When Patients With Diabetes Have Lower Extremity Nerve Entrapments
A Closer Look At Surgical Decompression For DPN
Surgeons affiliated with Johns Hopkins University have been operating on DPN for almost 20 years. A. Lee Dellon, MD, the pioneer of this work, first published his results in 1992.5 However, Dellon’s work is still received skeptically by many within the medical community. The American Association of Neurology cannot recommend this procedure because there are not enough studies.6 Yet the American Association of Neurology has no problem having patients undergo carpal tunnel, cubital tunnel or radial sensory releases. The bottom line is many patients with diabetes and neuropathy probably have superimposed nerve entrapments in both the upper and lower extremity. The surgery to decompress peripheral nerves is fairly easy as it involves only soft tissue releases. The most common procedure involves release of the common peroneal nerve at the fibular head, the deep peroneal on the dorsum of the foot, and the tibial nerve and its branches in the tarsal tunnel. Most patients are going to tolerate the procedure very well. Many will have improved sensation and decreased pain while they are still in the recovery room. Although this procedure is fairly easy to perform, about 300 surgeons from all backgrounds are performing this “triple” decompression. It is strongly recommended that one should learn the procedure from someone trained at the Peripheral Nerve Institute at Union Memorial Hospital in Baltimore. The institute also offers an intense workshop with cadaver surgery and observation of live procedures.
Can The Procedure Have An Impact?
We see patients every day with various levels of neuropathy. In the past, we have been told it is a progressive disease that we can only treat by controlling the underlying cause and providing a battery of pain relievers (anticonvulsants, etc.). No one disagrees on treating the underlying cause. However, with few exceptions, we have watched those patients go on a downward spiral. For 18 years now, I have been treating lower extremity complications in patients with diabetes and watch patients with neuropathy go from having a little numbness and tingling to developing ulcers, nasty infections, Charcot, amputations, etc. In 1999, there were 92,000 amputations directly linked to DPN in comparison to 54,000 in 1990.7 The cost alone of these complications is staggering. I wish I could go back and reevaluate those patients, and see how many had nerve entrapments that could have been treated before the problems became irreversible. It is true there are not any very large, double-blinded studies on the surgical treatment of DPN. One interesting study in the Annals of Plastic Surgery in 2004 retrospectively looked at 50 patients who only underwent surgery on one limb. With an average follow up of 4.7 years, researchers found none of these limbs developed ulcers or were subject to amputations. The nonoperative limbs had 12 ulcers and three amputations, according to the study.8