Ultrasound Guided Alcohol Ablation of Morton's Neuroma

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2012 33: 196Foot Ankle IntRachel E. Musson, Jasdev S. Sawhney, Leslie Lamb, Antony Wilkinson and Haron Obaid

Ultrasound Guided Alcohol Ablation of Morton's Neuroma

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FOOT & ANKLE INTERNATIONAL

Copyright 2012 by the American Orthopaedic Foot & Ankle Society

DOI: 10.3113/FAI.2012.0196

Ultrasound Guided Alcohol Ablation of Morton’s Neuroma

Rachel E. Musson, MRCP, FRCR; Jasdev S. Sawhney, MBBS, FRCR; Leslie Lamb, Bsc, Msc; Antony Wilkinson, FCPoDs;

Haron Obaid, MBChB, FRCR

Doncaster, UK

ABSTRACT

Background: Morton’s neuroma is a common cause of meta-

tarsalgia. This study evaluated the efficacy of ultrasound guided

alcohol injection as a treatment for this condition. Method:

Data from 87 treatment courses were included in this study

with a mean follow of 14.3 months. Results: Technical success

was 100%. One patient developed symptoms consistent with

an allergic reaction to the injection and one patient declined

further injection because of periprocedural pain. Partial or total

treatment response was achieved in 66%, with 32% of patients

having complete resolution of pain. The median visual analogue

score (VAS) decreased from 8 pre-procedure to 4 post-procedure

(p < 0.0001). Procedural success was greater in patients under

55 years old and in those with solitary neuromas. Seventeen

patients (20%) went on to have surgery due to continuing

pain. Conclusion: Ultrasound guided alcohol ablation for the

treatment of Morton’s neuroma was a safe procedure that

significantly reduced pain and may offer an alternative therapy

to surgery.

Level of Evidence: IV, Retrospective Case Series

Key Words: Alcohol Ablation; Morton’s Neuroma;

Metatarsalagia

INTRODUCTION

Morton’s neuroma or interdigital neuroma was first

described in 1876 and is a common cause of forefoot pain

No benefits in any form have been received or will be received from a commercial

party related directly or indirectly to the subject of this article.

Corresponding Author:

Rachel Musson, MRCP, FRCR

Nuffield Orthopaedic Centre

Windmill Rd

Headington

Oxford

OX3 7HE

United Kingdom

E-mail: [email protected]

For information on pricings and availability of reprints, email [email protected]

or call 410-494-4994, x232.

and sensory disturbance.30,15 Morton’s neuroma is not truly

a neuroma but perineural fibrosis, local vascular proliferation

and nerve degeneration of the common digital nerve which

results in neuropathic pain. This is believed to be a result

of compression of the plantar interdigital nerve as it passes

inferior to the intermetatarsal ligament. Ill-fitting footwear

and pathomechanics such as forefoot and hindfoot varus are

recognized causative factors. The most frequent site for a

Morton’s neuroma is in the third web space (between the

third and fourth metatarsals), followed by second web space

and is rarely seen in the first and fourth web spaces.

The diagnosis is suspected with pain radiating from

the forefoot to the toes, paraesthesias and other sensory

symptoms. Symptoms often improve immediately following

removal of shoes while activities such as driving often exac-

erbate the symptoms. Examination may detect a Mulder’s

click, which is an audible and palpable click on trans-

verse compression of the metatarsal heads.17 Ultrasound and

magnetic resonance (MR) are both useful in confirming the

clinical diagnosis of Morton’s neuroma. Ultrasound shows

the lesion as hypoechoic rounded mass in the web space.

Studies have shown the sensitivity and specificity of ultra-

sound to be as high as 85% to 98% and is the first line

imaging investigation in most centers.19,20,22,26 It is used

to exclude other causes of forefoot pain and determine the

number of neuromas present. Contrast MR is an alternative

and also has a high sensitivity (87% to 100%) in detecting

these lesions. 29,31,33 It is also accurate at detecting other

causes of metatarsalgia.7

There are a number of treatment methods available for

Morton’s neuroma. Most patients are conventionally treated

in a stepwise manner with conservative methods initially.

