Neurosurgical prevention of ulceration and amputation by decompression of lower extremity peripheral nerves in diabetic neuropathy: update 2006

The efficacy and safety of traditional Chinese medicine physiotherapy combined with acupoint injection on diabetic peripheral neuropathy: A protocol for systematic review and meta-analysis

BACKGROUND

The efficacy and safety of traditional Chinese medicine physiotherapy combined with acupoint injection in treating diabetic peripheral neuropathy remains unknown. As a result, we will conduct a systematic review and meta-analysis to assess the evidence.

METHODS

We will look for pertinent randomized controlled trials in the following databases: China National Knowledge Infrastructure, WanFangData, Chinese biological medical database, Medline, Cochrane Library, PubMed, and Embase up to January 2022. Following the standards of Cochrane Review 6.2, 2 researchers independently evaluated the quality of the evidence in the relevant papers. Data analysis will be conducted by using Review Manager 5.4, including statistical analysis, subgroup analysis, making forest plot and funnel chart.

RESULTS

The results will be submitted to a peer-reviewed journal.

CONCLUSION

The research will verify the safety and efficacy of traditional Chinese medicine physiotherapy in combination with acupoint injection for diabetic peripheral neuropathy.

Nerve Decompression and Distal Transtibial Amputation

Approximately 20% of patients with diabetic peripheral neuropathy (DPN) endorse painful sensations such as prickling, stabbing, and burning pain that reflect small-fiber involvement. Although glycemic control is crucial to delay the onset and progression of DPN, there have been many reports on the use of decompression nerve surgery to aid in the treatment of DPN.

Evidence-based conservative limb preserving surgery for the diabetic foot complications: A systematic review of systematic reviews

BACKGROUND

Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC.

METHODS

PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies' quality.

RESULTS

22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82.

CONCLUSIONS

There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.

Value of shear wave elastography combined with the Toronto clinical scoring system in diagnosis of diabetic peripheral neuropathy

To evaluate the diagnostic values of shear wave elastography (SWE) alone and in combination with the Toronto clinical scoring system (TCSS) on diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM).The study included 41 DPN patients, 42 non-DPN patients, and 21 healthy volunteers. Conventional ultrasonography and SWE were performed on the 2 sides of the tibial nerves, and cross-sectional area (CSA) and nerve stiffness were measured. TCSS was applied to all patients. A receiver operating characteristic curve analysis was performed.The stiffness of the tibial nerve, as measured as mean, minimum or maximum elasticity, was significantly higher in patients in the DPN group than the other groups (P < .05). The tibial nerve of subjects in the non-DPN group was significantly stiffer compared to the control group (P < .05). There was no significant difference of the tibial nerve CSA among the 3 groups (P > .05). Mean elasticity of the tibial nerve with a cutoff of 71.3 kPa was the most sensitive (68.3%) and had a higher area under the curve (0.712; 0.602-0.806) among the 3 shear elasticity indices for diagnosing DPN when used alone. When combining SWE with TCSS in diagnosing DPN, the most effective parameter was the EMax, which yielded a sensitivity of 100.00% and a specificity of 95.24%.SWE is a better diagnostic tool for DPN than the conventional ultrasonic parameter CSA, and a higher diagnostic value is attained when combining SWE with TCSS.

Acute Improvement in Intraoperative EMG During Common Fibular Nerve Decompression in Patients with Symptomatic Diabetic Sensorimotor Peripheral Neuropathy: EMG and Clinical Attribute Interrelations

STUDY AIMS

 Electromyographic (EMG) recordings of the fibularis longus and tibialis anterior muscles were performed intraoperatively during nerve decompression (ND) of the common fibular nerve (CFN) in patients with symptomatic diabetic sensorimotor peripheral neuropathy. Patient demographics and clinical attributes were compared against changes in EMG after ND and analyzed for possible correlations.

METHODS

 Intraoperative changes in CFN EMG were analyzed for correlations against sex, age, body mass index (BMI), hemoglobin A1c (A1c), and type and duration of diabetes.

RESULTS

 Statistically significant changes were found between EMG changes and patient attributes, but no individual correlations were established. Significant EMG improvement was observed for both men and women (p < 0.0001 and p < 0.05, respectively), age groups (4th decade: p < 0.05; 5th decade: p < 0.05; 6th decade: p < 0.01; 7th decade: p < 0.005), diabetes duration (0-9 years: p = 0.002; 10-19 years: p = 0.002; 20-29 years: p = 0.03), and for type 1 and 2 diabetes (type 1: p < 0.005; type 2: p < 0.001). EMG improvement was greater in patients with the highest BMI levels (30-34.9: p = 0.014; 35-39.9: p = 0.013; > 39.9: p = 0.043), and highest A1c levels (> 6.4%; p < 0.0001).

