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Suggest Treatment For Recurrent Neuroma Inspite Of Having Foot Infection And Peroneal Nerve Damage

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Posted on Mon, 2 Jun 2014
Question: I have had 5 surgeries done on my left foot the first was when they had to cut the top of my foot open starting to the right of my big toe from a life threating infection. Since then it's been a nightmare. After that one surgery was which was the deep peroneal nerve and from then on 2 nueroma's and another nerve surgery. Now I'm left with a neuroma again, along with what else in going on in this foot. I was diagnosed with RSD after the initial surgery which doesn't help matters any. My doctor who has done these surgeries has jumped ship, I've been told to find a neurologist by the dr. who just performed my last emg last week. I really am in a bad position because I don't know if someone else wants to explore inside of my foot if that is the right decision. I would like to continue walking and don't want to lose my foot altogether. Any suggestions??? I have been involved with a pain center and dealing with an excellent dr. there as far as meds are concerned but right now I might as well be on no pain meds. Do I remove the neuroma which is my main question or will this just make things worse. I'm wondering if the neuroma was removed some of the entrapment issues would disappear. Very complex!!!!
doctor
Answered by Dr. Karl Logan (32 minutes later)
Brief Answer:
Many modalities of treatment available

Detailed Answer:
Hi,

Thanks for your question. I'm sorry to hear about your problems.

If you could indulge me repeating what I think the question is, it sounds like you had surgeries for an infection in your foot and neuromas following this surgery and now have damage to your deep peroneal nerve and further painful neuromas.

Further surgery can always be done to try and find and remove the neuroma although as you have found this often does not completely resovle the pain or causes further neuroma's. Neuroma's can be difficult to find when operating particularly if there is a lot of scare tissue.

The nerve damage is a more difficult problem to manage. The deep peroneal nerve only really supplies a small area of skin in the foot next to the big toe and so this nerve could always be removed although you would then have permanent numbness in this location and may be at risk of developing a further neuroma at the site of removal.

Your history of RSD, CRPS complicated matters as it could be that some of your ongoing nerve type symptoms are related to this. The measures to treat RSD or CRPS will be useful in helping the symptoms from your neuromas and nerve damage also, these include The following therapies are often used:

Rehabilitation therapy. An exercise program to keep the painful limb or body part moving can improve blood flow and lessen the circulatory symptoms. Additionally, exercise can help improve the affected limb’s flexibility, strength, and function. Rehabilitating the affected limb also can help to prevent or reverse the secondary brain changes that are associated with chronic pain. Occupational therapy can help the individual learn new ways to work and perform daily tasks.

Psychotherapy. CRPS and other painful and disabling conditions often are associated with profound psychological symptoms for affected individuals and their families. People with CRPS may develop depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehabilitation efforts more difficult. Treating these secondary conditions is important for helping people cope and recover from CRPS.

Medications. Several different classes of medication have been shown to be effective for CRPS, particularly when used early in the course of the disease. No drug is approved by the U.S. Food and Drug Administration specifically for CRPS. No single drug or combination of drugs is guaranteed to be effective in every person. Drugs to treat CRPS include:

non-steroidal anti-inflammatory drugs to treat moderate pain, including over-the-counter aspirin, ibuprofen, and naproxin
corticosteroids that treat inflammation/swelling and edema, such as prednisolone and methylprednisolone (used mostly in the early stages of CRPS)
drugs initially developed to treat seizures or depression but now shown to be effective for neuropathic pain, such as gabapentin, pregabalin, amitriptyline, nortriptyline, and duloxetine
botulinum toxin injections
opioids such as oxycontin, morphine, hydrocodone, fentanyl, and vicodin
N-methyl-D-aspartate (NMDA) receptor antagonists such as dextromethorphan and ketamine
nasal calcitonin, especially for deep bone pain, and
topical local anesthetic creams and patches such as lidocaine.
All drugs or combination of drugs can have various side effects such as drowsiness, dizziness, increased heartbeat, and impaired memory. Inform a healthcare professional of any changes once drug therapy begins.

Sympathetic nerve block. Some individuals report temporary pain relief from sympathetic nerve blocks, but there is no published evidence of long-term benefit. Sympathetic blocks involve injecting an anesthetic next to the spine to directly block the activity of sympathetic nerves and improve blood flow.

Surgical sympathectomy. The use of this operation that destroys some of the nerves is controversial. Some experts think it is unwarranted and makes CRPS worse; others report a favorable outcome. Sympathectomy should be used only in individuals whose pain is dramatically relieved (although temporarily) by sympathetic nerve blocks. It also can reduce excess sweating.

