Changing the Natural History of Diabetic Neuropathy: Incidence of Ulcer/Amputation in the Contralateral Limb of Patients With a Unilateral Nerve Decompression Procedure

Abstract

The natural history of diabetes neuropathy is progressive and irreversible loss of sensibility in the feet, leading to ulceration and/or amputation in 15% of patients. The prevalence of neuropathy is more than 50% in those who have been diabetic for 20 years. Decompression of the tibial and peroneal nerves in those with diabetic neuropathy improves sensation in 70% of patients. The impact of this surgery on the development of ulcers and amputations in both the operated and the contralateral, nonoperated limb was evaluated in a retrospective analysis of 50 patients with diabetes a mean of 4.5 years (range, 2-7 years) from the date of surgery. No ulcers or amputations occurred in the index limb of these patients. In contrast, there were 12 ulcers and 3 amputations in 15 different patients in contralateral limbs. This difference was significant at P < 0.001. It is concluded that decompression of lower extremity nerves in diabetic neuropathy changes the natural history of this disease, representing a paradigm shift in health care costs.

Nerve decompression and neuropathy complications in diabetes: Are attitudes discordant with evidence?

“…Each and every complication event in 50 subjects occurred in the contralateral, non-operated leg ( p  = 0.001). At least six studies have confirmed ND can provide significant, although not total protection against DFU and recurrence [17,21–25]. Studies also exist using as outcomes perineural tissue pressure [18], transcutaneous oxygen pressures [37], and measured balance [56,72].…”

“…Immediate pain relief in the recovery suite, bilateral pain improvement after unilateral surgery, and 80–92% of patients reporting relief were too astounding to believe, and no hypothesis for such an unexpected finding was proferred [17,21–25]. Not dispositive.…”

“…Protection against primary diabetic foot ulcer (DFU) and amputation in the medium term has been demonstrated with ND for advanced DSPN [21,25,33]. …”

Biologic Basis of Nerve Decompression Surgery for Focal Entrapments in Diabetic Peripheral Neuropathy

“…In a landmark multicenter prospective registry study of 628 patients (839 operated limbs) and 38 surgeons performing neurolysis of chronically compressed tibial nerves, Dellon et al 53 report that 0.2% of patients with no previous ulceration history developed new ulcers, 3.8% of patients with a past ulceration had recurrent ulcerations, and 1 patient underwent amputation. Aszmann et al 54 reported that 50 DSPN cases who had unilateral ND for pain relief subsequently had 3 amputations and 12 ulcers in 4.5 years, all in the contralateral leg that had not been operated. Nickerson and Rader 55 describe retrospectively a durable 80% reduction in diabetic foot ulceration (DFU) recurrence risk lasting at least 5 years.…”

Reconsidering Nerve Decompression: An Overlooked Opportunity to Limit Diabetic Foot Ulcer Recurrence and Amputation

“…2,30,31 Objective outcome studies and prospective or randomized controlled trial protocols now report beneficial ND effects on balance, tunnel tissue pressures, ulceration risk, DFU recurrence risk, and electrophysiological parameters, as Figure 2 shows. [32][33][34][35][36][37][38][39] These often include and correlate common subjective measures of DSPN symptoms and signs. Aszmann and coauthors 32 first published the unanticipated finding that every ulceration and amputation in 50 DSPN cases that had unilateral ND surgeries for leg pain occurred in the contralateral, nonoperated legs.…”