This article originally posted 10 August, 2004 and appeared in Issue 220
Surgical Decompression and Diabetes Neuropathy.
Michael Jay, MD
Advertisement
The role of surgical decompression in treatment of the symptoms of diabetic
neuropathy has been reviewed this past month in an article in Foot and Ankle
Clinics of North America. The article, written by Kent Biddinger, MD, and Orthopedic
Foot and Ankle Surgeon from Midland, Michigan, and his research associate Keri
Amend, MA.
(Biddinger, K., Amend, K.A.,
The role of surgical decompression for diabetic neuropathy, Foot & Ankle
Clinics N. Amer, 9:239-254, 2004) reviews the entire subject of the susceptibility
of diabetic nerves to compression, and the possibilities that surgical decompression
of the lower extremity nerves at the knee, the ankle, and the foot level can
relieve pain and restore sensation to diabetics with symptomatic neuropathy.
These concepts that offer a new optimism (Dellon AL: Optimism in diabetic neuropathy.
Ann Plast Surg 20:103-105, 1988) for diabetics are the logical extension of
the pioneering basic science and clinical work done by A. Lee Dellon, MD, Director
of the Dellon Institutes for Peripheral Nerve Surgery http://www.dellonipns.com
The peripheral nerve in the diabetic is susceptible to compression due to its
1) increased endoneurial water content from conversion of glucose to sorbitol
by aldose reductase, 2) decreased anterograde component of the slow axoplasmic
transport, and 3) stiffness of the nerve due to glycosylation of collagen within
the nerve. At known sites of anatomic narrowing in the lower extremity, analogous
to carpal tunnel syndrome in the upper extremity, nerves can become entrapped;
the common peroneal nerve at the knee, the deep peroneal nerve over the dorsum
of the foot , and tibial nerve in the four medial ankle tunnels. Dellon first
realized that the tightness along the tibial nerve was distal to the traditional
tarsal tunnel, and emphasized the need to decompress the medial and lateral
plantar as well as the calcaneal tunnels.
In his review, Biddinger concludes that previous surgeons who reported their
own personal series each came to the same conclusion, that applying Dellon's
method of decompression could restore sensation and relieve pain in the diabetic
with symptoms of neuropathy. The results of the published peer-reviewed papers
on this subject have been tabulated below, including the results of Biddinger’s
first series of patients. The references are appended.
Biddinger and Amend concluded that
“the literature supports the belief that classic stocking glove diabetic
neuropathy is caused by a combination of metabolic changes, axonal ischemic,
and mechanical compression. Previous published articles showed that when properly
selected, surgical releases can decrease pain and improve sensation. When specific
surgical criteria were used is selecting (our) patients, 80% of the patients
and 88% of the legs had successful surgical outcomes. The preoperative selection
criteria are: 1) diabetes as the only known cause of neuropathy, 2) medical
and vascular stability, 3) signs of axonal damage (widening two-point discrimination),
and 4) presence of a Tinel’s sign over known areas of compression.”
The measurement technique that Biddinger and Amend used to document the presence
of neuropathy and stage the degree of neuropathy was the Pressure-Specified
Sensory Device? (sensorymanagement.com). This is a painless, non-invasive, computer-linked
device that measures the cutaneous pressure threshold by applying paired tactile
stimuli at discrete skin areas related to specific peripheral nerves. When a
symmetric pattern of sensory loss is present for both the tibial and peroneal
nerves, and axonal loss is documented (two-point static touch is > 99% confidence
limit for age), then the sufficient degree of neuropathy is present to consider
peripheral nerve decompression. The presence of a positive Tinel sign at the
site of known anatomic narrowing identifies the superimposed nerve compression
in the presence of the underlying neuropathy. This cannot be determined reliably
with traditional electrodiagnostic testing (Perkins,B.A.,
Based on the Data presented here, I would recommend we investigate the value
of decompression surgery for our patients.
1. Dellon AL: Treatment of symptoms of diabetic neuropathy by
peripheral nerve decompression. Plast Reconstr Surg 89:689-697, 1992.
2. Wieman, T.J., Patel, V.G., Treatment of hyperesthetic neuropathic
pain in diabetics; decompression of the tarsal tunnel. Ann Surg, 221:660-665,
1995. (University of Kentucky, Louisville, Kentucky, General Surgery)
3. Chafee, H., Decompression of peripheral nerves for diabetic
neuropathy, Plast Reconstr Surg, 106:813-815,2000.
4. Aszmann, O.A., Kress, K.M., Dellon, A.L., Results of decompression
of peripheral nerves in diabetics: a prospective, blinded study, Plast Reconstr
Surg, 106;816-821, 2000.
5. Wood, W.A., Wood, M.A., Decompression of peripheral nerve for diabetic neuropathy
in the lower extremity, J Foot & Ankle Surg, 42: 268-275, 2003.
6. Biddinger, K., Amend, K.A., The role of surgical decompression
for diabetic neuropathy, Foot & Ankle Clinics N. Amer, 9:239-254, 2004.
7. Olaleye, D., Bril, V., Carpal tunnel syndrome in patients
with diabetic neuropathy, Diabetes Care, 2002;25:565-574.).
DISCLAIMER: The content of this Website is independent of the views of our advertisers and sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.
Copyright @ 1999-2012 Diabetes In Control, Inc.. All rights reserved.
Entries (RSS News)