Spinal cord stimulation. Placing stimulating electrodes through a needle into the spine near the spinal cord provides a tingling sensation in the painful area. Typically the electrode is placed temporarily for a few days to assess whether stimulation will be helpful. Minor surgery is required to implant all the parts under the skin on the torso. Once implanted, the stimulator can be turned on and off, and adjusted using an external controller. Data shows that about one-fourth of individuals develop equipment problems that may require additional surgeries.

Other types of neural stimulation. Neurostimulation can be delivered at other locations along the pain pathway, not only at the spinal cord. These include near injured nerves (peripheral nerve stimulators), outside the membranes of the brain (motor cortex stimulation with dural electrodes), and within the parts of the brain that control pain (deep brain stimulation). A recent option involves the use of magnetic currents applied externally to the brain (called repetitive Transcranial Magnetic Stimulation, or rTMS). The advantage is that no surgery is required; the disadvantage is need for repeated treatment sessions.

Intrathecal drug pumps. These devices pump pain-relieving medications directly into the fluid that bathes the spinal cord, typically opioids and local anesthetic agents such as clonidine and baclofen. The advantage is that pain-signaling targets in the spinal cord can be reached using doses far lower than those required for oral administration, which decreases side effects and increases drug effectiveness. There are no studies that show benefit specifically for CRPS.

Emerging treatments for CRPS include:

Intravenous immunoglobulin (IVIG). Researchers in Great Britain reported that low-dose IVIG reduced pain intensity in a small trial of 13 patients with CRPS for 6 to 30 months who did not respond well to other treatments. Those who received IVIG had a greater decrease in pain scores than those receiving saline during the following 14 days after infusion. A larger study involving individuals with acute-phase CRPS is planned.
Ketamine. Investigators are using low doses of ketamine—a strong anesthetic—given intravenously for several days to either reduce substantially or eliminate the chronic pain of CRPS. In certain clinical settings, ketamine has been shown to be useful in treating pain that does not respond well to other treatments.
Hyperbaric oxygen. Several studies have investigated the use of hyperbaric oxygen therapy for chronic pain. Individuals lie down in a tank containing pressurized air, which delivers more oxygen to the body’s organs and tissues. Although research is still experimental, some researchers report hyperbaric oxygen can reduce swelling and pain, and improve range of motion in individuals with CRPS.
Several alternative therapies have been used to treat other painful conditions. Options include behavior modification, acupuncture, relaxation techniques (such as biofeedback, progressive muscle relaxation, and guided motion therapy), and chiropractic treatment.

I hope this information is helpful to you.

Best wishes


Note: For further queries, consult a joint and bone specialist, an Orthopaedic surgeon. Book a Call now.

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
doctor
Answered by
Dr.
Dr. Karl Logan

Orthopaedic Surgeon

Practicing since :1999

Answered : 705 Questions

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Suggest Treatment For Recurrent Neuroma Inspite Of Having Foot Infection And Peroneal Nerve Damage

