Ultrasound Guided Alcohol Ablation of Mortons Neuroma
Morton’s neuroma is a complicated and chronic condition of foot in which the patients experience considerable pain and discomfort due to compression of interdigital nerve. In long standing or poorly managed cases, the soft tissues in the surrounding of nerve undergoes fibrotic thickening and swelling. The nerve involvement is reportedly more common in the third web space (between third and fourth toe) due to a variety of anatomical and physiological reasons, but virtually any web-space can be affected.
The pathophysiology of symptoms revolve around persistent and ongoing inflammation and nerve dysfunction due to long standing compression. The symptoms of pain and discomfort typically worsens when a person walks too fast or exert for extended periods of time. Treatment options for Morton’s neuroma include conventional methods, use of drugs and other supportive devices (such as orthotics) in addition to lifestyle and footwear modification.
Ultrasound Guided Alcohol Ablation is one of the most preferred modalities of care in the setting of painful neuromas that does not respond to conventional or over-the-counter regimens. The alcohol ablation procedure involves administration of highly concentrated ethanol via injection under ultrasound guidance into the Morton’s neuroma. Despite eh description, the use of local anesthetic makes this procedure irritating but not painful.
The procedure of ethanol ablation involves the insertion of a very thin needle into the Morton’s neuroma under direct ultrasound guidance. To improve the precision, your practitioner will numb the area with the help of local anesthetic agent before administering ethanol injection.
The benefits of using ultrasound guidance are many fold:
- It reduces the chance of error
- It increases the accuracy of the procedure
- The duration of overall procedure can be reduced too
Some patients may report localized discomfort that resolves spontaneously within a couple of days and does not require additional treatments.
The average number of therapeutic sessions may range from 1 to rarely 4 (an average of 1-2 sessions to achieve noticeable improvement in symptoms.) According to a recent study(1), close to 80% patients reported satisfactory relief from the painful symptoms at 1-year follow-up.
Post-procedure Rehabilitation and Recovery:
Ultrasound guided alcohol ablation is an extremely safe and reliable procedure. You can improve the efficacy of procedure by adopting some simple tips:
- Make sure to take rest for a period of at least 24 hours after the procedure; this will help in decreasing the localized discomfort and hasten the pace of overall recovery.
- Application of cold packs or ice packs after every two hours is very effective as a post procedure measure. Ideally, ice-packs or cold compresses at the site of injection are very helpful in resolving pain and swelling after first 24 hours.
- Some over the counter analgesics or anti-inflammatory medications such as ibuprofen or Tylenol can be taken if your pain does not respond to cold packs.
Risks of ethanol ablation
The risk of major complications or adverse effects is extremely low with procedures like ultrasound guided alcohol ablation. Some post-procedure issues may include:
- Burning sensation at the site of infection.
- Localized redness with mild transient swelling.
- Appearance of localized bruising.
- Mild pain at the site of injection.
- In some extremely rare cases, some patients may develop nerve damage and associated numbness/ paresthesia.
- Very few people report constant swelling and pain lasting for up to two weeks after the alcohol injection; however, such issues are virtually negligible if the procedure is performed under ultrasound guidance.
The success rate of this procedure is usually over 80 %. Very few people may require an additional procedure (such as a repeat alcohol ablation, radiofrequency ablation or rarely even surgical excision of neuroma).
Investigators(2) estimated that the use of ultrasound guidance improves the technical precision of procedure by 100%. It is critical that the clinician performing the procedure be well experienced in doing these procedures under ultrasound guidance. We use nerve stimulator guidance in addition to Ultrasound guidance to further increase the accuracy of the procedure.
- Pasquali, C., Vulcano, E., Novario, R., Varotto, D., Montoli, C., & Volpe, A. (2015). Ultrasound-Guided Alcohol Injection for Morton’s Neuroma. Foot & ankle international, 36(1), 55-59.
- Musson, R. E., Sawhney, J. S., Lamb, L., Wilkinson, A., & Obaid, H. (2012). Ultrasound guided alcohol ablation of Morton’s neuroma. Foot & ankle international, 33(3), 196-201.
Janet D. Pearl, MD, MSc is the Medical Director of The Center for Morton’s Neuroma and Complete Spine and Pain Care, an interventional and integrated Pain Management program located in Framingham, Massachusetts. Previously, Dr. Pearl was the Co-Director of the Pain Management Center at St. Elizabeth’s Medical Center, where she was also the Director of the Fellowship program. She is the former Director of a satellite pain center of the Brigham and Women’s Hospital, Pain Management Center, located at the HealthSouth Braintree Rehabilitation Hospital. Dr. Pearl held academic appointments at Harvard Medical School and Tufts Medical School. She serves on the Health Care Services Board of the Commonwealth of Massachusetts Department of Industrial Accidents since 2000 as one of its physician representatives and is Chair of the Committee on Pain Management.