Surgical decompression of lower-extremity nerves of high-risk feet at fibro-osseous anatomical tunnels was followed by a low annual incidence of ulcer recurrence. This objective outcome measure suggests benefits of nerve decompression in diabetic neuropathy, as have previous reports using pain and sensory change as subjective measures. Unrecognized nerve entrapment may frequently coexist with diabetic sensorimotor peripheral neuropathy in patients with diabetic foot ulcer.
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 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.
Electromyographic (EMG) recordings of the fibularis longus (FL) and tibialis anterior (TA) muscles were performed intraoperatively during common fibular nerve (CFN) nerve decompression (ND) in patients with symptomatic diabetic sensorimotor peripheral neuropathy (DSPN) and clinical nerve compression. Forty-six legs in 40 patients underwent surgical ND by external neurolysis; FL and TA muscles were monitored intraoperatively. Evoked EMGs were recorded just prior to and within 1 minute after ND. Thirty-eight legs (82.6%) demonstrated EMG improvement 1 minute after ND. Sixty muscles (31 FL, 29 TA) were monitored, with 44 (73.3%) improving in EMG amplitude. Mean change in EMG amplitude represented a 73.6% improvement ( < 0.0001). Changes in EMG amplitudes correlated with visual analog scale pain improvement ( = 0.03). This is the first report of acute changes in objective EMG responses during ND of CFN in DSPN patients and demonstrates that patients with symptomatic DSPN and clinical nerve entrapment have latent but functional axons that surgical ND can improve immediately.
The most recent (2011) National Diabetes Fact Sheet states the tally of diagnosed and undiagnosed diabetes cases in the United States is approaching 25 million, and another 79 million are prediabetic. Of the diabetes patients, 60-70% suffer from mild to severe neuropathy.1 This combined loss of sensory and motor control in diabetic limbs is usually considered an irreversible, progressive process. Patients suffering from these losses are at significantly higher risk for development of foot ulceration, frequently leading to infection, and minor or major limb amputation. 2-8However, a review of surgical decompression literature addressing focal nerve entrapment suggests that several diabetic sensorimotor polyneuropathy (DSPN) symptoms and complications are potentially partially reversible or preventable. The following review surveys current research regarding the biological basis for diabetic focal entrapment neuropathy, observational studies correlated to that biological basis, and the clinical rationale and outcomes related to nerve decompression (ND) surgery. BackgroundIt is important to note that diabetic neuropathies are heterogeneous disorders. This discussion is focused on the somatic subset described as distal symmetric peripheral polyneuropathy, classically known as "stocking-glove anesthesia." Determinants affecting the rate of development and ultimate severity of the neuropathy include: duration of diabetes and adequacy of glucose control, 9 a conclusion morphologically confirmed by Perkins et al. 10 Two separate types of focal neuropathies are recognized: mononeuropathies and entrapment.11 Mononeuropathies are felt to be the consequence of vascular injury, and are said to resolve with only supportive care management. Entrapment neuropathies (the focus of this discussion) are said to occur in up to 30% of all diabetic neuropathy 12 and are postulated to occur as the result of a "double crush" phenomena. AbstractThe most recent (2011) National Diabetes Fact Sheet states the combined diagnosed and undiagnosed number of diabetes cases in the United States is approaching 25 million, and another 79 million are prediabetic. Of the diabetes patients, 60-70% suffer from mild to severe neuropathy. This combined loss of sensory and motor control in diabetic limbs is usually considered an irreversible, progressive process. Patients suffering from these losses are at a significantly higher risk for development of foot ulceration, frequently leading to infection and partial or major limb amputation. However, a review of focal nerve entrapment surgical decompression literature suggests that several diabetic sensorimotor polyneuropathy (DSPN) symptoms and complications are potentially partially reversible or preventable. Decompression surgery represents a paradigm shift in treatment protocols because it both relieves pain and restores protective sensation, while providing significant protection against a cascade of serious foot complications. This review surveys current research regarding the biological basis for...
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