Conservative methods include the use of metatarsal pads

and orthotic devices which may provide some relief.1,24

Steroid and local anesthetic have been used for many

years showing variable response rates and used in many

centers as a nonoperative measure. 1,6,8,14,27 Surgery has

been found to be effective with positive results in excess

of 80%.1,2,12,13,18,25,32

196

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Foot & Ankle International/Vol. 33, No. 3/March 2012 ALCOHOL ABLATION OF MORTON’S NEUROMA 197

Alcohol ablation as an alternative therapy, in the treatment

of Morton’s neuroma, has shown positive initial results.

Experimental data has shown that ethanol when injected into

a nerve causes neurolysis by means of dehydration, necrosis

and precipitation of protoplasm.23 The initial evidence from

the few studies published show good efficacy with partial

or complete resolution of symptoms ranging from 61% to

94%.3,5,9,10,16

The aim of this study was to evaluate our experience

of alcohol injections in the treatment of Morton’s neuroma

with review of the literature. We performed a retrospective

analysis of the treatment with respect to safety and outcome.

METHODS

Ninety-two consecutive patients underwent alcohol injec-

tion treatment in our institution between June 2008 and

December 2009. Twelve patients had treatment in both feet at

separate times, totaling 104 separate treatments. All patients

had been assessed by their general practitioner, podiatric

surgeon or orthopaedic surgeon and had a diagnostic ultra-

sound prior to treatment to confirm presence of a Morton’s

neuroma. Record was made of the size of the neuroma,

presence of multiple neuromas, co-existence of other foot

pathology and number of injections. No patient was excluded

on the basis of co-existing symptoms or multiple lesions.

Only symptomatic lesions were treated.

Seventeen patients had incomplete pre-treatment and

followup data and were therefore excluded. Seventy-five

patients were therefore included in the analysis. Of these 75

patients, 66 were female and nine male. The average age was

57.5 (range, 22 to 80) years. Twelve patients went on to have

a second, separate course of treatment in the contralateral

foot, resulting in 87 treatments in 75 patients. In 63 of the 87

treatments performed, there was a single neuroma present in

the treated foot. In 24 of the treatments, two neuromas were

present in the treated foot. Thirteen of these had both injected

as they appeared to be symptomatic and in the remaining

11, one neuroma of the two was injected based on symp-

tomatology. We considered treatment to the whole foot as

one event and did not evaluate the outcome of each neuroma

treatment within the same foot separately. The average size of

the neuromas treated was 8.2 mm. Of the total 100 neuromas

which received treatment, 37 were in the second web space

(between the second and third metatarsals), 59 were in the

third web space (between the third and fourth metatarsals)

and four within the fourth web space (between the fourth and

fifth metatarsals).

Informed written consent was obtained for all patients

prior to the start of treatment and patients were advised that

they might experience a transient increase in pain. Patients

were in the supine position with the knee 90-degree flexed

and the foot flat on the couch. Ultrasound using a high

frequency linear probe was used to identify the lesion and

used to place the tip of a 23G needle within its center via a

dorsal approach. A mixture of 0.1 ml of 100% ethyl alcohol

diluted in 0.4 ml of 0.25% bupivacaine (0.5 ml of 20% ethyl

alcohol) was injected with careful real time ultrasound to

ensure no leakage of solution (Figure 1). Two experienced

musculoskeletal radiologists performed all of the procedures.

Patients were advised to undertake gentle mobilization on the

day of treatment. The standard treatment regime was planned

to consist of four injections, two weeks apart.

Patients were asked to grade their pain prior to the proce-

dure taking place using a visual analogue score (VAS)

and this was compared to a post-procedure VAS at tele-

phone followup. The mean followup time following the last

injection was 14.3 (range, 6 to 26) months. Any proce-

dural complications, treatment tolerance and any subsequent

treatments were recorded. The normality of the difference

between the pre and post VAS scores was assessed using

the Kolmogorov-Smirnov test. The data did not follow a

Gaussian distribution and therefore a Wilcoxon signed rank

matched pairs test was used to analyze the data.

