DESCRIPTION
A neuroma is pathology of peripheral nerve that develops as part of a normal reparative process after injury or because of chronic irritation. Morton intermetatarsal neuroma is a common and painful compression neuropathy of the common digital nerve of the foot that may also be referred to as interdigital neuroma, interdigital neuritis, and interdigital or Morton metatarsalgia. Morton neuroma is usually associated with a throbbing, burning, or shooting pain localized to the plantar aspect of the foot. It is typically located between the third and fourth metatarsal heads, although it may appear in other proximal locations. It is histologically characterized by perineural fibrosis, endoneurial edema, axonal degeneration, and local vascular proliferation.
Management of Morton neuroma typically begins with conservative approaches such as the use of metatarsal pads in shoes and orthotic devices that alter supination and pronation of the affected foot. These approaches may reduce pressure and irritation of the affected nerve to provide relief, but they do not alter the underlying pathology. Surgical intervention is considered the definitive therapy.
Alternative approaches under investigation to treat refractory Morton neuroma include minimally invasive procedures aimed at in situ destruction of the pathology. These include radiofrequency ablation (RFA), cryoablation (also known as cryoneurolysis, cryolysis, cryoanalgesia), and chemical neurolysis of the nerve with alcohol injections.
POLICY
Minimally invasive ablation procedures for the treatment of peripheral neuromas, including, but not limited to, the following are considered investigational:
Radiofrequency Ablation
Cryoablation
Alcohol Injections
IMPORTANT REMINDERS
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ADDITIONAL INFORMATION
No controlled studies were found in the published literature that validate the application of ablation procedures for peripheral neuromas or provide comparisons to other forms of treatment.
SOURCES
American College of Foot and Ankle Surgeons. (2009). Diagnosis and treatment of forefoot disorders: Section 3. Morton’s intermetatarsal neuroma. Retrieved July 5, 2017 from http://www.jfas.org.
Association of Extremity Nerve Surgeons. (2020). Clinical practice guidelines. Retrieved November 21, 2022 from http://www.aens.us.
BlueCross BlueShield Association. Evidence Positioning System. (7:2023). Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas (7.01.147). Retrieved December 4, 2023 from www.bcbsaoca.com/eps/. (42 articles and/or guidelines reviewed)
Brooks, D., Parr, A., & Bryceson, W. (2017). Three cycles of radiofrequency ablation are more efficacious than two in the management of Morton’s neuroma. Foot & Ankle Specialist, 2017 May 1:1938640017709905. Doi:10.1177/1938640017709905. [Epub ahead of print]. Abstract retrieved July 5, 2017 from PubMed database.
Cazzato, R., Garnon, J., Ramamurthy, N., Tsoumakidou, G., Caudrelier, J., Thenint, M., et al. (2016). Percutaneous MR-guided cryoablation of Morton’s neuroma: rationale and technical details after the first 20 patients. Cardiovascular and Interventional Radiology, 39 (10), 1491-1498. Abstract retrieved July 5, 2017 from PubMed database.
Chuter, G., Chua, Y., Connell, D., & Blackney, M. (2013). Ultrasound-guided radiofrequency ablation in the management of interdigital (Morton’s) neuroma. Skeletal Radiology, 42 (1), 107-111. Abstract retrieved March 16, 2015 from PubMed database.
Connors, J. C., Boike, A. M., Rao, N., & Kingsley, J. D. (2020). Radiofrequency ablation for the treatment of painful neuroma. The Journal of Foot and Ankle Surgery: Official Publication of the American College of Foot and Ankle Surgeons, 59 (3), 457-461, doi: 10.1053/j.jfas.2019.09.003. Abstract retrieved November 22, 2022 from PubMed database.
Matthews, B. G., Hurn, S. E., Harding, M. P., Henry, R. A., & Ware, R. S. (2019). The effectiveness of non-surgical interventions for common plantar digital compressive neuropathy (Morton's neuroma): a systematic review and meta-analysis. Journal of Foot and Ankle Research, 12, 12. (Level 2 evidence)
National Institute for Health and Care Excellence. (2015, December). Radiofrequency ablation for symptomatic interdigital (Morton’s) neuroma. Retrieved May 3, 2016 from www.nice.org.uk/guidance/ipg539.
National Institute for Health and Care Excellence. (2023, January). Percutaneous image-guided cryoablation of peripheral neuroma for chronic pain. Retrieved December 4, 2023 from www.nice.org.uk/guidance/ipg539.
Pasquali, C., Vulcano, E., Novario, R., Varotto, D., Montoli, C., & Volpe, A. (2015). Ultrasound-guided alcohol injection for Morton’s neuroma. Foot & Ankle Specialist, 36 (1), 55-59. Abstract retrieved July 5, 2017 from PubMed database.
Thomson, L., Aujla, R. S., Divall, P., & Bhatia, M. (2020). Non-surgical treatments for Morton's neuroma: A systematic review. Foot and ankle surgery, 26 (7), 736-743. Abstract retrieved September 30, 2021 from PubMed database.
ORIGINAL EFFECTIVE DATE: 8/8/2015
MOST RECENT REVIEW DATE: 1/11/2024
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