Neuropathy Decompression Surgery Physician Info
Information for Physicians
Info for Primary Care Physicians
There may be some optimism for patients with diabetes who suffer from peripheral neuropathy. By having yearly measurements made of the sensibility in your hands and feet, the earliest stages of neuropathy can be identified and appropriate changes in your diabetes management can be made. In certain cases, it may be found that areas are present in both your arms and legs that cause compression of your nerves. These sites of pressure on the nerves can be treated with surgery to restore sensation to your hands and feet.
Why would nerves in the diabetic be compressed?
Nerves begin in the spinal cord and extend into the fingers and toes. Along with this path, there are anatomic areas of narrowing. These exist in everyone, and many are already known to you, such as your "funny bone" at the elbow and the carpal tunnel at the wrist. In the leg, there are similar tight places at the outside of your knee and the inside of your ankle called the tarsal tunnel. Although some people may have been born with structures that would make the tunnels more narrow and the nerves more likely to become pinched, like a smaller wrist or extra muscles that go through one of these tunnels, the diabetic has two unique reasons to make nerves susceptible to compression. Firstly, diabetics may develop swollen nerves due to the high blood sugars. Secondly, these swollen nerves travel through tight tunnels that are stiffening over time, also due to the high blood sugars. The combination of these effects can create severe compression points on specific peripheral nerves.
What are the symptoms of nerve compression?
You will feel buzzing, tingling or numbness in the areas that are supplied by that nerve. In the foot, the problem similar to carpal tunnel syndrome is called tarsal tunnel syndrome. It involves compression of the posterior tibial nerve in the bony tunnel on the inside of the ankle. This nerve supplies the entire bottom of the foot, including the heel. Compression of the posterior tibial nerve can result in numbness or tingling of the heel, the arch, the ball of the foot, and the bottom and tips of the toes. The loss of sensation in the feet can cause a loss of balance, a feeling of unsteadiness, and cause you to fall.
What type of surgery can be done?
The surgery to decompress the nerve does not change the basic, underlying metabolic (diabetic) neuropathy that made the nerve susceptible to compression in the first place. When the surgical decompression is done early in the course of nerve compression, restoration of blood flow to the nerve will stop the numbness and tingling, and permit strength to recover. When the decompression is done later in the course of nerve compression, and nerve fibers have begun to die, decompression of the nerve will permit the diabetic nerve to regenerate.
Introducing PSSD - Painless Nerve Testing
For the countless people who live with the pain, numbness, tingling, and reduced functionality due to nerve injury, PSSD or Pressure Specified Sensory Device testing signals a breakthrough inaccurate diagnosis. This revolutionary new technology is a pain-free means of testing nerve function in a way never before possible. Utilizing innovative computer technology, the PSSD unit enables accurate, non-invasive neurosensory and motor testing (NMT) without the pain associated with traditional electrodiagnostic testing.
The PSSD is a psychophysical diagnostic measuring device that interfaces with a computer to create a system of instruments which measure sensory and motor function. The PSSD requires the patient to make a complex psychophysical decision at the cortical level in order to provide information about the peripheral nervous system allowing early detection of nerve malfunction. The patient responds by pressing the button on a "joy buzzer" type indicator. The patient is touched with an instrument consisting of two prongs connected via a strain gauge to a laptop computer. The patient's ability to feel and distinguish the distance between the points is measured by the PSSD and shown graphically on a series of charts and graphs. The pressure threshold required to initiate a response is also precisely measured in g/mm2.
PSSD - Why and When
Patients from all backgrounds suffer pain from peripheral nerve injury due to compression neuropathy. PSSD's revolutionary new technology gives healthcare providers a new tool in the diagnosis of chronic nerve pain. PSSD is instrumental in the early detection of many nerve disorders, including tarsal tunnel syndrome and diabetic neuropathy.
PSSD allows for early identification of changes in sensation. Its graphical representation of results provides quantitative data to record the degree of sensory loss which, in turn, enables a health care professional to monitor the progression of a condition or the effectiveness of treatment, including surgery.
Traditional electrodiagnostic testing is prone to error. Faster conducting impulses are measured and do not give an accurate picture of mild to moderate nerve damage when both normal and abnormal nerve fibers are present. Combined with variations in testing, technique this can lead to false negative test results as high as 45%. Due to the inherent pain and expense associated with electrodiagnostic testing, PSSD stands poised as the method of choice for future diagnosis.
Since PSSD testing measures the resultant sensation and strength factors for a patient, it provides the most complete picture of a condition. Using one and two points sensory testing provides a measurement of the sensibility loss in a nerve (comparable to measuring weakness in a muscle). During one-point tests, a pressure threshold above normal signals abnormal functioning of the touch receptors and an underlying problem with the nerve fibers servicing those receptors. With two-point testing, a patient's discrimination of the points wider than normal signals a loss of receptors and the degeneration of associated nerve fibers (comparable to atrophy of muscle).
Clearly, PSSD testing raises the standard for diagnosis of peripheral nerve injury. Its painless application, level of accuracy, cost-effectiveness, and ease of repetitive testing are making it the tool of choice. Patients suffering nerve pain now have hope for early diagnosis and effective treatment plans to alleviate chronic pain and prevention of amputation.
- DIABETIC PATIENTS
- WEIGHT LOSS SURGERY PATIENTS
- PATIENTS WITH CERTAIN TYPES OF CHEMOTHERAPY
- PERSONS WITH HEREDITARY FACTORS
- CHRONIC PAIN AFTER AN INJURY OR SURGERY
Peripheral neuropathy is a painful and debilitating nerve condition that affects the body's extremities, like the feet and legs. Patients with neuropathy are challenged with numbness, pain, and loss of strength or balance.