CONCLUSION

 Although long-term clinical studies are needed, these results provide insight into which patients might benefit most from this surgery. These results also suggest that surgical ND can produce an acute improvement in nerve function for both men and women, for people with type 1 and 2 diabetes, and across a wide range of ages, BMI, A1c levels, and disease duration.

Shear wave elastography evaluation of the median and tibial nerve in diabetic peripheral neuropathy

Background

To evaluate the value of shear wave elastography (SWE) in the detection of diabetic peripheral neuropathy (DPN) of the median and tibial nerves.

Methods

The study included 40 DPN patients, 40 diabetic mellitus (DM) patients without DPN, and 40 healthy subjects. High-resolution ultrasonography (US) and SWE were performed on the median nerve (MN) and tibial nerve (TN), and cross-sectional area (CSA) and nerve stiffness were measured. ROC analysis was also performed.

Results

The patients with DPN demonstrated higher stiffness of the median and tibial nerve compared with that of healthy volunteers and DM patients (P<0.001). Bilateral analysis showed that there was no significant difference in nerve stiffness between the left and right median nerves and tibial nerves in DPN patients (P>0.05). The stiffness of median nerve and tibial nerve in each one side also had no significant difference in patients with DPN (P>0.05). The CSA of the tibial nerve in the DPN group was significantly larger than that in the other groups (P<0.001), while there was no significant difference of median nerve CSA among the three groups (P>0.05). The area under curve (AUC) of SWE (MN: 0.899, TN: 0.927) to diagnose DPN was significantly greater than that of CSA (TN: 0.798). The optimal cut-off value in SWE of the tibial nerve and median nerve for diagnosis of DPN was 4.11 and 4.06 m/s, respectively, with a good sensitivity and specificity.

Conclusions

Median and tibial nerve stiffness was significantly higher in patients with DPN. These findings suggest that SWE-based stiffness measurement of the nerve was a better method than CSA, and it can be used as another effective assistant method in the diagnosis of DPN.

Decompression nerve surgery for diabetic neuropathy: a structured review of published clinical trials

AIM

To assess lower extremity decompression nerve surgery (DNS) to treat the consequences of diabetic distal symmetric peripheral neuropathy (DPN).

RESEARCH DESIGN AND METHODS

MEDLINE, PubMed, and related registries were searched through December 2017 to identify randomized, quasi-randomized or observational trials that evaluated the efficacy of lower extremity DNS on pain relief (primary outcome) or other secondary outcomes. Observational studies were included, given investigators' reluctance to use sham surgery controls. Outcome effect size was estimated, and a weighted average was calculated.

RESULTS

Eight of 23 studies evaluated pain relief, including a double-blind randomized controlled trial (with a sham surgery leg), an unblinded trial with a nonsurgical control leg, and 6 observational studies. All reported substantial pain relief post-DNS with average effect sizes between two and five. Unexpectedly, the double-blind trial showed improvement in the sham leg comparable to the DNS leg and exceeding the improvement observed in the nonsurgical leg in the unblinded study. Sensory testing showed generally favorable results supporting DNS, and nerve conduction velocities increased post-DNS relative to deterioration in controls. Ultrasound revealed fusiform nerve swelling near compression sites. Morphological results of DNS were generally favorable but inconsistent, whereas hemodynamic measures showed a positive effect on arterial parameters, as did transcutaneous oximetry (improved microcirculation). The incidence of initial and recurrent neuropathic diabetic foot ulcers appeared reduced post-DNS relative to the contralateral foot (borderline significant).

CONCLUSION

The data remain insufficient to recommend DNS for painful DPN, given conflicting and unexpectedly positive results involving sham surgery relative to unblinded controls. The generally supportive sensory and nerve conduction results are compromised by methodological issues, whereas more favorable results support DNS to prevent new or recurrent neuropathic foot ulcers. Future studies need to clarify subject selection vis-à-vis DPN vs superimposed compressed nerves, utilize appropriate validated instruments, and readdress use of sham surgical controls in light of recent results.

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

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.

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration

The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current $6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of $1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of $1.296 billion (year 3) to $1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly $1 billion the annual cost of DFU treatment in the United States.

