Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence

Nickerson, D. Scott; Rader, Andrew J.

doi:10.7547/0003-0538-104.1.66

Cited by 27 publications

(30 citation statements)

References 13 publications

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“…A 3 year prospective study of unilateral ND after DFU finds the non-operated intact legs to have 5.5 times the risk of ulceration. 56 Zhang et al 35 reinforce these findings in their prospective study that included 208 prior ulcer DSPN patients who underwent bilateral decompression, reporting that no patient had new ulcers, reulceration, wound infections, or amputation in an 18 month follow-up.…”

Section: Clinical Resultsmentioning

confidence: 84%

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

Sessions

Nickerson

2014

J Diabetes Sci Technol

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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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Section: Clinical Resultsmentioning

confidence: 84%

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

Sessions

Nickerson

2014

J Diabetes Sci Technol

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“…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].…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

Section: The Skeptics Casementioning

confidence: 99%

“…Nerve decompression appears to reduce the documented 25–30% annual DFU recurrence risk [51] by 80% or more [17,22–26], Figure 3 demonstrates one report. Trignano et al [52] reported 100% healing and 0/8 recurrences of neuro-ischemic DFU at 18 months after ND.

Figure 3.A Kaplan Meier survival curve illustrates the ulcer-free survival of 42 cases with prior healed unilateral DFU and subsequent ND of that leg only.…”

Section: Objective Outcomesmentioning

confidence: 99%

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

Nickerson¹

2017

Diabetic Foot & Ankle

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External neurolysis of the nerve at fibro-osseous tunnels has been proprosed to treat or prevent signs, symptoms, and complications in the lower extremity of diabetes patients with sensorimotor polyneuropathy. Nerve decompression is justified in the presence of symptomatic compressed nerves in the several fibro-osseous tunnels of the extremities, which are known to be frequent in diabetes. Quite a body of literature has accumulated reporting results after such nerve decompression in the leg, describing pain relief and sensibility improvement, as well as balance recovery, diabetic foot ulcer prevention, curtailed ulcer recurrence risk, and amputation avoidance.Historical academic hesitance to endorse surgical treatments for pain and numbness in diabetes was based primarily on the early retrospective reports’ potential for bias and placebo effects, and that the hypothetical basis for surgery lies outside the traditional etiology paradigm of length-dependent axonopathy. This reticence is here critiqued in view of recent studies using objective, measured outcome protocols which nullify such potential confounders. Pain relief is now confirmed with Level 1 studies, and Level 2 prospective information suggests protection from initial diabetic foot ulceration and most neuropathic ulcer recurrences. In view of the potential for nerve decompression to be useful in addressing some of the more difficult, expensive, and life altering complications of diabetic neuropathy, this secondary compression thesis and operative treatment methodology may deserve reassessment.

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“…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.…”

Section: The Entrapment Hypothesismentioning

confidence: 99%

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

Nickerson

2013

J Diabetes Sci Technol

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Nerve decompression for relief of subjective diabetic sensorimotor polyneuropathy pain and numbness has been labeled of "unknown" benefit. Objective outcomes in treatment and prevention of diabetic foot complications are reviewed. There is growing evidence that plantar foot ulceration and recurrence in high-risk feet are minimized with this operation. Avoiding neuropathic and neuroischemic ulcer wounds should theoretically reduce amputations and perhaps mortality risk. Protective effects are hypothesized to act via relief of neurovascular entrapment, thereby improving neurally modulated tissue homeostasis factors. Nerve decompression deserves considerable research attention to understand its role in limiting foot complications. Its apparent benefits challenge the paradigm that diabetic neuropathy is a purely length-dependent axonopathy and may necessitate appreciation of superimposed nerve entrapment as an significant operant factor.

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Nerve Decompression After Diabetic Foot Ulceration May Protect Against Recurrence

Cited by 27 publications

References 13 publications

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

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

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

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

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