Neuroma di Morton

Il Neuroma di Morton è una patologia provocata dall’irritazione meccanica della guaina del Nervo Comune Digitale (NCD) nel suo passaggio tra le ossa lunghe del metatarso dell’avampiede. Interessa i nervi comuni digitali del piede , nervi sensitivi che compongo la parte terminale del nervo sciatico. Istologicamente è dato da un ispessimento del tessuto connettivo perineurale comunemente chiamata guaina del nervo. Non si ha proliferazione nervosa ne alcun specifico processo infiammatorio. Perciò il Neuroma di Morton non è un processo neoplastico tumorale.

L’ispessimento della guaina del nervo (sclerosi del perinervio) comprime le fibre nervose sensitive sottostanti. Questo nel tempo innesca una alterazione vascolare endoneurale con ischemia locale e successiva demielinizzazione e degenerazione delle fibre nervose stesse provocando cosi un danno permanente del nervo.

Il NCD nasce dalle divisioni terminali dei rami plantari del Nervo Tibiale posteriore, coda finale del nervo sciatico. Ogni spazio intermetatarsale (IM – lo spazio tra le ossa lunghe dell’avampiede) ha il suo NCD. Il nervo termina con due rami digitali propri che corrono sui lati delle dita del piede per terminare a livello dell’unghia. E’ un nervo sensitivo quindi da informazione sull’ambiente che lo circonda. Non da ordini diretti ai muscoli del piede.

Le cause che provocano l’insorgenza di un Neuroma di Morton sono varie: eventi traumatici, l’uso di calzature che aumentano la compressione laterale dell’avampiede (tacchi alti, scarpe sportive, scarpe anti infortunistiche). Sembra che ci sia una certa predisposizione anatomica che favorisce questa compressione.
Le cause che possono creare una irritazione meccanica del NCD si possono raggruppare in 3 gruppi:
1. alterazione congenite della posizione delle ossa dell’avampiede che creano un spazio IM stretto
2. eventi traumatici diretti sul nervo o indiretti riducendo lo spazio IM
3. alterazioni anatomiche del nervo stesso che lo rendono più vincolato nei tessuti

Lo spazio più interessato e il 3° (70-80% dei casi) seguito poi dal 2° (15-20%) e in fine dal 4° e 1° (5%). Si può presenta poi nel tempo in entrambi i piede (20-25% dei casi) proprio per la predisposizione anatomica spesso rilevato come causa. Raramente interessa più di un spazio IM nello stesso piede (3-5%).

La sintomatologia con cui si presenta è quella tipica del nervo sensitivo:
• dolore acuto improvviso intenso che si avverte anche nello stomaco con l’impulso di rimuovere la calzatura il più presto possibile (che fa scomparire il dolore in pochi minuti)
• bruciore profondo che sale verso la caviglia o le dita stesse (spesso coinvolgendo l’unghia del dito innervato)
• scosse locali e irradiate anche a riposo e notturne
• formicolio e crampi notturni
• sensazione di gonfiore che non viene confermato con il tatto.
• Insensibilità alle dita coinvolte con la sensazione di un piede fatto di legno.
• Difficoltà nel tempo nel localizzare il punto dove insorge il dolore.

IMAGING
La diagnosi di Neuroma di Morton è clinica ma occorre di essere confermata dagli esami strumentali in grado di visualizzare il neuroma quando di dimensioni e morfologia apprezzabili (circa dai 2 mm) e necessari comunque per escludere altre patologie che possono dare una sintomatologia simile . Un segno clinico spesso rilevato è il cosi detto “click di Mulder” ma anche questo segno può essere negativo nelle forme con crescita concentrica.

L’ecotomografia viene spesso impiegata in prima istanza come indagine strumentale; in generale la capacità di visualizzazione del neuroma dipende dalle sue dimensioni ma soprattutto dalla capacità del radiologo, in quanto metodica operatore dipendente, in relazione comunque alle capacità diagnostiche dell’apparecchiatura utilizzata e nello specifico dalla sonda superficiale, che dovrebbe almeno lavorare ad una frequenza di 10MhZ.

La Risonanza Magnetica mostra una accuratezza diagnostica elevata per questa patologia con una specificità e sensibilità rispettivamente del 100 e 87%. Come per l’ecografia permette il riconoscimento della sede e delle dimensioni del neuroma a livello della porzione plantare dello spazio intercapito-metatarsale, a contatto con il legamento metatarsale trasverso.Determinare la grandezza del neuroma è importante per la successiva fase terapeutica: Ma l’indicazione elettiva ad eseguire la RM nel sospetto di questa patologia è la panoramicità della metodica che consente di escludere eventuali diverse o concomitanti patologie presenti a livello del mesopiede ed avampiede.

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