The Dellon Approach to Neurolysis in the Neuropathy Patient with Chronic Nerve Compression

Abstract

Impaired glucose tolerance creates a peripheral nervous system that is susceptible to chronic nerve compression. While it is accepted that surgical decompression of the median nerve at the wrist, for carpal tunnel syndrome, is appropriate in the diabetic, application of this concept to the lower extremity has not yet gained widespread recognition. Traditional electrodiagnostic studies demonstrate the presence of neuropathy, but usually are much less able to demonstrate superimposed nerve compression in the lower extremity in the presence of neuropathy. The clinician must rely upon the presence of a positive Hoffmann-Tinel sign to identify the patient with diabetic neuropathy and nerve compression. Combining sensory territories of common peroneal and tibial nerves gives a stocking pattern of sensory impairment. A positive Hoffmann-Tinel sign over the tibial nerve in the tarsal tunnel has a 90 % positive predictive value for the diabetic patient to recover sensibility in the foot after decompression of the four medial ankle tunnels. A meta-analysis of clinical studies that have decompressed the tibial nerve branches at the ankle in diabetics with neuropathy and tibial nerve compression demonstrate pain relief in 80 % of the patients from a mean of 8.5 on the VAS to 2.0, and demonstrate 80 % of the patients recover more than just protective sensation. With sensibility partially restored, ulceration and subsequent amputation can be prevented. Balance can recover, and with it, morbidity from falls/fracture can be prevented. Hospitalization for foot infection can be reduced. This review includes description of the surgical approaches to accomplish these outcomes.

Zusammenfassung

Eine gestörte Glukosetoleranz im Stoffwechsel von Patienten bewirkt eine höhere Anfälligkeit peripherer Nerven für Kompressionssyndrome. An der oberen Extremität ist die Behandlung des Karpaltunnelsyndroms (KTS) durch operative Dekompression des N. medianus bei Patienten mit Diabetes mellitus als effektive Behandlungsmaßnahme anerkannt. Die Behandlung von Kompressionssyndromen an der unteren Extremität bei Patienten mit Diabetes mellitus hat dagegen bisher wenig Beachtung gefunden. Herkömmliche elektrophysiologische Untersuchungsverfahren können an der unteren Extremität zwar eine Neuropathie nachweisen, haben aber bei Vorliegen einer Neuropathie oftmals Schwierigkeiten, zusätzliche Nervenkompressionssyndrome nachzuweisen. Oft ist bei Patienten mit diabetischer Neuropathie und einem peripheren Nervenkompressionssyndrom ein positives Hoffmann-Tinel-Zeichen das einzige klinische nachweisbare Zeichen. Sind sowohl N. fibularis communis als auch N. tibialis von einem Nervenkompressionssyndrom betroffen, ergibt sich eine „strumpfartig“ angeordnete Sensibilitätsstörung. Ein positives Hoffmann-Tinel-Zeichen über dem N. tibialis im Tarsaltunnel hat nach Untersuchungen des Autors einen 90 % positiven prädiktiven Wert für einen Patienten mit Diabetes mellitus, die Sensibilität wiederzugewinnen, wenn alle vier Engstellen am Sprunggelenk dekomprimiert werden. Metaanalysen von klinischen Studien weisen bei Patienten mit Diabetes mellitus, bei welchen eine operative Dekompression des N. tibialis und seiner Äste durchgeführt wurde, in 80 % eine Schmerzreduktion von einem Punktwert von 8,5 auf 2,0 auf der visuellen Analogskala nach. Dabei erreichen 80 % dieser Patienten mehr als nur Schutzsensibilität. Durch die teilweise wiederhergestellte Sensibilität im Fuß kann eine spätere Ulzeration oder gar Amputation oft vermieden werden. Zusätzlich wird durch die verbesserte Sensibilität im Fuß auch das Gleichgewicht beim Gehen verbessert, sodass zusätzliche Folgeschäden durch Stürze wie etwa Frakturen ebenfalls reduziert werden. Die vorliegende Arbeit gibt eine Übersicht über das Behandlungskonzept und die chirurgische Vorgangsweise des Autors, um diese Ziele zu erreichen.

