Michael Jay, MD 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.
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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.
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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.).