今日の臨床サポート

Morton神経腫

著者: 須田康文1) 国際医療福祉大学塩谷病院

著者: 井口傑2) 井口医院

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2021/03/10
患者向け説明資料

概要・推奨   

薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
須田康文 : 特に申告事項無し[2021年]
井口傑 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 定期レビューを行い、保存療法、手術療法の有効性について加筆した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 足底部の神経は、脛骨神経から分岐した内側足底神経と外側足底神経が中足部で総底側趾神経に、趾部で固有底側趾神経に移行する[1]
 
足底部の神経

内側足底神経と外側足底神経から総底側趾神経が形成され、MTP関節遠位で固有底側趾神経が分岐する。

 
  1. Morton神経腫はMorton病とも呼ばれ、中足骨頭間での総底側趾神経の絞扼性神経障害を指す。神経は、絞扼部で肥大し神経腫となる。
  1. 病変部は、中足骨頭間を結ぶ深横中足靱帯の底側やや遠位に位置し、ハイヒール歩行などで前足部に過度な荷重が加わるとこの靱帯と足底の間で神経が絞扼される[2]
 
Morton神経腫と深横中足靱帯の関係

背側からみた図。深横中足靱帯底側やや遠位に神経腫が存在する。

出典

img1:  著者提供
 
 
 
  1. 第3趾間(3-4趾の間)、第2趾間(2-3趾の間)の順に好発し、中足趾節(MTP)関節底側痛、足趾への放散痛、足趾のしびれが主症状となる[2][3][4]
  1. 総底側趾神経が複数箇所で同時に障害される場合もある[3][4]
  1. 歩行時、長時間立位時や窮屈な靴を履く際症状が顕在化する。重症例では安静時痛もある。
  1. 中年女性に好発し、ハイヒールや先の細い靴の愛用、開張足、外反母趾などが要因となる[5]
問診・診察のポイント  
問診:
  1. 足底から足趾にかけての痛みやしびれが、どこに生じるか確認する。

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文献 

著者: K K Wu
雑誌名: Curr Opin Rheumatol. 2000 Mar;12(2):131-42.
Abstract/Text Morton neuroma is most likely a mechanically-induced degenerative neuropathy that predilects the third common digital nerve in middle-aged women who frequently wear fashionable shoes that are not designed for the physiology of the foot. A compression test of the affected web space is quite specific for its diagnosis, and an ultrasonograph can tell its exact size. If conservative means fail to relieve the painful symptoms of a Morton neuroma, surgical removal can produce dramatic pain relief. Metatarsalgia means pain in the metatarsal head region, and exists in three general forms: metatarsalgia of the first metatarsal head region, metatarsalgia of the fourth lateral metatarsal head region, and generalized metatarsalgia. There are numerous causes of metatarsalgia; a selected and important group of causes is discussed in this article. When conservative means fail to relieve metatarsalgia, specific surgical operations are quite effective for relief of pain, and are briefly described in the text.

PMID 10751016  Curr Opin Rheumatol. 2000 Mar;12(2):131-42.
著者: M J Coughlin, T Pinsonneault
雑誌名: J Bone Joint Surg Am. 2001 Sep;83-A(9):1321-8.
Abstract/Text BACKGROUND: The literature regarding the outcome of surgical treatment of interdigital neuroma is incomplete. The purpose of this study was to assess the demographics associated with the presentation of an interdigital neuroma as well as the long-term clinical results of operative resection by a single surgeon.
METHODS: A retrospective review of the patient records of one orthopaedic foot and ankle surgeon identified eighty-two patients who had been treated operatively for a primary, persistently painful interdigital neuroma more than three years previously. Of these eighty-two patients, sixty-six (seventy-one feet, seventy-four neuromas) returned at an average of 5.8 years for a follow-up evaluation, which included a review of the interval history since the surgery, a physical examination, a radiographic evaluation, and an assessment of the patient's satisfaction with the result of the surgery.
RESULTS: Overall satisfaction was rated as excellent or good by fifty-six (85%) of the sixty-six patients. Forty-six (65%) of the seventy-one feet were pain-free at the time of final follow-up. The patients who had had either bilateral neuroma excision or excisions of adjacent neuromas in the same foot in a staged fashion had a slightly lower level of satisfaction, but this difference was not significant. While major activity restrictions following surgery were uncommon, mild or major shoe-wear restrictions were noted by forty-six of the sixty-six patients. Although there was subjective numbness in thirty-six of the seventy-one feet, the pattern of numbness was quite variable and it was bothersome in only four feet.
CONCLUSION: With careful preoperative evaluation and patient selection, resection of a symptomatic interdigital neuroma through a dorsal approach can result in a high percentage of successful results more than five years following the procedure.