Key words

below‐knee reconstruction - interdisciplinary plastic surgery - foot - nerve compression syndrome - lower leg

Schlüsselwörter

Unterschenkelrekonstruktion - interdisziplinäre plastische Chirurgie - Fuß - Nervenkompressionssyndrom - Unterschenkel

References

• 1 AAEM Quality Assurance Committee . Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome.  Muscle Nerve. 1993;  16 1392-1414
• 2 American Diabetes Association . Economic costs of diabetes in the U.S. in 2002.  Diab Care. 2003;  26 917-932
• 3 Argoff C, Backonja M, Belgrade M J. et al . Consensus guidelines: treatment planning and options.  Mayo Clinic Proc. 2006;  81 (Suppl. 4) S12-S25
• 4 Aszmann O A, Kress K M, Dellon A L. Results of decompression of peripheral nerves in diabetics: a prospective, blinded study.  Plast Reconstr Surg. 2000;  106 816-822
• 5 Aszmann O C, Tassler P L, Dellon A L. Changing the natural history of diabetic neuropathy: incidence of ulcer/amputation in the contralateral limb of patients with a unilateral nerve decompression procedure.  Ann Plast Surg. 2004;  53 517-522
• 6 Bae S, Biddinger K, Shon L. Independent, retrospective review of surgical nerve decompression for diabetic neuropathy. Presented at the Amer Acad Orthop Surg Foot & Ankle Soc meeting, San Diego, February 2007. 
• 7 Biddinger K R, Amend K J. The role of surgical decompression for diabetic neuropathy.  Foot Ankle Clin. 2004;  9 239-254
• 8 Boulton A JM, Arezzo J C, Malik R A. et al . Diabetic somatic neuropathies.  Diabetes Care. 2004;  27 1458-1486
• 9 Chafee H. Decompression of peripheral nerves for diabetic neuropathy.  Plast Reconstr Surg. 2000;  106 813-815
• 10 Chaudhry V, Stevens J C, Kincaid J. et al . Practice advisory: utility of surgical decompression for treatment of diabetic neuropathy: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.  Neurology. 2006;  66 1805-1808
• 11 Cornblath D R, Vinik A, Feldman E. et al . Commentary: surgical decompression for diabetic sensorimotor polyneuropathy.  Diab Care. 2007;  30 421-422
• 12 Dellon A L. Optimism in diabetic neuropathy.  Ann Plast Surg. 1988;  20 103-105
• 13 Dellon A L. Entrapment of the deep peroneal nerve on the dorsum of the foot.  Foot and Ankle. 1990;  11 73-80
• 14 Dellon A L. Treatment of symptoms of diabetic neuropathy by peripheral nerve decompression.  Plast Reconstr Surg. 1992;  89 689-697
• 15 Dellon A L. Decompression of peripheral nerves for symptoms of diabetic neuropathy: pain management considerations.  The Pain Clinic. 2001;  3 11-16
• 16 Dellon A L. Prevention of foot ulceration and amputation by decompression of peripheral nerves in patients with diabetic neuropathy.  Ostomy Wound Manage. 2002;  48 36-45
• 17 Dellon A L. Medical and surgical management of diabetic neuropathy.  Clinics in Podiatric Med and Surg. 2007;  24 425-428
• 18 Dellon A L, Ebmer J, Swier P. Anatomic variations related to decompression of the common peroneal nerve at the fibular head.  Ann Plast Surg. 2002;  48 30-34
• 19 Dellon A L, Kim J, Spaulding C M. Variations in the origin of the medial calcaneal nerve.  J Amer Pod Med Assoc. 2002;  92 97-101
• 20 Dellon A L, Mackinnon S D. Tibial nerve branching in the tarsal tunnel.  Arch Neurol. 1984;  41 645-646
• 21 DiNucci K. Results of decompression of multiple lower extremity peripheral nerves in diabetic with symptomatic neuropathy. Presented at the Amer College of Foot and Ankle Surgery meeting, New Orleans, March 2005. 