RESULTS

A total of 75 patients were included in the study, with

injections performed in 87 feet. A mean number of 3.9

injections were performed for each neuroma. Technical

success, as defined by visualization of intralesional posi-

tioning of the needle under ultrasound guidance with no

evidence of extralesional alcohol leakage, was achieved in

100% of patients. One patient developed symptoms of facial

swelling and vomiting soon after the first treatment. As this

was consistent with an allergic reaction to a component

of the treatment, the patient received no further injections.

One patient found the injection very painful and declined

further treatment. One patient developed significant pain and

swelling following the second injection so the third treat-

ment was delayed by one week. The symptoms subsided

and course of injections were completed with no subsequent

complications. There were no other complications and all

other patients tolerated the treatment well.

The VAS was measured by asking the patients on a scale

of zero to 10, the severity of the pain. The median VAS score

pre-procedure was eight (mean, 8.5; range, 4 to 10; SD, 1.2)

and the median post-procedure VAS score was 4 (mean, 4.2;

range, 0 to 10; SD, 3.8) (p < 0.0001) (Figure 2).

Of the 85 treatment courses, following the exclusion

of two patients (both with multiple neuroma), 55 (66%)

showed complete or partial symptom relief. Twenty-seven

(32%) resulted in complete resolution of symptoms at

followup (post VAS of zero) and 28 (33%) resulted in a

partial response. In 30 (35%) the treatment provided no

improvement in symptoms. Of those who had a partial

treatment response, ten had a post treatment VAS score of

1 or 2 and eight patients had a post-treatment VAS score

of 3 or 4. The improvement in VAS in those with a partial

response is shown in Table 1.




198 MUSSON ET AL. Foot & Ankle International/Vol. 33, No. 3/March 2012

A B

C

D

Fig. 1: A Ultrasound showing a rounded hypoechoic mass consistent with a Morton’s neuroma prior to treatment – longitudinal view. B Transverse view of

a Morton’s neuroma prior to treatment. C. Longitudinal view with hyperechoic needle tip in the lesion. D The needle can be seen entering the skin in the left

top corner of the image and hyperechoic particles are seen within the lesion during the injection

Fig. 2: A Box and Whisker plot comparing the pre and post VAS scores in

those undergoing alcohol ablation therapy.

Sixteen patients with no improvement in symptoms went

on to have surgery, as did one patient with an improvement in

VAS score of two (20% of the series). Fourteen patients who

did not improve with alcohol treatment had not proceeded to

surgery at the time of followup. One patient with a partial

treatment response subsequently had a steroid injection,

which provided further relief but not complete resolution of

symptoms.

The presence of multiple neuromas in a treated foot

appeared to correlate with less favorable results. The median

pre-VAS score in the solitary neuroma group was eight (range

Table 1: Breakdown of VAS Score Improvement by

Number of Points of Improvement in Patients With

Partial Treatment Response (n = 28)

Improvement in VAS score

(number of points) Number of patients

8 3

7 3

6 6

5 3

4 3

3 5

2 5

six to ten) and the median post VAS score was 3 (range, 0

to 10). By comparison in the multiple neuroma group, the

median pre-VAS score was 8 (range, 6 to 10) and median

post VAS score was 7 (range, 0 to 10). This difference was,

however, not statistically significant (Table 2).

Younger age appeared to correlate with improved VAS

reduction. In the group aged 55 years and younger (n = 35),

the median pre-VAS score was 9 (range, 4 to 10) and median

post VAS score was 2 (range, 0 to 10). In the group aged

over 55 years (n = 50), the median pre VAS was 8 (range,





Table 2: Breakdown of Response to Treatment in Different Sub-Groups

Response

All patients

(n = 85)

Single neuroma

(n = 63)

Multiple neuroma (n = 22)

1 injected / Both injected

Age < 55

(n = 35)

Age > 55

(n = 50)

Complete 27 (32%) 21 (33%) 5 (45%) 1 (9%) 13 (37%) 14 (28%)

Partial 28 (33%) 24 (38%) 1 (9%) 3 (27%) 14 (43%) 14 (28%)

None 30 (35%) 18 (29%) 5 (45%) 7 (64%) 7 (20%) 22 (44%)

5 to 10) and median post VAS score was 5 (range, 0 to

10) (Table 2). The differences however were not statistically

significant. With respect to the size of the neuroma, this did

not influence the treatment effectiveness in that it did not

significantly affect the change in VAS.