Impact of diabetes mellitus duration on effect of lower extremity nerve decompression in 1,526 diabetic peripheral neuropathy patients

BACKGROUND

Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus (DM). The aim of this study was to analyze DM duration in the prognosis of diabetic peripheral neuropathy of the lower extremity.

METHODS

A total of 1,526 DPN patients who were treated with DELLON surgical nerve decompression were divided into a short DM duration group and long DM duration group using a length of 5 years as the standard duration. Before and 1.5 years after surgery, high-resolution ultrasound, quantitative sensory testing (QST), and nerve conduction velocity (NCV) were performed and compared to the normal control.

RESULTS

Postoperative NCV of all the patients in either treatment group significantly increased (p < 0.05) and postoperative CSA significantly decreased (p < 0.05) compared with that before surgery. The CPT significantly increased compared with the preoperative value (p < 0.05). The postoperative WPT was significantly lower than the preoperative value (p < 0.01), and the postoperative VPT was significantly lower than the preoperative value (p < 0.05). Overall, the postoperative NCV, CSA, CPT, WPT, and VPT values from the short DM duration group were significantly different from that of the long DM duration group (p < 0.05).

CONCLUSIONS

The duration of DM is critical to the prognosis of DPN of the lower extremity, and the data from this study suggest that an early diagnosis and subsequent surgery for DPN have important clinical value.

Low long-term risk of foot ulcer recurrence after nerve decompression in a diabetes neuropathy cohort

BACKGROUND

Use of nerve decompression in diabetic sensorimotor polyneuropathy is a controversial treatment characterized as being of unknown scientific effectiveness owing to lack of level I scientific studies.

METHODS

Herein, long-term follow-up data have been assembled on 65 diabetic patients with 75 legs having previous neuropathic foot ulcer and subsequent operative decompression of the common peroneal and tibial nerve branches in the anatomical fibro-osseous tunnels.

RESULTS

The cohort's previously reported low recurrence risk of less than 5% annually at a mean of 2.49 years of follow-up has persisted for an additional 3 years, and cumulative risk is now 2.6% per patient-year. Nine of 75 operated legs (12%) have developed an ulcer in 4,218 months (351 patient-years) of follow-up. Of the 53 contralateral legs without decompression, 16 (30%) have ulcerated, of which three have undergone an amputation. Fifty-nine percent of patients are known to be alive with intact feet a mean of 60 months after decompression.

CONCLUSIONS

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.

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

The 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 diabetic focal entrapment neuropathy. Metabolic dysfunction related to aldose reductase, oxidative stress, and advanced glycation end products are considered and correlated to peripheral nerve enlargement and entrapment. In addition, observational studies correlated to that biological basis are presented as well as surgical outcomes illustrating the effect of decompression on DSPN symptomatic relief, nerve function, and protection against complications.

Reconsidering nerve decompression: an overlooked opportunity to limit diabetic foot ulcer recurrence and amputation

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 neuro-vascular 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.

Evaluation of the clinical efficacy of multiple lower-extremity nerve decompression in diabetic peripheral neuropathy

OBJECTIVE

To evaluate the value of high-resolution ultrasonography and neural electrophysiology in early diagnosis, operative opportunity selection, and clinical effect assessment of DPN.

METHODS

Five hundred and sixty patients with diabetic peripheral neuropathy (DPN) were treated with DELLON surgical nerve decompression in our hospital in the past 5 years. Before and after 18 months surgery, the tests of the Toronto clinical scoring system, high-resolution ultrasonography, QST, and Nerve Conduction Velocity (NCV) were evaluated in all cases. The control group included 40 diabetic patients in the same age range but without DPN.

RESULTS

Ultrasonographic images revealed an apparently normal proximal common peroneal nerve, tibial nerve marked swelling, enlarged, and hypoechogeneity with loss fascicular pattern. The cross-sectional-area, anteroposterior and transverse diameter were measured preoperative and prooperative, and the differences had statistical significance (P < 0.01). NCV-positive cases amount to 74.9% DPN patients in this study and QST-positive cases amount to 90.9% and had significant differences between them (P < 0.05). Postoperative NCV and cold perception threshold significantly increased (P < 0.05) compared with that of the before surgery. Postoperative warm perception threshold (P < 0.01) and vibration perception threshold (P < 0.05) were significantly lower than the preoperative value. NCV was positively correlated with cold perception threshold (r = 0.395, P < 0.01), and negatively correlated with warm perception threshold (r = - 0.387, P < 0.01) and vibratory perception threshold (r = - 0.367, P < 0.01). The preoperative TCSS score was 19 points for all the cases, and 420 cases (75%) improved to 10-13 points (P < 0.01).

