Clinical UM Guideline
|Subject:||Injection Treatment for Morton’s Neuroma|
|Guideline #:||CG-SURG-25||Current Effective Date:||10/01/2016|
|Status:||Reviewed||Last Review Date:||08/04/2016|
This document addresses the indications for injection treatment of Morton's neuroma, a common paroxysmal neuralgia affecting the web spaces of the toes.
Injections of anesthetic, sclerosing (neurolytic), or steroid agents are considered medically necessary for treatment of Morton's neuroma when all of the following conservative therapies have failed:
Not Medically Necessary:
Injection treatment of Morton's neuroma is considered not medically necessary when the above criteria are not met.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|64455||Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma)|
|64632||Destruction by neurolytic agent; plantar common digital nerve|
|3E0T33Z||Introduction of anti-inflammatory into peripheral nerves and plexi, percutaneous approach|
|3E0T3CZ||Introduction of regional anesthetic into peripheral nerves and plexi, percutaneous approach|
|3E0T3TZ||Introduction of destructive agent into peripheral nerves and plexi, percutaneous approach|
|G57.60||Lesion of plantar nerve, unspecified lower limb|
|G57.61||Lesion of plantar nerve, right lower limb|
|G57.62||Lesion of plantar nerve, left lower limb|
A neuroma is typically described as a benign tumor of a nerve characterized by exuberant proliferation of nerve endings. Morton's neuroma is not a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes. It occurs as the nerve passes under the ligament connecting the toe bones (metatarsals) in the forefoot. The cause of Morton's neuroma is unclear and most frequently develops between the third and fourth toes. Possible causes include nerve entrapment, the abnormal anatomy of the plantar nerve in this location, structural/mechanical foot abnormalities, trauma, or excessive pressure.
Multiple treatment approaches have been utilized for Morton's neuroma including conservative care, such as orthotics, padding, and alternative shoe styles to relieve the pressure on the forefoot. More invasive treatments include anesthetic blocks, sclerosing or steroid injections, and surgical excision of the painful nerve. The peer-reviewed literature contains varied conclusions. In a Cochrane review, Thomson and colleagues (2004) cited that there is insufficient evidence with which to assess the effectiveness of surgical and non-surgical interventions for Morton's neuroma and that well-designed trials are needed to begin to establish an evidence base for the treatment of Morton's neuroma pain.
Serial ethanol injection therapy has been reported as an effective alternative to surgical excision at 10 months follow-up (Fanucci, 2004). Hughes and colleagues (2007) reported on a large case series of 101 individuals with a confirmed diagnosis of Morton's neuroma. A total of 4 ultrasound-guided injections (total=0.5 mL of 20% ethanol) were administered at 14-day intervals with an average follow-up of 10.5 months after the last injection. Additional injections were performed at 14-day intervals if the response was partial or incomplete based on participant-assessed level of pain. The main outcome was pain measured on a visual analog scale (VAS) scored from 0 to 10. Partial or total symptom improvement was reported by 94% of the participants, with 84% becoming totally pain-free. The median VAS pain score decreased from 8 before treatment to 0 after treatment (p<0.001). No major complications were reported. Three participants went on to surgical resection. Musson and colleagues (2012) reported on outcomes of a case series of 75 individuals who received intralesional alcohol injections for symptomatic Morton's neuroma. A standard course of treatment consisted of 4 injections administered 2 weeks apart. Outcomes were participant-reported pain score on a VAS scale (range, 0-10) with a mean follow-up of approximately 14 months (range, 6-26 months). The mean VAS pain score was 8.5 (range, 4-10) before treatment and 4.2 (range, 0-10) after treatment (p<0.001). At follow-up, 32% of participants reported complete symptom resolution, 33% reported partial relief, and 35% reported no relief. Complications of the injections were rare (n=3) and self-resolving. A total of 17 participants (20%) went on to surgery at the time of last follow-up.
Gurdezi and colleagues (2013) reported on the long-term effectiveness of alcohol injection for Morton's neuroma (mean follow-up: 61 months, range, 33-73 months) in 45 individuals from the original cohort of the Hughes study (2013). Of the 45 individuals evaluable at 5 years, 16 (36%) had undergone surgical treatment and 13 (29%) individuals had only transient relief of symptoms (2 weeks or fewer). Only 29% (13 of 45) remained symptom free. The authors concluded that alcohol injection for Morton's neuroma does not offer permanent resolution of symptoms for most individuals and can be associated with complications such as immense pain at the time of injection despite local anesthetic infiltration (n=9 of 12 adverse events). Despite wide use of alcohol injection, no randomized, double blind, placebo-controlled study exists to verify the efficacy of this treatment in comparison to longstanding similar therapies such as corticosteroid injection for the treatment of Morton's neuroma.
Morgan and colleagues (2014) performed a systematic review that included the studies previously discussed and an earlier study by Dockery and colleagues (1999). The review compared the need for subsequent surgery after alcohol injections for Morton's neuroma under ultrasound guidance versus unguided injections. The authors suggested the use of ultrasound guidance for alcohol injections to treat Morton's neuroma can reduce the need for subsequent surgery compared with unguided treatments.