DISCUSSION

Variations in the management of Morton’s neuroma exist.

Conservative methods involving orthotics and footwear

modifications are usually attempted first. There is sparse

evidence showing the efficacy of these measures alone.

One study reported an improvement in symptoms in 41%.1

Steroid and local anesthetic has been used for many years.

Saygi et al. showed superior results in the randomized group

with blind steroid injection compared to conservative treat-

ment but failed to show statistical significance at 1 year.24

Other studies have shown considerable variation in response

to steroid injection. 6,8,14,21,27 Greenfield et al. reported total

symptom relief from multiple blind steroid injections in 30%

of cases and partial response in 50%.6 This improved to 80%

at 2-year followup. Bennett et al. reported patient satisfaction

of 47% and Rasmussen et al. initially showed 80% symptom

response but long-term satisfaction of only 22%.1,21 Both

used single injections and were performed blind. Markovic

et al.’s study of 39 injections showed complete response

in 38% at 9 months.14 Hassouna et al. studied 39 patients

of which 31% were completely satisfied following a single

ultrasound guided steroid injection.8 A more recent study of

44 ultrasound guided injections showed 76% were symptom

free at 1 week following a single injection, but were not

followed up further.27

Surgery is the most established treatment and is performed

in patients who do not respond to less invasive measures.

Neurectomy via the dorsal or less frequently the plantar

approach is the most commonly used technique. Coughlin

et al. found overall satisfaction of excellent or good in

85% with 65% being pain free at final followup (average

5.8 years).2 Similarly Keh et al. and Pace et al. reported

similarly favorable results with postoperative success of

82% and 93%, respectively.13,18 Womack et al. showed less

positive long-term followup results with 51% of patients

reporting good or excellent results,12 (10%) fair results, and

48 (40%) poor results.32 Surgery although effective is not

without complications. Numbness is common following both

surgery and alcohol injection and footwear restrictions are

reported following surgery in up to 70% in some studies.18,28

Persistent or recurrent symptoms, particularly due to stump

neuromas, are difficult to manage and re-exploration has only

variable success.28 Other local complications may also occur

and were reported in 23% of cases in the study of Pace

et al.18 These included wound infection, hypersensitive scars,

and keloid formation.

Studies have shown alcohol ablation may be an effective

alternative to surgery. Our results showed a significant

reduction in pre- and post-median VAS scores following

alcohol injections with 32% of patients having a complete

response and 33% partial response. This supports the findings

of some published studies.5,9,10,16 Hughes et al. reported a

higher complete success rate in 84% of their 100 patients

with 62% of patients being completely satisfied with their

treatment. The median VAS score pre-procedure was 8 and

decreased to 0 post-procedure. Statistical analysis found the

difference to be significant.9 Slightly less favorable results

were reported by Fanucci et al. in their study of 40 patients

with a total response in 47.5%, partial treatment response

in 42.5% and 10% showing no response to treatment at

followup based modified Johnson scoring system.5,11 This

study used an alcohol concentration of 30%. Mozena et al.

treated 49 feet, 16 (33%) had complete resolution and 14

(29%) had improvement of symptoms. Nineteen feet (39%)

were unimproved, with 12 of those progressing to surgical

neurectomy.16 This study used 4% alcohol solution. Hyers

et al. reported good response in six of the eight treatments

in their group.10

A more recent study has shown less favorable results with

alcohol ablation undertaken without the use of ultrasound

guidance.4 Espinosa et al reported that only seven of the

patients in their study of 35 had significant symptom relief.

The remaining 25 patients had no significant change in

symptoms and went on to have or were considered for

surgery. This study was conducted in the outpatient setting

and diagnosis was established clinically and 25 (78%) of

patients had the presence of a neuroma confirmed during the

treatment course with MRI. An average of 4.1 injections

were performed using a 20% alcohol solution. The poor

outcome resulted in the authors discouraging the use of

alcohol ablation in this setting and they concluded ultrasound

guided intervention increased cost when compared to clinic




200 MUSSON ET AL. Foot & Ankle International/Vol. 33, No. 3/March 2012

treatment. It does, however, confirm the diagnosis and is less

expensive than MRI as a diagnostic tool.

