Diabetic Neuropathy: Is Surgery An Option?
As we evolve in our treatment of foot and ankle conditions, it seems like each treatment meets with some reservation from the medical community. As podiatric physicians, our mindset is scientific in nature and we need hard facts and evidence-based results to show each treatment option is beneficial. I am with the mainstream in that thinking but I also try to rationalize a treatment option and see why it may or may not benefit a patient.
To that extent, there has been a great deal of interest in treatment options for diabetic neuropathy. A. Lee Dellon, MD, a peripheral nerve plastic surgeon from Johns Hopkins University in Baltimore, first advanced the idea of surgical nerve decompression. He originally was a hand surgeon and many of his patients were diabetic. These patients expressed an interest in treating their painful feet similar to how Dr. Dellon treated their hands. Dr. Dellon has dedicated the past 20 years or so to treating peripheral nerve conditions and has made significant inroads in the surgical treatment of peripheral neuropathy conditions.
With time, Dr. Dellon has also developed a nerve testing machine that allows for the quantitative analysis and diagnosis of peripheral nerve entrapments. One would employ this machine in the workup and postoperative re-evaluation of peripheral nerve surgery in the lower extremity. About 200 doctors of all surgical backgrounds are now performing peripheral nerve releases in the foot and leg around the world. The background of these surgeons ranges from podiatry and orthopedics to plastic surgery and neurosurgery.
What Research Reveals About The Etiology Of Diabetic Neuropathy
There is extensive research on the potential causes of diabetic neuropathy. Many of these animal studies examined streptozotocin injections. Many of the studies noted there was increased intraneural edema from sorbitol infiltration as well as increased fibrosis surrounding the nerve and involving the ligamentous retinaculum at sites of potential compression. Tightness and stiffness of the retinaculum and edema of the nerves have been noted to cause a decrease in axoplasmic flow and eventual vascular damage to the nerve, resulting in axonal degeneration and the dropout of nerve fibers. Researchers have also noted the compression may be the potential cause of pain, axonal degeneration and sensation loss.
Although one must consider metabolic issues in the cause of diabetic neuropathy, several studies have compared regions of potential nerve compression to normal nerve regions in patients with diabetes. These comparisons show a dramatic difference in the quality and damage noted to the nerve. While we are essentially still learning the overall causes of nerve pain and neuropathy in patients with diabetes, there is enough evidence and basic science-based research to show compression plays a role in part of the underlying pain and symptoms.
Understanding The Essential Elements Of Peripheral Nerve Surgery
One would perform this surgery with the patient under sedation or a general anesthesia with a local nerve block as a possible option. The outpatient procedure lasts about one and one-half to two hours.