Pasquali and colleagues (2015) retrospectively assessed the effectiveness of ultrasound-guided alcohol injection to treat Morton's neuroma. A total of 508 individuals with 540 second or third web-space Morton's neuromas who had failed 3 months of conservative treatment (insoles and NSAIDs) were included in this study. A mean number of 3.0 (range, 1 to 4) injections were performed for each neuroma. The mean local inflammatory reaction was 0.7 (range, 0 to 2). There were no other local or systemic complications. The overall mean pre-injection VAS score was 8.7 (range, 6 to 10), while the post-injection VAS score at 1 year was 3.6 (range, 0 to 9). The delta VAS between the pre- and post-injection was statistically significant (p<0 .0001). At 1-year follow-up 74.5% of participants were satisfied with the procedure.
Success rates with corticosteroid injections for Morton's neuroma vary greatly. Marcovic and colleagues (2008) found that 26 of 39 individuals (66%) had a positive outcome at 9 months after a single ultrasound-guided cortisone injection. Complete pain relief was achieved in 11 of 39 (28%) neuromas after treatment. A total of 12 of 39 (31%) neuromas did not respond to conservative treatment and required surgery. The results of treatment suggested improvement in efficacy if injection was used early. The size of the lesion measured on ultrasound showed no correlation with pain relief after injection. Makki and colleagues (2012) prospectively compared the effectiveness of a single ultrasound-guided steroid injection in the treatment of Morton's neuroma and whether the response to injection correlated with the size of the neuroma. A total of 43 participants with clinical features of Morton's neuroma underwent ultrasound scan assessment. A single corticosteroid injection was given using 40 mg of methylprednisolone along with 1% lidocaine. Participants were divided into 2 groups on the basis of the size of the lesion measured on the scan. Group 1 included participants with neuromas of 5 mm or less and group 2 participants had neuromas larger than 5 mm. A VAS score for pain (scale 0 to 10), an American Orthopaedic Foot and Ankle Society (AOFAS) score, and a Johnson satisfaction scale were used to assess participants before injection and at 6 weeks, 6 months, and 12 months following the injection. Group 1 (lesion ≤ 5 mm) included 17 participants and group 2 (lesion > 5 mm) had 22 participants. The VAS scores, AOFAS scores, and Johnson scale improved significantly in both groups at 6 weeks (p<0.0001). At 6 months post injection, this improvement remained significant only in group 1 with all scores (p<0.001). At 12 months, there was no difference between both groups and outcome scores nearly approached preinjection scores. At the final review, 2 participants in group 1 and 4 participants in group 2 had severe recurrent symptoms and underwent surgical excision of the neuroma after they rejected the offer for a repeat injection (p=0.6). The authors concluded that the effectiveness of cortisone injection appears to be more significant and long-lasting for Morton's neuroma lesions smaller than 5 mm.
Jain and colleagues (2013) reviewed the peer-reviewed published literature of the available treatment options for Morton's neuroma, stating current nonoperative treatment strategies include shoe-wear modifications, custom made orthoses, and injections of local anesthetic agents, sclerosing agents, and steroids; however, despite a lack of high quality evidence-based research, some success was reported with use of local steroid injection, nerve decompression, and neurectomy.
In 2009 the American College of Foot and Ankle Surgeons (ACFAS) released a clinical practice guideline on the diagnosis and treatment of forefoot disorders - Morton's intermetatarsal neuroma. The guideline was retitled in 2012 as a clinical consensus statement which identifies the use of conservative care that focuses on elimination of pressure and irritation of the nerve. Other interventions include injection therapies for pain relief using local anesthetic blocks, corticosteroids and neurolytic alcohol injections. The consensus statement reports that 3 to 7 dilute alcohol injections of 4% alcohol injected at 5 to 10 day intervals has been associated with an 89% success rate with 82% of individuals achieving complete relief of symptoms. However, overuse of corticosteroid injections was cautioned as it may result in atrophy of the plantar fat pad as well as joint subluxation.
Peer Reviewed Publications:
Government Agency, Medical Society and Other Authoritative Publications:
|Websites for Additional Information|
|Reviewed||08/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion, References, and Websites for Additional Information sections. Removed ICD-9 codes from Coding section.|
|Revised||08/06/2015||MPTAC review. Format changes to the medically necessary statement. Updated Discussion, References, and Websites for Additional Information sections.|
|Reviewed||11/13/2014||MPTAC review. Updated Description, Discussion, References, and Websites for Additional Information sections.|
|Revised||11/14/2013||MPTAC review. Added not medically necessary statement to Clinical Indications. Format change to medically necessary statement and Coding section. Updated Description, References, and Websites for Additional Information sections.|
|Reviewed||11/08/2012||MPTAC review. Updated Coding, Discussion, References, Websites for Additional Information and Index.|
|Reviewed||11/17/2011||MPTAC review. Discussion and References updated.|
|Reviewed||11/18/2010||MPTAC review. References updated.|
|Reviewed||11/19/2009||MPTAC review. Discussion and References updated. Place of service removed.|
|Reviewed||11/20/2008||MPTAC review. References updated. Coding section updated to include 01/01/2009 CPT changes, removed HCPCS S2135 deleted 12/31/2008.|
|Reviewed||11/29/2007||MPTAC review. References updated.|
|Revised||12/07/2006||MPTAC revision. Deleted surgical procedures from criteria. References updated.|
|New||09/14/2006||MPTAC initial guideline development.|