Publication: Neuroma de Morton: actualización de conocimientos en el tratamiento conservador y quirúrgico
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2019-07-02
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Abstract
El Neuroma de Morton consiste en una fibrosis perineural del nervio plantar digital con un amplio espectro de factores etiológicos como los traumatismos crónicos, la pronación o el atrapamiento que sufre el nervio con el borde anterior del ligamento transverso intermetatarsiano profundo. El diagnóstico debe basarse fundamentalmente en la clínica, siendo de interés los signos de Mulder y Tinel. En caso de duda podemos ayudarnos de la ecografía o la resonancia magnética indistintamente.
El tratamiento ortopodológico consiste en una pieza retrocapital y un calzado más amplio. La ablación por radiofrecuencia y las ondas de choque extracorpóreas pueden considerarse como otras líneas de tratamiento aunque la evidencia científica que tenemos de las mismas es escasa; así como las inyecciones localizadas de alcohol, que ecoguiadas pueden reducir significativamente el dolor del paciente.
El tratamiento conservador mejor descrito es la infiltración de corticoesteroides, que debe realizarse dorsal, ecoguiada y asociada a un anestésico; sin embargo su efectividad se reduce a los tres meses y un porcentaje significativo de los pacientes recidiva en los siguientes años.
Respecto al tratamiento quirúrgico, la neurectomía presenta mayor reflejo en la literatura en comparación con la descompresión endoscópica, refiriendo resultados similares tanto el abordaje dorsal como el plantar si bien es cierto que se observan diferentes efectos adversos en función del abordaje empleado.
The Morton Neuroma is a perineural fibrosis with a wide range of etiological factors such as chronic trauma, pronation or nerve entrapment by the anterior edge of the deep transverse metatarsal ligament. Diagnosis should be based in clinical examination, where Mulder and Tinel signs could be helpful. If the diagnosis is still uncertain, we could employ ultrasonography or magnetic resonance equally. Orthesic treatment consists on inserts to reduce pressure beneath the metatarsal heads and widen footwear. Radiofrequency ablation and extracorporeal shock wave therapy could be considered as different treatment lines however the scientific evidence reported is limited. Alcohol injections combined with ultrasonography are also a conservative treatment widely used which have proved relieving significantly pain. The conservative treatment best described is the corticoid injection, which should be performed dorsal, ultrasound guided and with an anesthetic; nevertheless its effectiveness decreases after three months and a significative percentage relapses within the next few years. When it comes to surgical treatment, neurectomy it is the most widely used in published literature compared with endoscopic decompression, referring similar results either dorsal or plantar approach, while it is true the complications vary depending the approach employed.
The Morton Neuroma is a perineural fibrosis with a wide range of etiological factors such as chronic trauma, pronation or nerve entrapment by the anterior edge of the deep transverse metatarsal ligament. Diagnosis should be based in clinical examination, where Mulder and Tinel signs could be helpful. If the diagnosis is still uncertain, we could employ ultrasonography or magnetic resonance equally. Orthesic treatment consists on inserts to reduce pressure beneath the metatarsal heads and widen footwear. Radiofrequency ablation and extracorporeal shock wave therapy could be considered as different treatment lines however the scientific evidence reported is limited. Alcohol injections combined with ultrasonography are also a conservative treatment widely used which have proved relieving significantly pain. The conservative treatment best described is the corticoid injection, which should be performed dorsal, ultrasound guided and with an anesthetic; nevertheless its effectiveness decreases after three months and a significative percentage relapses within the next few years. When it comes to surgical treatment, neurectomy it is the most widely used in published literature compared with endoscopic decompression, referring similar results either dorsal or plantar approach, while it is true the complications vary depending the approach employed.