Nerve decompression surgery for neuroma
There are two types of open surgery for neuroma. The one discussed on this page is nerve decompression surgery, also called external neurolysis.
Who is a candidate for nerve decompression surgery?
Patients who have failed nonsurgical treatments for neuroma, as well as have failed minimally invasive surgical procedures for neuroma, are candidates for open nerve decompression surgery.
What is nerve decompression surgery?
This type of neuroma surgery involves removing the forces on the nerve that cause the nerve to become inflamed and painful. This kind of surgery does not remove the nerve. It allows the nerve to exist without the surrounding anatomy putting pressure on it and causing it to be inflamed.
Anatomy related to a neuroma decompression
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.
How is nerve decompression surgery neuroma done?
External neurolysis involves removing some of the forces on the nerve, and allows the neuroma to exist without irritation. The best way to accomplish this is to remove the top part of the anatomy, the deep transverse intermetatarsal ligament. This allows the nerve to move freely up and down. When one puts pressure on the foot, the nerve displaces up and out of the way alleviating the forces after the deep transverse intermetatarsal ligament had been cut or removed.
Two types of nerve decompression surgery
There are two ways to perform nerve decompression, or external neurolysis surgery for the neuroma. The older way involves making an incision on top of the foot and cutting the deep transverse intermetatarsal ligament. The newer way involves a special device that has been fabricated that allows us to perform a small incision between the toes and insert this instrumentation. Called a Kobygard, this instrument allows us to isolate the deep transverse intermetatarsal ligament without ever visualizing it. This instrumentation also allows for severing the deep transverse intermetatarsal ligament, again without seeing it.
Where is nerve decompression surgery performed?
Nerve decompression surgery for neuromas 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 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 nerve decompression procedure, open surgery
Open surgery for nerve decompression and external neurolysis is performed by making an incision on top of the foot. Through this small incision, we are able to visualize the deep transverse intermetatarsal ligament that forms the top border of the tunnel with the neuroma just below it. Once we have visualized the deep transverse intermetatarsal ligament, we introduce an instrument right below it in order to protect the nerve. We then cut the deep transverse intermetatarsal ligament and do not repair it.
Once the deep transverse intermetatarsal ligament has been severed, the nerve is free to move up and down and not be irritated with weightbearing, activity and external forces. We then close the soft tissue structures above the ligament including the layers of the skin, but do not repair of the ligament.
The nerve decompression procedure, Kobygard surgery
For the Kobygard procedure, a small incision is made between the toes. A blunt instrument called the tissue separator is introduced into the incision and moved around in order to bluntly dissect above and below the deep transverse intermetatarsal ligament. This is done by feel and the ligament is not visualized through the very small incision. Next, another instrument is introduced that has two projections such that one is above the ligament, and one is below the ligament. This instrument has a hole down the center. The next step is to insert the blade through this hole. This very sharp blade severs the deep transverse intermetatarsal ligament.
Once the deep transverse intermetatarsal ligament has been severed, the nerve is free to move up and down and not be irritated with weightbearing, activity and external forces. We then close the layers of the skin, but do not repair of the ligament.
What to expect immediately after nerve decompression surgery
After nerve decompression 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 nerve decompression 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 nerve decompression surgery painful?
Most patients have little to no pain after nerve decompression surgery, however, a small amount of patients do report having more pain. We prescribe prescription painkillers, usually 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 nerve decompression 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 go 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 nerve decompression 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 between weeks two and four, depending on the amount of inflammation present.
Patients will then follow-up at week three or four. At this time, we allow them to return to sneakers and increased their activity to tolerance.
What to expect intermediate-term after nerve decompression 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. Occasionally, patients will complain of increased nerve type pain due to inflammation of, and around the nerve. This usually only lasts a short period of time.
What to expect long-term after nerve decompression 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.
What are the possible complications that can occur after nerve decompression 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, it is possible to have no relief of symptoms after surgery. In this case, we recommend having additional surgery for removal of the neuroma. On rare occasions, patients have reported increased pain after surgery, greater than before the surgery.
Is nerve decompression surgery covered by insurance?
Nerve decompression surgery is covered by almost all insurances.
Why are we the best surgeons for nerve decompression surgery?
Our doctors have extensive experience in performing nerve decompression 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 nerve decompression surgery. The sheer volume of patients that we see for the treatment of neuroma allows us to perform more nerve decompression surgery than most doctors. It is these years of experience that have allowed us to become experts in nerve decompression surgery for the treatment of neuromas.