Revision nerve surgery

Why symptoms can persist or return

• The original diagnosis was incomplete. Pain in the ball of the foot or the sole can have more than one cause, and conditions such as peripheral neuropathy or a pinched nerve in the lower back can coexist with a local nerve problem.^[1,4]
• The release was incomplete. In one series of failed tarsal tunnel releases, the main finding at revision surgery was that the tunnels further down into the sole had not been fully released.^[3]
• A painful nerve end (“stump” neuroma). After a nerve is cut — for example when a Morton’s neuroma is removed — the cut end can form a new, sensitive neuroma, particularly if it sits where it is pressed on when you walk.^[1]
• Scar tissue can tether a nerve or compress it again.
• Another nerve was injured during the original operation.

A fresh evaluation comes first

Before any further surgery, the aim is to understand exactly why the symptoms are still there:

• a detailed history of the original problem, the operation and how symptoms have changed since
• a review of previous operative reports, imaging and test results
• a careful examination: mapping numbness and sensitivity, tapping along nerves and around scars, and checking for other causes such as neuropathy, circulation problems or the lower back
• imaging, or nerve studies arranged with another specialist, when they would change the plan

Sometimes the evaluation points to non-surgical care — footwear and padding changes, desensitization therapy, or medication managed with your other clinicians — rather than another operation. See nerve pain after surgery or injury.

Revision options

Recurrent or persistent Morton’s neuroma

Revision usually means removing the nerve further back from the area that bears weight, so that the new nerve end sits away from pressure. Relocating the cut end into muscle or bone may help prevent another painful neuroma. Both top-of-foot (dorsal) and sole (plantar) incisions are used.^[1,2] In a long-term study of revision through a dorsal incision, 18 of 23 patients reported excellent or good results.^[2]

Failed tarsal tunnel release

Revision typically involves re-releasing the tibial nerve and each of its branches in their own tunnels, and dealing with scar tissue or a painful scar nerve. In one series, 78% of patients reported excellent or good results after revision, and results were poorer in people who also had lower-back disc disease or neuropathy.^[4] A smaller series reported satisfactory results in seven of eight patients.^[3]

Painful neuromas after several operations

For a painful nerve end, options include removing the neuroma and relocating the nerve end, reconstructing the nerve, or giving it a target to grow into.^[6] In a pooled analysis of published studies, when pain had lasted more than two years or several operations had already been done, relocating the nerve end or covering it with healthy tissue was more likely to help than other techniques.^[5] See also nerve repair and reconstruction.

Realistic expectations

Revision surgery is more complex than a first operation. Scar tissue makes the surgery harder, nerves that have been compressed or injured for longer may recover less completely, and the published evidence consists mainly of small case series. The goal is a meaningful improvement in pain and function; complete relief is not always possible, and it is reasonable to take time to decide.

Recovery

Recovery is often similar to, or a little slower than, recovery after the first operation: a period of elevation and protected walking, gradual return to shoes and activity over several weeks, and nerve symptoms that continue to settle over months. Desensitization therapy is often part of recovery.

Second opinions

If you still have nerve symptoms after a previous operation — whether it was done here or elsewhere — a second-opinion visit can help clarify what is going on and what the options are. Please bring your operative reports, imaging reports and any nerve-study results, or ask your previous surgeon’s office to fax them.

When to seek care

Consider an evaluation if nerve pain, burning or numbness hasn’t improved several months after nerve surgery, or if it returns after a period of improvement.