Brief Answer: Many modalities of treatment available Detailed Answer: Hi, Thanks for your question. I'm sorry to hear about your problems. If you could indulge me repeating what I think the question is, it sounds like you had surgeries for an infection in your foot and neuromas following this surgery and now have damage to your deep peroneal nerve and further painful neuromas. Further surgery can always be done to try and find and remove the neuroma although as you have found this often does not completely resovle the pain or causes further neuroma's. Neuroma's can be difficult to find when operating particularly if there is a lot of scare tissue. The nerve damage is a more difficult problem to manage. The deep peroneal nerve only really supplies a small area of skin in the foot next to the big toe and so this nerve could always be removed although you would then have permanent numbness in this location and may be at risk of developing a further neuroma at the site of removal. Your history of RSD, CRPS complicated matters as it could be that some of your ongoing nerve type symptoms are related to this. The measures to treat RSD or CRPS will be useful in helping the symptoms from your neuromas and nerve damage also, these include The following therapies are often used: Rehabilitation therapy. An exercise program to keep the painful limb or body part moving can improve blood flow and lessen the circulatory symptoms. Additionally, exercise can help improve the affected limb’s flexibility, strength, and function. Rehabilitating the affected limb also can help to prevent or reverse the secondary brain changes that are associated with chronic pain. Occupational therapy can help the individual learn new ways to work and perform daily tasks. Psychotherapy. CRPS and other painful and disabling conditions often are associated with profound psychological symptoms for affected individuals and their families. People with CRPS may develop depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehabilitation efforts more difficult. Treating these secondary conditions is important for helping people cope and recover from CRPS. Medications. Several different classes of medication have been shown to be effective for CRPS, particularly when used early in the course of the disease. No drug is approved by the U.S. Food and Drug Administration specifically for CRPS. No single drug or combination of drugs is guaranteed to be effective in every person. Drugs to treat CRPS include: non-steroidal anti-inflammatory drugs to treat moderate pain, including over-the-counter aspirin, ibuprofen, and naproxin corticosteroids that treat inflammation/swelling and edema, such as prednisolone and methylprednisolone (used mostly in the early stages of CRPS) drugs initially developed to treat seizures or depression but now shown to be effective for neuropathic pain, such as gabapentin, pregabalin, amitriptyline, nortriptyline, and duloxetine botulinum toxin injections opioids such as oxycontin, morphine, hydrocodone, fentanyl, and vicodin N-methyl-D-aspartate (NMDA) receptor antagonists such as dextromethorphan and ketamine nasal calcitonin, especially for deep bone pain, and topical local anesthetic creams and patches such as lidocaine. All drugs or combination of drugs can have various side effects such as drowsiness, dizziness, increased heartbeat, and impaired memory. Inform a healthcare professional of any changes once drug therapy begins. Sympathetic nerve block. Some individuals report temporary pain relief from sympathetic nerve blocks, but there is no published evidence of long-term benefit. Sympathetic blocks involve injecting an anesthetic next to the spine to directly block the activity of sympathetic nerves and improve blood flow. Surgical sympathectomy. The use of this operation that destroys some of the nerves is controversial. Some experts think it is unwarranted and makes CRPS worse; others report a favorable outcome. Sympathectomy should be used only in individuals whose pain is dramatically relieved (although temporarily) by sympathetic nerve blocks. It also can reduce excess sweating. Spinal cord stimulation. Placing stimulating electrodes through a needle into the spine near the spinal cord provides a tingling sensation in the painful area. Typically the electrode is placed temporarily for a few days to assess whether stimulation will be helpful. Minor surgery is required to implant all the parts under the skin on the torso. Once implanted, the stimulator can be turned on and off, and adjusted using an external controller. Data shows that about one-fourth of individuals develop equipment problems that may require additional surgeries. Other types of neural stimulation. Neurostimulation can be delivered at other locations along the pain pathway, not only at the spinal cord. These include near injured nerves (peripheral nerve stimulators), outside the membranes of the brain (motor cortex stimulation with dural electrodes), and within the parts of the brain that control pain (deep brain stimulation). A recent option involves the use of magnetic currents applied externally to the brain (called repetitive Transcranial Magnetic Stimulation, or rTMS). The advantage is that no surgery is required; the disadvantage is need for repeated treatment sessions. Intrathecal drug pumps. These devices pump pain-relieving medications directly into the fluid that bathes the spinal cord, typically opioids and local anesthetic agents such as clonidine and baclofen. The advantage is that pain-signaling targets in the spinal cord can be reached using doses far lower than those required for oral administration, which decreases side effects and increases drug effectiveness. There are no studies that show benefit specifically for CRPS. Emerging treatments for CRPS include: Intravenous immunoglobulin (IVIG). Researchers in Great Britain reported that low-dose IVIG reduced pain intensity in a small trial of 13 patients with CRPS for 6 to 30 months who did not respond well to other treatments. Those who received IVIG had a greater decrease in pain scores than those receiving saline during the following 14 days after infusion. A larger study involving individuals with acute-phase CRPS is planned. Ketamine. Investigators are using low doses of ketamine—a strong anesthetic—given intravenously for several days to either reduce substantially or eliminate the chronic pain of CRPS. In certain clinical settings, ketamine has been shown to be useful in treating pain that does not respond well to other treatments. Hyperbaric oxygen. Several studies have investigated the use of hyperbaric oxygen therapy for chronic pain. Individuals lie down in a tank containing pressurized air, which delivers more oxygen to the body’s organs and tissues. Although research is still experimental, some researchers report hyperbaric oxygen can reduce swelling and pain, and improve range of motion in individuals with CRPS. Several alternative therapies have been used to treat other painful conditions. Options include behavior modification, acupuncture, relaxation techniques (such as biofeedback, progressive muscle relaxation, and guided motion therapy), and chiropractic treatment. I hope this information is helpful to you. Best wishes