PMID 11568193  J Bone Joint Surg Am. 2001 Sep;83-A(9):1321-8.
著者: J D MULDER
雑誌名: J Bone Joint Surg Br. 1951 Feb;33-B(1):94-5.
Abstract/Text
PMID 14814167  J Bone Joint Surg Br. 1951 Feb;33-B(1):94-5.
著者: R Torres-Claramunt, A Ginés, G Pidemunt, Ll Puig, S de Zabala
雑誌名: Indian J Orthop. 2012 May;46(3):321-5. doi: 10.4103/0019-5413.96390.
Abstract/Text BACKGROUND: The diagnosis of Morton's neuroma is based primarily on clinical findings. Ultrasonography (US) and magnetic resonance image (MRI) studies are considered complementary diagnostic techniques. The aim of this study was to establish the correlation and sensitivity of both techniques used to diagnose Morton's neuroma.
MATERIALS AND METHODS: Thirty seven patients (43 intermetatarsal spaces) with Morton's neuroma operated were retrospectively reviewed. In all cases MRI or ultrasound was performed to complement clinical diagnosis of Morton's neuroma. In all cases, a histopathological examination confirmed the diagnosis. Estimates of sensitivity were made and correlation (kappa statistics) was assessed for both techniques.
RESULTS: Twenty seven women and 10 men participated with a mean age of 60 years. Double lesions presented in six patients. The second intermetatarsal space was affected in 10 patients and the third in 33 patients. An MRI was performed in 41 cases and a US in 23 cases. In 21 patients, both an MRI and a US were performed. With regard to the 41 MRIs performed, 34 were positive for Morton's neuroma and 7 were negative. MRI sensitivity was 82.9% [95% confidence interval (CI): 0.679-0.929]. Thirteen out of 23 US performed were positive and 10 US were negative. US sensitivity was 56.5% (95% CI: 0.345-0.768). Relative to the 21 patients on whom both techniques were carried out, the agreement between both techniques was poor (kappa statistics 0.31).
CONCLUSION: Although ancillary studies may be required to confirm the clinical diagnosis in some cases, they are probably not necessary for the diagnosis of Morton's neuroma. MRI had a higher sensitivity than US and should be considered the technique of choice in those cases. However, a negative result does not exclude the diagnosis (false negative 17%).

PMID 22719120  Indian J Orthop. 2012 May;46(3):321-5. doi: 10.4103/001・・・
著者: Francesco Di Caprio, Renato Meringolo, Marwan Shehab Eddine, Lorenzo Ponziani
雑誌名: Foot Ankle Surg. 2018 Apr;24(2):92-98. doi: 10.1016/j.fas.2017.01.007. Epub 2017 Feb 4.
Abstract/Text Morton's neuroma is one of the most common causes of metatarsalgia. Despite this, it remains little studied, as the diagnosis is clinical with no reliable instrumental diagnostics, and each study may deal with incorrect diagnosis or inappropriate treatment, which are difficult to verify. The present literature review crosses all key points, from diagnosis to surgical and nonoperative treatment, and recurrences. Nonoperative treatment is successful in a limited percentage of cases, but it can be adequate in those who want to delay or avoid surgery. Dorsal or plantar approaches were described for surgical treatment, both with strengths and weaknesses that will be scanned. Failures are related to wrong diagnosis, wrong interspace, failure to divide the transverse metatarsal ligament, too distal resection of common plantar digital nerve, an association of tarsal tunnel syndrome and incomplete removal. A deep knowledge of the causes and presentation of failures is needed to surgically face recurrences.

Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
PMID 29409221  Foot Ankle Surg. 2018 Apr;24(2):92-98. doi: 10.1016/j.f・・・
著者: Adnan A Faraj, Acuth Hosur
雑誌名: Chin Med J (Engl). 2010 Aug;123(16):2195-8.
Abstract/Text BACKGROUND: The choice for the surgical approach of interdigital neuroma in the foot is controversial. Plantar approach can leave a painful scar on weight bearing area; hence, some prefer dorsal approach. The aim of the current study was to measure the outcome of interdigital (Morton's) neurectomy performed by a single surgeon using dorsal and plantar approaches.
METHODS: A retrospective review of the patient records of one orthopaedic foot and ankle surgeon identified thirty-six patients (42 feet) who had been treated operatively for a primary, persistently painful interdigital neuroma. The mean follow-up was 18 months. Pain, weight bearing, wound problems and rehabilitation period were studied.
RESULTS: The duration to full weight bearing, return to work, driving and recreational activities were at least one week shorter in the dorsal group. The overall satisfaction for surgery was rated as excellent or good in 85% of the thirty six patients. Scar problems were more troublesome and common in the plantar group. There was residual numbness noticed in twenty feet, the pattern of numbness was quite variable and it was bothersome in only seven feet. There was one recurrence in the plantar group.
CONCLUSIONS: Resection of a symptomatic interdigital neuroma through a dorsal or a plantar approach can result in a good outcome. Dorsal approach, however, is associated with better rehabilitation and less scar problems.

PMID 20819664  Chin Med J (Engl). 2010 Aug;123(16):2195-8.

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