The Positive Effect of Neurolysis on Diabetic Patients with Compressed Nerves of the Lower Extremities

Abstract

Background:Despite proven benefits of upper extremity nerve decompression in diabetics, neurolysis for diabetic patients with lower extremity (LE) nerve compression remains controversial.Methods:A search of ClinicalTrials.gov and Cochrane clinical trials registries, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, CINAHL, SCOPUS, and Google Scholar from 1962 to 2012, yielded 1956 citations. Any potential randomized or quasi-randomized controlled trials and observational cohort studies of diabetics with neurolysis of the common peroneal nerve, deep peroneal nerve, or tibial nerve were assessed. We included articles in any language that 1) provided information about diabetic patients who had neurolysis for symptomatic nerve compression diagnosed by (+) Tinel sign or electrodiagnostic study, and 2) quantified outcomes for pain, sensibility, or ulcerations/amputations. Case reports, review articles, animal or cadaver studies, and studies with <10 patients were excluded. We assessed pain relief, recovery of sensibility, and postoperative incidence of ulcerations/amputations at follow-up >3 months. A meta-analysis of descriptive statistics was performed.Results:Ten clinical series with a mean clinical relevance score of 70% and a mean methodologic quality score of 50% met inclusion criteria. We included 875 diabetic patients and 1053 LEs. Pain relief >3 points on visual analog scale occurred in 91% of patients; sensibility improved in 69%. Postoperative ulceration/amputation incidence was significantly reduced compared to preoperative incidence (odds ratio = 0.066, 95% confidence interval = 0.026–0.164, P < 0.0001).Conclusions:Observational data suggest that neurolysis significantly improves outcomes for diabetic patients with compressed nerves of the LE. No randomized controlled trials have been published.

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

“…Valdivia et al 47 found in a series of 200 peripheral ND surgeries that 87% of patients subjectively had increased sensation and 83% of patients report sensibility recovery post-decompression. Baltodano et al 48 report in a meta-analysis of ND studies that 91% of 875 patients (1053 lower extremities) experienced visual analog score (VAS) pain relief > 4 points. Dellon's meta-analysis 49 found that 80% of patients improved VAS pain scores from a mean of 8.5 to 2.…”

Susceptibility of Nerve in Diabetes to Compression

“…The systematic review by Baltodano et al 42 identified wound dehiscence as the commonest complication at 15% and wound infection at 6%. About 6% of patients reported worsening of symptoms, but this is a consequence of nerve regeneration after neurolysis and can be treated with neuropathic pain medication.…”

“…Postoperative ulceration/amputation incidence was significantly reduced compared with preoperative incidence (odds ratio = 0.066; 95% confidence interval, 0.026-0.164; P < 0.0001). 42 The first randomized clinical trial of this approach included patients with diabetes with advanced neuropathy who still had a positive Tinel sign over the tibial nerve in the tarsal tunnel. That study concluded that significant relief of pain can be achieved, comparing the Dellon approach done to one leg with the contralateral (nonoperated) limb serving as the control.…”

“…42 Meeting the inclusion criteria for this new review were 10 clinical series with a mean relevance score of 70% and a mean methodologic quality score of 50%. Included were 875 patients with diabetes and 1053 lower extremity surgeries.…”

Comment on Tesfaye et al. Mechanisms and Management of Diabetic Painful Distal Symmetrical Polyneuropathy. Diabetes Care 2013;36:2456–2465

“…Riazi et al (2) and others (3) have pointed out that ultrasonographic nerve enlargement is present in these neuropathy cases and might actually be used as a bedside diagnostic tool. Meta-analyses (4,5) have reviewed the favorable response of DSPN patients to nerve decompression (ND) by surgical external neurolysis at the several fibro-osseous tunnel nerve trunk entrapment sites in the lower extremity. Indications for the procedure are a painful DSPN diagnosis, failure of adequate response to pharmacologic agents, and a positive Tinel's percussion test at a lower-extremity entrapment site.…”