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- Author or Editor: Andrew J. Rader x
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Peripheral neuropathy can be a devastating complication of diabetes mellitus. This article describes surgical decompression as a means of restoring sensation and relieving painful neuropathy symptoms. A prospective study was performed involving patients diagnosed as having type 1 or type 2 diabetes with lower-extremity peripheral neuropathy. The neuropathy diagnosis was confirmed using quantitative sensory testing. Visual analog scales were used for subjective assessment before and after surgery. Treatment consisted of external and as-needed internal neurolysis of the common peroneal, deep peroneal, tibial, medial plantar, lateral plantar, and calcaneal nerves. Subjective pain perception and objective sensibility were significantly improved in most patients who underwent the described decompression. Surgical decompression of multiple peripheral nerves in the lower extremities is a valid and effective method of providing symptomatic relief of neuropathy pain and restoring sensation. (J Am Podiatr Med Assoc 95(5): 446–450, 2005)
Background: Charcot neuroarthropathy (CN) is a devastating complication of some diseases affecting the peripheral nervous system. Initial subjective and objective presentation of the disease can be variable. Common among all presentations seems to be uncontrolled inflammation yielding dislocations and/or fractures. The exact cause remains the subject of much debate.
Methods: Our study retrospectively looks at the function of olfactory function in consecutive patients with CN and compares the findings with a nonaffected population. The University of Pennsylvania Smell Identification Test was used to assess olfaction and document microsomia.
Results: Twenty consecutive patients presenting with CN demonstrated significant (P < .0001) microsomia when compared to an unaffected population with diabetes.
Conclusions: Microsomia is strongly associated with CN. This finding may be correlated to voltage-gated sodium 1.7 channel impairment and appears to be a candidate precursor for the development of CN.
Background:
Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies.
Methods:
Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels.
Results:
The cohort’s previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression.
Conclusions:
The prospective, objective, statistically significant finding of a large, long-term diminution of diabetic foot ulcer recurrence risk after operative nerve decompression compares very favorably with the historical literature and the contralateral legs of this cohort, which had no decompression. This finding invites prospective randomized controlled studies for validation testing and reconsideration of the frequency and contribution of unrecognized nerve entrapments in diabetic sensorimotor polyneuropathy and diabetic foot complications. (J Am Podiatr Med Assoc 103(5): 380–386, 2013)
Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence
A 3-Year Controlled, Prospective Analysis
Background
Nerve entrapment, common in diabetes, is considered an associated phenomenon without large consequence in the development of diabetes complications such as ulceration, infection, amputation, and early mortality. This prospective analysis, with controls, of the ulcer recurrence rate after operative nerve decompression (ND) offers an objective perspective on the possibility of frequent occult nerve entrapment in the diabetic foot complication cascade.
Methods
A multicenter cohort of 42 patients with diabetic sensorimotor polyneuropathy, failed pharmacologic pain control, palpable pulses, and at least one positive Tinel's nerve percussion sign was treated with unilateral multiple lower-leg external neurolyses for the indication of pain. All of the patients had healed at least one previous ipsilateral plantar diabetic foot ulceration (DFU). This group was retrospectively evaluated a minimum of 12 months after operative ND and again 3 years later. The recurrence risk of ipsilateral DFU in that period was prospectively analyzed and compared with new ulcer occurrence in the contralateral intact, nonoperated control legs.
Results
Operated legs developed two ulcer recurrences (4.8%), and nine contralateral control legs developed ulcers (21.4%), requiring three amputations. Ulcer risk is 1.6% per patient per year in ND legs and 7% in nonoperated control legs (P = .048).
Conclusions
Adding operative ND at lower-leg fibro-osseous tunnels to standard postulcer treatment resulted in a significantly diminished rate of subsequent DFU in neuropathic high-risk feet. This is prospective, objective evidence that ND can provide valuable ongoing protection from DFU recurrence, even years after primary ulcer healing.
The soleal sling may be a site of tibial nerve entrapment. Objective diagnosis of this syndrome is difficult with current nerve conduction study techniques, magnetic resonance imaging, and neurosensory testing. Diagnostic ultrasound is ideally suited to visualize the tibial nerve statically and dynamically as it enters the soleal sling, thus making an objective diagnosis of soleal sling impingement much easier.
