Cryosurgery Or Sclerosing Injections: Which Is Better For Neuromas?
This palpable “click” is commonly called Mulder’s sign.13 One may also pursue diagnostic testing to either confirm your clinical diagnosis or rule out a variety of differential diagnoses.14 How To Perform Alcohol Sclerosing Injections If initial conservative therapy in the form of orthotics, shoe modifications and/or physical therapy modalities has failed, one should consider sclerosing injections with dehydrated alcohol. Prior to initiating this therapy, inform patients that you will be giving them three serial injections and will evaluate success based on their clinical response. Let them know that they may receive up to seven injections. Caution them that pain is often associated with the initial injection due to the induced damage to the nerve but this typically resolves with subsequent injections. In order to prepare the injection solution, one would mix 48 ml of 0.5% bupivicaine HCl with epinephrine with 2 ml of dehydrated alcohol. This produces a 50 ml solution of 4% sclerosing solution, which is good for three months. Initially, one should mark the point of maximum tenderness at the region of the neuroma “bulb.” Proceed to introduce the 1.25-inch, 27-gauge needle dorsally and manipulate it until the patient experiences pain and radiation to one or both toes. At this point, you should proceed to inject 0.5 cc of 4% sclerosing solution into the intermetatarsal nerve. One would subsequently perform injections every five to 10 days. In my experience, it averages out to every seven days. If you appreciate skin or soft tissue atrophy plantarly, discontinue the injections. One should follow up with the patients one month after the final injection to determine short-term success and give them instructions to follow up if they have persisting symptoms. Encourage functional support throughout the injection and post-injection process. If sclerosing injections fail to provide relief, one should proceed to discuss surgical intervention with the patient in order to alleviate his or her symptoms. Final Notes In my experience, I have found that using sclerosing injections with dehydrated alcohol is an excellent alternative to surgical excision or release in treating both primary and recurrent neuromas. Dr. Peebles is a Fellow of the American College of Foot and Ankle Surgeons, and is on the faculty of the Podiatry Institute. References 1. Bennett GL, Graham CE, Mauldin DM: Morton’s interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int. 16:760-763, 1995. 2. Greenfield J, Rea J, Illfeld FW: Morton’s interdigital neuroma: indications for treatment by local injection versus surgery. Clin Orthop 185: 142-144, 1984. 3. Steinberg MD: The use of vitamin B-12 in Morton’s neuralgia. J Am Podiatry Assoc 45: 41-42, 1955. 4. Dockery GL, Nilson RZ: Intralesional injections. Clin Pod Med Surg 3: 473-485, 1986. 5. Dockery GL: The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. J Foot Ankle Surg 38(6): 403-408, 1999. 6. Peebles CF: Sclerosing injections in the treatment of intermetatarsal neuromas. In Mahan KT, Miller SJ, Ruch JA, Yu GV, Vickers NS, eds. Update 2001: The Proceedings of the Annual Meeting of the Podiatry Institute Tucker, GA: The Podiatry Institute, Inc: 2001: 34-36. 7. Peebles CF: The use of sclerosing injections in the treatment of neuromas. In Mahan KT, Miller SJ, Ruch JA, Yu GV, Vickers NS, eds. Update 2003: The Proceedings of the Annual Meeting of the Podiatry Institute Tucker, GA: The Podiatry Institute, Inc: 2003: 122-124. 8. Downey MS: Recurrent interdigital neuroma: current considerations and treatment approaches. In Vickers NS, Miller SJ, Mahan KT, Yu GV, Camasta CA, Ruch JA, eds. Reconstructive Surgery of the Foot and Leg – Update ’96 Tucker, GA: The Podiatry Institute, Inc: 1996: 186-192. 9. Banks AS, Vito GR, Giorgini TL: Recurrent intermetatarsal neuroma: a follow-up study. JAPMA 86(7): 299-306, 1996. 10. Intermetatarsal neuroma: Preferred Practice Guideline from American College of Foot Ankle Surgeons. 1996. 11. Rengachry SS, Watanabe IS, Singer P, Bopp WJ: Effect of glycerol on peripheral nerve: an experimental study. Neurosurgery 13:681-688, 1983. 12. Package Insert. Dehydrated Alcohol Injections, USP. American Regent Laboratories, Inc., Subsidiary of Luitpold Pharmaceuticals, Shirley, NY 11967. 13.