Diabetic Neuropathy: Is Surgery An Option?

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When it comes to patients with diabetic peripheral neuropathy (like the patient shown above), the author says there is enough evidence and basic science-based research to show compression plays a role in part of the underlying nerve pain and symptoms.
In regard to peripheral nerve surgery in diabetic patients with painful peripheral neuropathy, the author says the “outcomes can change lives” when one ensures appropriate patient selection.
Diabetic Neuropathy: Is Surgery An Option?
Diabetic Neuropathy: Is Surgery An Option?
By Babak Baravarian, DPM

Final Thoughts

   What really changed my mind about this procedure and the underlying philosophy behind diabetic neuropathy and sensation restoration is the fact that a large number of carpal tunnel and ulnar nerve transposition surgeries in the upper extremity are performed on patients with diabetes. Many of the hand surgeons I know at UCLA and in my community do not think twice about the idea of carpal tunnel surgery on a patient with diabetes, and often will state that carpal tunnel syndrome may be partly due to diabetes and its complications.

   So why shouldn’t we perform nerve decompression in the foot? I have found, both through my cases and in the literature reviews, that it is very difficult to make a properly selected patient with symptoms worse. One may not make the patient perfect but there are good to excellent outcomes in most cases. Furthermore, what is the downside as long as there are no surgical complications? In the worst case scenario, a patient will have nerve pain that he or she may have had prior to surgery.

   What is most exciting about the progress of peripheral nerve surgery is that the peripheral neuropathy fellowship group to which I belong has begun further study of the benefits of nerve release on patients with diabetes. We have started to note potential benefits that may be far more detailed than nerve pain relief.

   Some studies show the shuffling gait pattern noted in patients with diabetes may be partly due to weakness of the dorsiflexors of the foot that are controlled by the common peroneal nerve. Calf pain may also partly be related to compression of the common peroneal nerve. Increases in temperature and vasodilation to the foot have been seen with tarsal tunnel and plantar nerve release due to the possible autonomic factors noted with nerve compression. Furthermore, the lateral plantar nerve is known to be associated with innervation of the intrinsic musculature of the foot, which may be the cause of hammertoe formation. There is a possible improvement in intrinsic muscle function of the foot with lateral plantar nerve release.

   I believe we need to keep the pendulum on diabetic nerve surgery swinging without the swing going to an extreme. Many physicians in all backgrounds of medicine have shown good to excellent outcomes in their patient population. However, we need to produce detailed studies of the results and also follow these patients for five to 10 years prior to making a full conclusion.
   That said, following in the findings of many hand surgeons, there is a definite positive to helping a patient with painful debilitating neuropathy. In my experience, I have not found medications or therapy to be very effective for this condition. I believe nerve decompression surgery is a far better treatment option when one ensures appropriate patient selection in a responsible and educated manner.

Dr. Baravarian (top photo) is Co-Director of the Foot and Ankle Institute of Santa Monica. He is an Associate Professor at UCLA Medical Center and is the Chief of Podiatric Surgery at Santa Monica/UCLA Medical Center. Dr. Baravarian may be reached via e-mail at bbaravarian@mednet.ucla.edu.

Dr. Steinberg (left photo) is an Assistant Professor in the Department of Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.

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