Neurectomy
In the case of nerve injury, nerve healing may occur with a local increase in the size of the nerve. This localized enlargement of a nerve is called a neuroma. In the case of a symptomatic neuroma, a neurectomy may be considered.
What is a Neurectomy?
A neurectomy (or neurectomy) is a surgical procedure that involves resecting, wholly or partially, a nerve, generally a peripheral one. This procedure is used to interrupt the transmission of nerve signals, most often with the goal of relieving chronic pain that has not responded to other treatments.
According to medical dictionaries, this refers to the surgical removal of a portion of a nerve, whether it be the main trunk or collateral branches.
For which conditions is a Neurectomy performed?
A neurectomy is usually proposed for a neuroma, that is, a hypertrophic lesion localized on a sensory nerve. Usually, this neuroma is responsible for electric shocks in the affected nerve area. The neuroma itself may be sensitive and cause a trigger zone. Palpation of this trigger zone induces electric pain or pain that is difficult for the patient to describe.
Other nerve conditions may require a neurectomy, notably tarsal tunnel syndrome in cases where conservative treatment fails.
The different types of Neurectomy
The Morton's neuroma is a term commonly used to refer to the compression of a sensitive plantar nerve located in an intermetatarsal space, most often the third, which is the most frequent site of this condition. The diagnosis is mainly based on the clinical examination and, more specifically, on the targeted palpation of the affected area. Ultrasound, meanwhile, allows for visualization and measurement of the plantar nerve at the suspected site.
The symptoms associated with Morton's neuroma are generally related to the compression of the nerve in this restricted space, which can cause nerve damage. These lesions often result in an increase in nerve thickness, which worsens its suffering due to the pressure applied. In addition, an inflammatory thickening of the surrounding tissues, called bursitis, may also develop. This bursitis further reduces the space available for the nerve, thereby increasing compression and related pain.
When the nerve shows a significant increase in thickness or suffers prolonged compression from the surrounding tissues, surgical intervention may be necessary. This procedure involves removing the affected nerve located in the third intermetatarsal space, which corresponds to a neurectomy. The aim of this procedure is to provide lasting pain relief by eliminating the source of nerve compression.
Neurectomy of the Superficial Peroneal Nerve
The superficial peroneal nerve is a sensory nerve that exits at the level of the crural aponeurosis to provide sensation to the dorsum of the foot. This nerve can suffer in cases of chronic ankle instability; hypermobility of the ankle causes hypermobility of the nerve, which may thicken in the form of a neuroma at the exit of the aponeurosis. This phenomenon is also known as superficial peroneal nerve entrapment.
If the pain of the superficial peroneal nerve is due to ankle instability, ligament repair of the ankle may help relieve nerve pain. In this case, it is simply an irritation of the superficial peroneal nerve.
If the pain persists, a local anesthetic injection may be performed at the exit of the leg aponeurosis around the nerve. This is a diagnostic test. Ultrasound will be used to check for the presence or absence of a neuroma.
In the case of a symptomatic neuroma of the superficial fibular nerve, a surgical procedure called neurectomy may be proposed. If no neuroma is detected by ultrasound, a surgical decompression of the superficial fibular nerve may be proposed; this is called a neurolysis.
Neurectomy of the sural nerve
The sural nerve is a sensory nerve that can be injured on the lateral side of the ankle. Crush injuries can cause damage to the sural nerve. Due to anatomical variations, this nerve is at risk during surgical procedures involving calcaneal fractures, peroneal tendon injuries, or ankle ligament injuries.
If a sural nerve neuroma is suspected, an ultrasound is performed to identify the location of the neuroma. An infiltration test may be done with a local anesthetic for diagnostic purposes. If a symptomatic neuroma is present, a surgical resection procedure may be considered, called a neurectomy.
How does a Neurectomy take place?
Under regional anesthesia and in a sterile environment in the operating room, the surgeon makes an incision adapted to the location of the neuroma (on the top of the foot, the sole, or between the toes) and first performs a neurolysis by cutting the intermetatarsal ligament and decompressing if necessary, then performs the section of the nervedownstream from the neuroma, followed by a proximal resection as far back as possible to limit any risk of recurrence, with burial of the nerve stump in the deep tissues, all performed in a generally brief procedure conducted on an outpatient basis.
Indications and contraindications of neurectomy
Neurectomy is indicated in several specific clinical situations. The main indications include symptomatic neuromas resistant to conservative treatment, notably severe tarsal tunnel syndrome, post-traumatic neuromas, and refractory Morton’s neuromas.
Absolute contraindications are rare but include active infections at the surgical site, uncontrolled severe coagulation disorders, and severe peripheral artery disease. Relative contraindications include poorly controlled diabetes, a history of pathological scarring, and psychiatric disorders that may compromise post-operative rehabilitation.
Possible complications of neurectomy
Like any surgical procedure, neurectomy involves risks and potential complications. Immediate complications include post-operative hematoma, infection of the surgical site, and reactions to anesthetics. These complications remain rare with rigorous surgical technique and appropriate post-operative care.
Delayed complications may include the formation of a recurrent neuroma, particularly if the technique for burying the nerve stump is not optimal. Permanent hypoesthesia in the territory of the resected nerve is an expected consequence rather than a complication, but it must be explained to the patient before the procedure.
Persistent neuropathic pain is a dreaded yet fortunately rare complication. It may require multidisciplinary management including specific drug treatments and sometimes a surgical reassessment. Preventing these complications relies on meticulous surgical technique and regular post-operative follow-up.
Rehabilitation after neurectomy
Post-neurectomy rehabilitation plays a crucial role in functional recovery and the prevention of complications. The initial phase, during the first two weeks, emphasizes relative rest with gentle mobilization to prevent scar adhesions. Applying ice and elevating the operated limb help to reduce post-operative swelling.
From the third week onwards, foot rehabilitation becomes more active. Desensitization exercises of the operated area are essential for managing residual hypoesthesia. Proprioceptive training helps to compensate for the loss of sensitivity in the affected nerve area.
The gradual resumption of walking is carried out according to a personalized protocol, generally with full weight-bearing allowed once skin healing is achieved. Wearing suitable, wide, and flexible shoes aids functional readjustment. The total duration of rehabilitation varies according to the type of neurectomy and individual recovery, generally ranging from 6 to 12 weeks.
Long-term results of neurectomy
The long-term results of neurectomy are generally favorable when the surgical indication is well established. For Morton's neuroma, studies report a satisfaction rate of over 80%, with complete disappearance or significant improvement of neuropathic pain. Patients' quality of life improves significantly, allowing them to resume daily and sports activities.
Residual hypoesthesia in the territory of the resected nerve persists permanently but is generally well tolerated. Most patients quickly adapt to this sensory change, which remains limited to a small area. Activities requiring fine sensitivity may require an adaptation period.
Painful recurrences remain rare, occurring in less than 5% of cases for well-performed neurectomies. They may be related to the formation of a neuroma on the proximal nerve stump or to an associated pathology that was not initially diagnosed. Long-term follow-up allows for early detection of these complications and adjustment of management if necessary.