type pain, pain is more procedural type pain, dull and aching.
What to expect long-term after neuroma excision surgery
Most patients report complete relief of symptoms between three and six months after surgery, however, it can take up to a year or more. As with all foot surgeries, it takes between twelve and eighteen months for everything to heal, and for scar tissue to go away.
Because the nerve has been removed, we expect patients to have a degree of numbness in the toes. The anatomy is such that the nerve being removed allows for sensation on the inside of the adjacent toes. This means the numbness will be half of one toe, and half of the adjacent toe. Some patients may not have complete numbness due to redundancy in the many small nerves that innervate the toes.
In the many years of performing neuroma excision surgery, I had no patients complain that this numbness was significant enough to regret having neuroma surgery. Patients always say will take numbness over pain any day.
What are the possible complications that can occur after neuroma excision surgery?
As with any kind of surgery, it is possible to have a postoperative infection. We prescribe postoperative antibiotics for five days to decrease the likelihood of infection. Also, as with any kind of foot surgery there are possible complications of hematoma, delayed healing of the skin or other soft tissues, wound dehiscence, scarring, blood clots, numbness, suture reaction, and need for additional surgery in the future.
Although not truly a complication, patients generally have some degree of numbness in the area. This is an expected result of removing the nerve that forms the neuroma.
Rarely, patients report that their pain continues even after the neuroma has been surgically excised. This is rare as the neuroma that has been completely removed, is not there to cause any pain. I speculate that these patients experience perceived pain similar to phantom limb pain. In phantom limb pain, the brain still perceives pain when there is no longer an extremity that was amputated. Similarly, the brain may perceive neuroma pain where the neuroma is no longer present.
Is neuroma excision surgery covered by insurance?
Neuroma excision surgery is covered by almost all insurances.
Why are we the best surgeons for neuroma excision surgery?
Our doctors have extensive experience in performing neuroma excision surgery. Although most patients do not require surgery and achieve relief of neuroma symptoms by using conservative, nonsurgical treatments, or relief after minimally invasive procedures, some patients do require neuroma excision surgery. The sheer volume of patients that we see for the treatment of neuroma allows us to perform more neuroma excision surgery than most doctors. It is these years of experience that have allowed us to become experts in neuroma excision surgery for the treatment of neuromas.