CONCLUSION

Ultrasonography is capable of depicting these nerves morphological information, with respect to exact location, course, and extent. QST is suitable for early diagnosis of DPN, and abnormal QST is an indication of lower extremity nerve decompression for DPN. The joint use of QST and NCV testing helps surgeons to grasp the timing of surgery. High-resolution ultrasound, QST and NCV testing can also be used as an outcome index for surgical treatment.

Touch pressure and sensory density after tarsal tunnel release in diabetic neuropathy

BACKGROUND

Limited quantitative information is available about the improvement of protective sensation after tarsal tunnel release in patients with diabetic peripheral neuropathy.

METHODS

Prospective, non-blinded, non-randomized case series of 10 feet in 8 diabetic patients and 24 feet in 22 non-diabetic patients who had tarsal tunnel release. Preoperative and postoperative (average, 8-9 months) anatomic, quantitative sensory testing was done with touch pressure 1-point threshold (Semmes-Weinstein monofilaments) and 2-point discrimination.

RESULTS

There was marked, significant postoperative improvement of mean touch pressure 1-point threshold, compared with preoperative values, for medial calcaneal, medial plantar, and lateral plantar nerves in both non-diabetic and diabetic patients. There was minimal improvement in 2-point discrimination only for the medial calcaneal nerve in non-diabetic, but not in diabetic, patients.

CONCLUSIONS

Nerve entrapment at the tarsal tunnel is an important component of diabetic peripheral neuropathy. Tarsal tunnel decompression may improve sensory impairment and restore protective sensation.

Role of neuropeptides in skin inflammation and its involvement in diabetic wound healing

IMPORTANCE OF THE FIELD

In 2010, the world prevalence of diabetes is 6.4%, affecting 285 million adults. Diabetic patients are at risk of developing neuropathy and delayed wound healing that can culminate in incurable diabetic foot ulcerations (DFUs) or even foot amputation.

AREAS COVERED IN THIS REVIEW

The contrast between cellular and molecular events of wound healing and diabetic wound healing processes is characterized. Neuropeptides released from the autonomous nervous system and skin cells reveal a major role in the immunity of wound healing. Therefore, the signaling pathways that induce pro/anti-inflammatory cytokines expression and its involvement in diabetic wound healing are discussed. The involvement of neuropeptides in the activation, growth, migration and maturation of skin cells, like keratinocytes, Langerhans cells, macrophages and mast cells, are described.

WHAT THE READER WILL GAIN

This review attempts to address the role of neuropeptides in skin inflammation, focusing on signal transduction, inflammatory mediators and pro/anti-inflammatory function, occurring in each cell type, as well as, its connection with diabetic wound healing.

TAKE HOME MESSAGE

Understanding the role of neuropeptides in the skin, their application on skin wounds could be a potential therapy for skin pathologies, like the problematic and prevalent DFUs.

What's new in the diagnosis and treatment of peripheral nerve entrapment neuropathies

Entrapment neuropathies can be common conditions with the potential to cause significant disability. Correct diagnosis is essential for proper management. This article is a review of recent developments related to diagnosis and treatment of various common and uncommon nerve entrapment disorders. When combined with classical peripheral nerve examination techniques, innovations in imaging modalities have led to more reliable diagnoses. Moreover, innovations in conservative and surgical techniques have been controversial as to their effects on patient outcome, but randomized controlled trials have provided important information regarding common operative techniques. Treatment strategies for painful peripheral neuropathies are also reviewed.

Early stage diabetic Charcot Foot syndrome may respond to nerve decompression

Diabetic Charcot Foot syndrome has been postulated to require a triggering event to initiate its puzzling inflammatory process, characterized by bony resorption, pathologic fractures, soft tissue ligamentous failure, and destruction of foot architecture. Two cases are presented where multiple lower extremity nerve decompression was performed early in the Charcot process. Resolution of clinical signs and radiographic abnormalities rapidly followed. The observation that these events were temporally concurrent suggests that nerve entrapment might reasonably be investigated as one of the postulated triggering events for the Charcot Foot in diabetes. (c) 2009 Wiley-Liss, Inc. Microsurgery 2009.

Painful diabetic neuropathy

The podiatric physician often encounters complex painful neuropathies in daily practice. Diabetic neuropathy is one form of chronic neuropathic pain dealt with on a regular basis. The goal of this article is to review the pathophysiology, diagnosis, and treatment options of this complaint. Medical and surgical interventions are discussed, with a clinical emphasis on patient selection and prevention.