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Morton's Neuroma - Coblation

Discussion in 'General Issues and Discussion Forum' started by hkpod, Jul 18, 2011.

  1. hkpod

    hkpod Active Member

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    I have seen another interesting patient today and would like to give her some alternatives to surgical excision of a Morton's neuroma.

    38yo female (note: still breast feeding) with a 15 x 9 x 7mm Morton's Neuroma in the L/3-4 met interspace. Constant pain unless barefoot. Cortisone didn't help. I am about to make some orthoses for her but that will be dependent on how quickly she can get some form of therapy for this monster neuroma residing in her foot.

    Her surgeon here would like to excise but with a plantar approach and the patient is quite concerned about scar tissue and residual nerve damage.

    The other options I know about are radiofrequency coblation, cryotherapy and alcohol sclerosis. I haven't had any other patients trial these methods.

    Does anyone have any information on how successful these procedures are?
    How many times would she need treatment (I thought the alcohol sclerosis was weekly?)?
    And where are these priocedures done (i.e., I thought the cryotherapy may have only been done in the States & the only options here in HK are surgery or coblation)?

    I would appreciate any information, whether from studies or anecdotal. I thank you in advance for your help. :D
  2. timharmey

    timharmey Active Member

    Hi Lisa
    Sorry to answer with a question , but I have been on an imaging module, which imaging modality was used, and do you routinely measure neuromas prior to treatment ?
  3. Peter

    Peter Well-Known Member

    alcohol is done weekly, and some authors propose a minimum of 4 to achieve satisfaction, some authors do more. Don't think its licensed in the UK yet, so few other papers other than Fanucci, Hughes, Dockery.

    Pm me if you want the exact references
  4. nick_700

    nick_700 Active Member

    That is a large neuroma. Assume measured on ultrasound?

    Have you tried locally infiltrating to attempt some brisement and hydrodilation of tissue in the IM space? I have had some success with plain local anaesthetic (3-4mls 2% Lignocain plain, weekly injections x 3) however I have typically found that patients with such large neuromas usually end up needing neurectomy.

    Regarding sclerosing therapy, there was a lot of talk about it in Melbourne here about 2 years ago. A pod surgeon returned from a preceptorship in the States and apparently it was commonly performed there at the time, with good results. There was concern amongst local practitioners regarding the potential for necrosis I believe so is not widely used here. From what I have been told people get good results anecdotally, however a quick google search revealed this article:
    Published 2011, quote: Alcohol sclerosing therapy administered in the clinic setting without alcohol is not an effective treatment in the nonoperative management of painful interdigital neuromas and has been abandoned in our clinic.

    32 patients used in that trial.

    Food for thought.

    Nick Ryan
  5. Peter

    Peter Well-Known Member

    also in one of the papers I have, 3 pts needed surgical intervention, not unusual at all, but the authors stipulated that all those cases were technically difficult due to the additional fibrosis probably endured during the alcohol injection procedures. I subject also had a CRPS.:mad:
  6. nick_700

    nick_700 Active Member

    Yes Peter I had heard the same regarding fibrosis post-injection with alcohol.

  7. hkpod

    hkpod Active Member

    Thanks for the response Tim. This patient is new to me and had already done the rounds and hence her doc had referred her to a foot & ankle surgeon (all in the same premises). The surgeon had requested an ultrasound and MRI (after performing a bone scan...) so that is why I was able to give you the exact dimensions. Normally, I would have ordered an ultrasound.

    Thanks for the information Nick & Peter. I didn't know about the possibility of fibrosis complication post-sclerosis. And no, I haven't tried (& didn't know about) infiltrating the local area. (Out of interest, what guage needle do you use?). The patient had a local before the surgeon tried the cortisone injection but as it was only a once off, it is hard to tell if it could have helped. It is certainly another therapy for her to think about but I think if it comes to getting more injections she would prefer to have a block and have the darn thing excised. Especially considering she is still breastfeeding.

    I really appreciate your input and hopefully some others will give me some more info regarding the radiofrequency coblation.
  8. Admin2

    Admin2 Administrator Staff Member

  9. nick_700

    nick_700 Active Member

  10. hkpod

    hkpod Active Member

    Thank you all, great info on the alcohol sclerosis (and definitely some interesting reading) but still chasing some/any info regarding the success of RF coblation....?
    The surgeon's report basically gave my patient only the options of surgery or RF coblation in Hong Kong but as I mentioned, she is prepared to travel to achieve the best outcome.
    By the way, the patient isn't against surgery (and almost feels it's inevitable), she just wants another opinion and preferably an opinion that says dorsal approach!
  11. nick_700

    nick_700 Active Member

    Sorry Lisa, totally missed that part of your question.

    Nope, no idea about RF coblation for neuroma. I know a radiologist in Melb who is about to start using it, I will email him and get some RCTs for you

  12. hkpod

    hkpod Active Member

    Thanks Mike. I can't believe this has been around for over 20 years and I have never had a patient that has trialled it! I thought this was a relatively new therapy... :eek:
    This says I am a poorly informed pod or else the treatment may not be as effective as the neurectomy. I will certainly pass on the info to my patient.
    Cheers, Lisa
  13. Frederick George

    Frederick George Active Member

    You don't need to fool around with all these alternative methods. Just take the thing out. It's precise, no sclerosing or freezing surrounding tissue (although there is damage from the incision), and the neuroma is gone.
    Please do it from dorsal though. Plantar may be quick and easy, but the scar can be a problem.
    And if you're neat, you can do it wet (no tourniquet) under local.
  14. NewsBot

    NewsBot The Admin that posts the news.

    Radiofrequency Thermoneurolysis for the Treatment of Morton’s Neuroma
    Joshua L. Moore, Ritchard Rosen, Jeffrey Cohen, Brad Rosen
    Jnl Foot Ank Surg (in press)
  15. Mark Egan

    Mark Egan Active Member

    Does anyone have info about this form of treatment ?

    Is there someone in Australia using it?
  16. NewsBot

    NewsBot The Admin that posts the news.

    Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton’s) neuroma
    Graham S. J. Chuter, Yeok Pin Chua, David A. Connell, Mark C. Blackney
    Skeletal Radiology October 2012
  17. NewsBot

    NewsBot The Admin that posts the news.

    "Radiofrequency Thermo-Ablation of Morton’s Neuroma: A Valid Minimally Invasive Treatment Procedure in Patients Resistant to Conservative Treatment,"
    R. Paolo, A. Roberto and B. Mihai,
    Open Journal of Orthopedics, Vol. 3 No. 8, 2013, pp. 325-330.
  18. NewsBot

    NewsBot The Admin that posts the news.

    Ultrasound-Guided Pulsed Radiofrequency Treatment in Morton's Neuroma
    Suleyman Deniz, Tarik Purtuloglu, Sukru Tekindur, Kadir Hakan Cansiz, Memduh Yetim, Oguz Kilickaya, Serkan Senkal, Serkan Bilgic, Abdulkadir Atim, and Ercan Kurt
    Journal of the American Podiatric Medical Association In-Press.
  19. daisyboi

    daisyboi Active Member

    Can't say I would be as keen as Frederick to opt for surgery as much of the literature reports a recurrence rate as high as 30%, and a fairly high level of patient dissatisfaction. The argument against a plantar approach also seems to be a largely theoretical one as studies comparing the two find broadly equal rates of satisfaction from either approach.

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