• 22 Ducic I, Chang S B, Dellon A L. The use of tourniquet in reconstructive surgery in patients with previous ipsilateral lower extremity revascularization: is it safe? A survey.  J Reconstr Microsurg. 2006;  22 183-189
• 23 Ducic I, Taylor N S, Dellon A L. Relationship between peripheral nerve decompression, gain of pedal sensibility and balance in patients with peripheral neuropathy.  Annals of Plastic Surg. 2006;  56 145-150
• 24 Dyck Jr J P, Dyck Sr J P, Klein C J. et al . Does impaired glucose metabolism cause polyneuropathy? Review of previous studies and design of a prospective controlled population-based study.  Muscle Nerve. 2007;  36 536-541
• 25 Dyck P J, Kratz K M, Karnes J L. et al . The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study.  Neurology. 1991;  43 817-824
• 26 Dyck P J, Ziegler D, Norell J E. et al . Challenges in design of multicenter trials: end points assessed longitudinally for change and monotonicity.  Diab Care. 2007;  30 2619-2625
• 27 Feyler S, Rawstron A, Jackson G. et al . Thalidomide maintenance following high-dose therapy in multiple myeloma: a UK myeloma forum phase 2 study.  Br J Haematol. 2007;  139 429-433
• 28 Greenwald D, Moffitt M, Cooper B. Effective surgical treatment of cubital tunnel syndrome based upon provocative testing without electrodiagnostics.  Plast Reconstr Surg. 1999;  104 215-218
• 29 Hossain P, Kawar B, Nahas M E. Obesity and diabetes in the developing world. A growing challenge.  New Eng J Med. 2007;  356 213-215
• 30 Ivers R Q, Mitchell P, Cumming R G. et al . Diabetes and risk of fracture.  Diabetes Care. 2001;  24 1198-1203
• 31 Kim J, Dellon A L. Neuromas of the calcaneal nerves: diagnosis and treatment.  Foot Ankle Internat. 2001;  22 890-894
• 32 Kim J, Dellon A L. Tarsal tunnel incisional pain due to neuroma of the posterior branch of saphenous nerve.  J Amer Pod Med Assn. 2001;  91 109-113
• 33 Latov N. Diagnosis of CIDP.  Neurology. 2002;  59 (12 Suppl. 6) S2-S6
• 34 Lee C, Dellon A L. Prognostic ability of Tinel sign in determining outcome for decompression surgery decompression surgery in diabetic and non-diabetic neuropathy.  Ann Plast Surg. 2004;  53 523-527
• 35 Mackinnon S E, Dellon A L. Homologies between the tarsal and carpal tunnels: Implications for treatment of the tarsal tunnel syndrome.  Contemp Orthop. 1987;  14 75-79
• 36 Maloney C T, Valdivia J V, Weinand M. Nerve decompression results in a consecutive series of 165 patients with neuropathy. Presented at the Assoc Neurologic Surgeons, Phoenix, Arizona, 2006. 
• 37 Massa E. Diabetic neuropathy: decompression of compressed lower extremity nerves. Presented at Internat Diab Fed meeting, Cape Town, S. Africa, Jan. 2007. 
• 38 Mont M A, Dellon A L, Chen F. et al . Operative treatment of peroneal nerve palsy.  J Bone Joint Surg [Am]. 1996;  78 863-869
• 39 Nelson S C, Little Jr E R. The 36 item Short-Form Health Survey for outcome evaluation for multiple lower extremity nerve decompressions in diabetic peripheral neuropathy: a pilot study.  J Amer Pod Med Assoc. 2007;  97 121-125
• 40 Peek M E, Cargill M A, Huang E S. Diabetes health disparities: a systematic review of health care interventions.  Med Care Res Rev. 2007;  64 (Suppl. 5) 101S-156S
