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

D Scott Nickerson

doi:10.1080/2000625x.2017.1367209

Abstract

ABSTRACTExternal 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.

Highlights

The use of operative nerve decompression (ND) in treating diabetic neuropathy symptoms and complications was suggested nearly 30 years ago
Based upon animal laboratory experimentation, the author postulated that metabolic effects of diabetes mellitus (DM) caused measureable physical nerve enlargement, resulting secondarily in focal nerve trunk compressions at fibro-osseous tunnels which serve as peri-articular anatomic anchoring points
Dellon’s [4] 1992 article on clinical results of such surgical ND for 154 compressed nerves in patients with diabetic sensorimotor polyneuropathy (DSPN) reported improved motor and/or sensory function in most, while progressive deterioration continued in contralateral limbs not operated on

Summary

Introduction

The use of operative nerve decompression (ND) in treating diabetic neuropathy symptoms and complications was suggested nearly 30 years ago. (3) Surgical ND by external neurolysis can improve the signs and symptoms related to the secondary nerve entrapments and appear to significantly relieve pain and protect against DSPN foot complications. (1) In DSPN, progressive distal axonal loss occurs, as do sensory and motor signs and symptoms proximal to the anatomic entrapment sites This point, even if accurate, is not dispositive of the ND thesis. The level 1 EBM randomized control trial of Macare van Maurik et al [19] found lasting pain relief in operated limbs at 1 year, in comparison to the contralateral control limbs, which interestingly improved and is pertinent to Cornblath et al.’s [11] point 6. Gentle fingertip percussion of nerve trunks at anatomic entrapment sites is prognostic of pain relief if it produces a tingling sensation distally or proximally This positive Tinel sign is common in DSPN. System skin effects, but such results have not been published in any study

Objective outcomes

Discussion

Findings

Notes on contributor