The alcohol concentration used in our treatment was 20%

similar to that used by Hughes et al.9 This was shown to

be the minimum concentration required to result in neural

inhibition in experimental studies.23 Higher concentrations

are theoretically likely to cause more local complications if

leakage occurs. We found the treatment to be well toler-

ated and reported no significant complications. One patient

developed symptoms highly suggestive of an allergy to the

alcohol-bupivicaine mixture, which has not been previously

reported. One patient found the treatment unbearable and

stopped the course after one injection. Another patient had

prolonged pain and swelling which delayed the third injec-

tion by 1 week. These symptoms may have related to leakage

of alcohol or extensive local inflammatory reaction. Most

other patients found the treatment transiently uncomfortable.

Hughes et al similarly reported few procedural complications

with 17% of their cohort having plantar pain, which subse-

quently resolved and one patient with complex regional pain

syndrome. This early mobility and low complication rate is

favorable to that in surgical studies.9,18 An important consid-

eration however is that our treatments were performed using

ultrasound by skilled operators and complications from blind

alcohol injections are likely to be higher due to extravasa-

tion which can potentially permanently damage surrounding

tissue. Intolerable transient pain was reported in 3 of 35

patients in the study undertaken by Espinosa et al using blind

alcohol injections, but no other major complications were

seen.4

Our results show a larger proportion of patients did

not respond to treatment when compared to the study by

Hughes et al with a much higher proportion of patients

proceeding to surgery.9 The treatment type, delivery and

number of injections were matched and both studies had

with medium-term followup time. Hughes et al. excluded

patients with multiple neuroma from their study, a subset of

patients which we included in our analysis. The presence of

multiple neuromas did appear to result in a less favorable

outcome in our small series, but did not show statistical

significance. Our study also included patients who had co-

existing foot problems if the Morton’s neuroma was thought

to be symptomatic. These patients were excluded in the study

of Hughes et al. Conditions which may mimic the symptoms

of Morton’s metatarsalgia include neuropathy, peripheral

vascular disease, arthritis and structural deformities of the

foot and the difference in our results may be due to the

inclusion of the patients.

We also examined the effect of age on reduction in

VAS. The median VAS pre treatment in the 55-year-old and

younger groups fell from 9 to 2 compared to 8 to 5 in the

over-55 years group. Twenty percent showed no response in

the under-55 years compared to 44% in the over 55-years-old

group. This may be due to a higher prevalence of coexisting

foot pathology in the older group.

We believe that physicians and patients need to be aware

of all the available treatments for Morton’s neuroma and their

advantages and side effects. This allows patients to make an

informed decision before embarking on a treatment pathway.

The approximate cost per visit for alcohol ablation is in

the order of approximately £200, which includes the use of

ultrasound, supplies and physician fee. The treatment course

of 4 injections does therefore equate to alcohol ablation being

a relatively expensive treatment option. The agreed price

varies between regions and would be covered by the National

Health Service in the United Kingdom. Our study has shown

that alcohol ablation can be optimized with better patient

selection, which can be achieved by excluding concomitant

forefoot disorders.

The main limitation of our study is that it is a retrospective

analysis of alcohol ablation treatment. We also do not have

surgical comparison group for this series.

CONCLUSION

Ultrasound guided alcohol injection of Morton’s neuromas

was a safe, generally well-tolerated treatment, which signif-

icantly reduced pain and resulted in complete or partial

symptom relief in two-thirds of patients. Alcohol injection

facilitates a shorter recovery time and fewer complications

than surgery, but requires more hospital visits, and may be

less effective than surgery. Alcohol ablation can also be

technically demanding, is relatively expensive and requires

specialist training in ultrasound guided techniques. However,

this technique could be helpful to patients who prefer a

non-operative approach or those patients who may not be

considered a good surgical candidate due to co-morbidities

or coagulopathy. Alcohol ablation may be more efficacious

in younger patients and those with solitary neuromas, while

size is probably not a significant factor in treatment response.

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