• 41 Perkins B A, Olaleye D, Bril V. Carpal tunnel syndrome in patients with diabetic polyneuropathy.  Diabetes Care. 2002;  25 565-569
• 42 Piatt G A, Zgibor J C. Novel approaches to diabetes care; a population perspective.  Curr Opin Endocrin Diab Obes. 2007;  14 158-165
• 43 Periera B M. Decompressive peripheral nerve surgery for the relief of neuropathic symptoms in diabetics. Presented at the Amer Assoc of Neurologic Surgeons. 2007
• 44 Rader A J. Surgical decompression in lower-extremity diabetic peripheral neuropathy.  J Am Podiatr Med Assoc. 2005;  95 446-450
• 45 Rather H M, Boulton A JM. Recent advances in the diagnosis and management of diabetic neuropathy.  J Bone Joint Surg [Br]. 2005;  87 1605-1610
• 46 Rempel D, Evanoff B, Amadio P C. et al . Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies.  Am J Public Health. 1998;  88 1447-1451
• 47 Rosson G D, Dellon A L. Superficial peroneal nerve anatomic variability changes surgical technique.  Clinical Orthop Rel Res. 2005;  438 248-252
• 48 Schwartz A V, Sellmeyer D E, Ensrud K E. et al . Older women with diabetes have an increased risk of fracture: a prospective study.  J Clin Endocrinol Met. 2001;  86 32-38
• 49 Shafiroff B. Decompression of lower extremity nerves in neuropathy. Presented at Lower Extr Peripheral Nerve Surg meeting, Santa Fe, New Mexico, Oct. 2006. 
• 50 Siemionow M, Alghoul M, Molski M. et al . Clinical outcome of nerve decompression in diabetic and non-diabetic peripheral neuropathy.  Ann Plast Surg. 2006;  57 385-390
• 51 Siemionow M, Demir Y. Diabetic neuropathy, pathogenesis and treatment: a review.  J Reconstr Microsurg. 2004;  20 241-252
• 52 Sorbe B, Andersson H, Boman K. et al . Treatment of primary advanced and recurrent endometrial carcinoma with a combination of carboplatin and paclitaxel-long-term follow-up.  Int J Gynecol Cancer. 2008;  18 803-808
• 53 Steck J. Results of decompression of lower extremity peripheral nerve for treatment of symptomatic neuropathy. Presented at Amer Soc Peripheral Nerve meeting, Puerto Rico, January 2005. 
• 54 Szabo R M, Slater R R, Farver T B. et al . The value of diagnostic testing in carpal tunnel syndrome.  J Hand Surg [Am]. 1999;  24 704-714
• 55 Tambwekar S R. Extended neurolysis of the posterior tibial nerve to improve sensation in diabetic neuropathic feet.  Plast Reconstr Surg. 2001;  108 1452-1453
• 56 Valdivia J M. et al . Surgical treatment of peripheral neuropathy: outcomes from 100 consecutive decompressions.  J Am Podiatr Med Assoc. 2005;  95 451-454
• 57 Vinik A I, Mehrabyan A, Colen L. et al . Focal entrapment neuropathies in diabetes.  Diabetes Care. 2004;  27 1783-1788
• 58 Wieman T J, Patel V G. Treatment of hyperesthetic neuropathic pain in diabetics; decompression of the tarsal tunnel.  Ann Surg. 1995;  221 660-665
• 59 Williams E, Dellon A L. Intra-septal superficial peroneal nerve.  Microsurgery. 2007;  27 477-480
• 60 Wood W A, Wood M A. Decompression of peripheral nerves for diabetic neuropathy in the lower extremity.  J Foot Ankle Surg. 2003;  42 268-275
• 61 Yao Y, Wang R-Z. Peripheral nerve decompression (Dellon procedure) and diabetic neuropathy.  Chinese J Med. 2005;  10 1756-1758
• 62 Yuksel F, Karagoz H, Yuksel F. et al . Early and late results of nerve decompression procedures in diabetic neuropathy: a series from Turkiye.  J Reconstr Microsurg. 2008;  24 95-101