Cryosurgery Or Sclerosing Injections: Which Is Better For Neuromas?
Intralesional injections. Clin Podiatr Med Surg 1986; 3:473-485. 2. Gudas CJ, Mattana GM. Retrospective analysis of intermetatarsal Neuroma excision with preservation of the transverse metatarsal ligament. J Foot Surg. 1986; 25:259-463. 3. Bradley MD, Miller WA, Evans JP. Plantar Neuroma: analysis of results following surgical excision in 145 patients. South Med J 1976; 69:853-845. 4. Davies E, Pounder D, Mansour S, Jeffery, I.T.A. Cryosurgery for chronic injuries of the cutaneous nerves in the upper limb. JBJS Vol. 82-B No.3. April 2000; p 413-415. 5. Barnard D, Lloyd J, Evans J. Cryoanalgesia in the management of chronic facial pain. J. Maxillofac Surg. 1981;9: 101-102. 6. Zakrzgwska JM, Nally FF. The role of cryotherapy (cryoanalgesia) in the management of paroxysmal neuralgia: A six year experience. Br J Oral Maxfac Surg. 1988; 26:18-25. 7. Caporusso EF, Fallat LM, Savoy-Moore R, Cryogenic Neuroablation for the Treatment of Lower Extremity Neuromas. J. Foot Ankle Surg. 41;286-290, 2002. Reviewing the literature and sharing pearls from his own experience, the author says sclerosing injections can be effective for treating intermetatarsal neuromas. By Charles F. Peebles, DPM My choice of sclerosing injections for treating neuromas comes down to one question: “What would I do if my neuroma didn’t respond to other conservative options?” Well, I wouldn’t treat my patients any differently than I would treat myself. Sclerosing injections with dehydrated alcohol are being used with increasing frequency in treating intermetatarsal neuromas and recurrent or “stump” neuromas. One can use this modality without significant risk to the patient and it does not compromise tissues in the event that surgical intervention is required. Numerous podiatric physicians have added this technique to their treatment algorithm for this condition with significant success. When conservative therapy fails, one may consider alternative methods, including various injections, neural destructions and surgical interventions (see “Where Does Injection Therapy Fall In The Treatment Algorithm?” below). However, using 4% alcohol sclerosing injections has shown significant promise as a conservative intervention for intermetatarsal or recurrent neuromas prior to surgical release or excision. Where Does Injection Therapy Fall In The Treatment Algorithm? One must consider conservative modalities and surgical options when treating intermetatarsal neuromas. When it comes to conservative management, you want to address mechanical etiologies through the use of padding, strapping and orthotic fabrication. Doing so helps to eliminate the pathologic forces that induce neuroma formation. Shoe selection and modification are essential in decreasing the tension on the nerve structures. One may also employ physical therapy modalities in order to decrease inflammation in the region and relieve neural tension from more proximal etiologies. If these modalities fail, one may pursue injection therapy. Injections with corticosteroids, vitamin B12 and ethyl alcohol have been employed with varying success in treating intermetatarsal neuromas.1-7 Surgical intervention consists of excising the involved nerve via neurectomy or releasing the deep intermetatarsal ligament. The success rates of these treatment options vary from 76 to 97 percent with most ranging closer to the former.5-10 Common complications may include infection, hematoma/seroma formation and recurrent or stump neuromas. When it comes to recurrent neuromas, treatment considerations include much more involved surgical intervention with success rates lower than those for primary neuromas. Conservative options include massage and desensitization modalities in combination with local steroid infiltration. Surgical management attempts to prevent nerve regrowth and eliminate symptoms. Neurectomy, epineuroplasty and nerve implantation have all been attempted with varying success in treating recurrent neuromas. Given the potential for complications with any surgical intervention, it is important to exhaust all conservative options prior to surgery. Taking A Closer Look At The Effectiveness Of Sclerosing Injections Injections of absolute ethyl alcohol (dehydrated sterile alcohol) affect nerves through damage at the cellular level. The cellular effect involves dehydration, necrosis and precipitation of protoplasm.