Etiology and Treatment Outcomes for Sural Neuroma

Abstract

Background: Neuroma results from disorganized regeneration following nerve injury and may be symptomatic. The aim of this study was to investigate the causes, treatment, and outcomes of operatively treated sural neuromas, and to describe the factors associated with persistent or unchanged postoperative pain symptoms. Methods: Consecutive patients with surgically treated sural neuromas in a 14-year period were identified using Current Procedural Terminology (CPT) codes ( n = 49), followed by a chart review to collect patient and treatment characteristics. Postoperative pain symptoms were categorized as complete resolution of pain, improvement of pain, no change in pain, or worse pain. The median patient age was 46.5 years (interquartile range [IQR], 39.1-51.3), and median follow-up was 4.0 years (IQR, 1.9-9.2). Results: Ninety percent of symptomatic sural neuromas developed as a result of previous lower extremity surgery. Initial surgery of sural neuroma led to improvement in pain in 63% of patients, and an additional 8.2% of the patients had improvement after secondary neuroma surgery. Pain relief after diagnostic injection showed a trend toward an association with postoperative pain improvement. Neuroma excision and implantation in muscle was the most common surgical technique used (67%). Four of the 7 patients that underwent a second neuroma operation reported symptom improvement. Conclusion: Sural neuromas may arise from prior surgery or trauma to the lower extremity. Surgical intervention resulted in either improvement or complete resolution of pain symptoms in 71% of patients, although occasionally more than one procedure was required to obtain symptomatic relief. Preoperative anesthetic injection may help identify patients that benefit from neuroma surgery. Level of Evidence: Level IV, retrospective case series.

Distribution patterns of the cutaneous nerves on the dorsum of the foot and their clinical significance

“…The superficial fibular, deep fibular, and sural nerves on the dorsum of the foot may be at risk of iatrogenic injury during surgical procedures such as removing painful neuromas in the foot (Canovas et al, ; Lans et al, ), neurovascular free flap from the dorsum of the foot (Daniel et al, ), ankle arthroscopy (Malagelada et al, ), and treating fractures involving the tarsal bone or distal fibula (Li, ; Mizia et al, ). These nerves can also be compressed in various conditions such as acute trauma, repetitive microtrauma, varicosities, hematoma, soft‐tissue edema, and bone, joint, or muscle abnormalities (Delfaut et al, ).…”

“…There is a risk of iatrogenic injury to the cutaneous nerves of the dorsum of the foot during various surgical procedures performed at the distal part of the fibula, the ankle, and the dorsum of the foot (Daniel et al, ; Canovas et al, ; Li, ; Mizia et al, ; Lans et al, ; Malagelada et al, ). Entrapment neuropathy secondary to trauma or excessive repetitive movement can also affect the cutaneous nerves on the dorsum of the foot (Styf, ; Schon, ).…”

Contemporary Review: Targeted Muscle Reinnervation for Foot and Ankle Applications

“…21,32,67 Imaging options include magnetic resonance imaging, computed tomography, and ultrasonography-these studies may be obtained to evaluate for the presence of a neuroma, and to rule out mechanical causes of nerve compression (eg, ganglion or mass) or other non-neural pain etiologies. 49 Magnetic resonance neurography has been used to localize peripheral nerve lesion location 18,40 and provide information about secondary muscle denervation. 44 However, its use is reserved as an adjunct when the clinical diagnosis is unclear.…”

A Cohort Study on Neuropathic Pain of the Sural Nerve—Can Neurectomy Be Considered a Valid Treatment Option?

“…[5][6][7] Several studies have shown that a significant number of patients will still report severe persistent pain despite surgical treatment. 3,7 In reconstructive surgery, the sural nerve is regularly used as an autologous nerve graft for multiple clinical applications. 8 The donor site morbidity is generally considered to be low and subordinate to the outcome of the acceptor site.…”

“…Different surgical techniques to treat neuroma have been described. Techniques involving neuroma excision and implantation/burying in muscle or bone have historically been the most commonly used 5–7 . Several studies have shown that a significant number of patients will still report severe persistent pain despite surgical treatment 3,7 .…”