Until now, patients were told that there was NOTHING that could be done and that they would just have to live with the condition. Treatments included anti-seizure drugs to mask the symptoms, temporary relief from awkward splints, or even surgically implanted electrical devices to stimulate the spinal cord.
We are pleased to inform you that there are HOPE and a SURGICAL option for sufferers of peripheral neuropathy. An effective and minimally invasive procedure that proves there is no need to just "live with" this condition anymore.
FOCAL NERVE DECOMPRESSION SURGERIES
A. Lee Dellon MD and his research associates in Baltimore, MD, discovered that neuropathy intensifies when nerves in the extremities become swollen. These pressure points constrict the internal blood flow that leads to lower extremity nerve becoming focally compressed in specific narrowing areas or "tunnels" which then leads to pain and dysfunction. Until now, suffers of peripheral neuropathy, whether from a systemic condition such as diabetes or from an idiopathic or unknown origin, were only treated with oral medications that help to keep symptoms under control, but did not provide any cure. A surgical technique has been developed to help relieve pressure and restore sensation to the feet by decompressing these focally compressed nerves in their respective tunnels. Only about 350 surgeons in the U.S. and worldwide are trained to perform these procedures, including the surgeons of the Texas Peripheral Nerve Institute.
The procedure is a sophisticated nerve release surgery, in which areas of tissue compression are identified and treated, allowing freedom of circulation, healing, and regeneration, thus reducing or eliminating the symptoms and effects of certain types of peripheral neuropathy. The surgery is done as an outpatient and does not require an overnight hospital stay.
Surgical Treatment of Peripheral Neuropathy: Outcomes from 100 Consecutive Decompressions
Juan M. V. Valdivia, MD *, A. Lee Dellon, MD, Martin E. Weinand, MD * and Christopher T. Maloney, Jr., MD
* Division of Neurosurgery, Department of Surgery, University of Arizona, Tucson.
Departments of Plastic Surgery and Neurosurgery, Johns Hopkins University, Baltimore, MD; Divisions of Plastic Surgery and Neurosurgery, Department of Surgery, and Department of Anatomy, University of Arizona, Tucson.
Divisions of Plastic Surgery and Neurosurgery, Department of Surgery, and Department of Anatomy, University of Arizona, Tucson; Dellon Institute for Plastic Surgery and Peripheral Nerve Surgery, Tucson, AZ.
Corresponding author: Christopher T. Maloney, Jr., MD, Dellon Institute for Plastic Surgery and Peripheral Nerve Surgery, 3170 Swan Rd, Tucson, AZ 85712.
Since 1992 it has been reported that patients with diabetes mellitus recover sensibility and obtain relief of pain from neuropathy symptoms by decompression of lower-extremity peripheral nerves. None of these reports included a series with more than 36 diabetic patients with lower-extremity nerves decompressed, and only recently has a single report appeared of the results of this approach in patients with nondiabetic neuropathy. No previous report has described a change in balance related to restoration of sensibility. A prospective study was conducted of 100 consecutive patients (60 with diabetes and 40 with idiopathic neuropathy) operated on by a single surgeon, other than the originator of this approach, and with the postoperative results reviewed by someone other than these two surgeons. Each patient had neurolysis of the peroneal nerve at the knee and the dorsum of the foot, and the tibial nerve released in the four medial ankle tunnels. After at least 1 year of follow-up, 87% of patients with preoperative numbness reported improved sensation, 92% with preoperative balance problems reported improved balance, and 86% whose pain level was 5 or greater on a visual analog scale from 0 (no pain) to 10 (the most severe pain) before surgery reported an improvement in pain. Decompression of compressed lower-extremity nerves improves sensation and decreases pain, and should be recommended for patients with neuropathy who have failed to improve with traditional medical treatment. (J Am Podiatr Med Assoc 95(5): 451-454, 2005)
Using Diagnostic Ultrasound and Neurosensory Testing to Select Candidates for Nerve Decompression
Doohi Lee, MD * and Damien M. Dauphine, DPM Texas Diagnostic Imaging PA, Plano, TX.
Foot and Ankle Associates of North Texas LLP, Lewisville, TX. Corresponding author: Damien M. DauphinÃ©e, DPM, Foot and Ankle Associates of North Texas LLP, 500 N Valley Pkwy, Ste 100, Lewisville, TX 75067.
It has been hypothesized that in individuals with diabetes mellitus the peripheral nerve is swollen owing to increased water content related to increased aldose reductase conversion of glucose to sorbitol. It has further been hypothesized that the tibial nerve in the tarsal tunnel is at risk for chronic nerve compression related to this swelling. We used diagnostic ultrasound to evaluate this hypothesis. Cross-sectional areas of the tibial nerve were measured in diabetic patients with neuropathy and compared with previously reported measurements in nondiabetic patients and diabetic patients without neuropathy. We used the Pressure-Specified Sensory Device (Sensory Management Services LLC, Baltimore, Maryland) to document the presence of neuropathy in 24 diabetic patients (48 limbs). Previous studies have found that the cross-sectional area of the tibial nerve in nondiabetic patients and in diabetic patients without neuropathy is not significantly different. We found that the mean cross-sectional area of the tibial nerve in diabetic patients with neuropathy is significantly greater than that in diabetic patients without neuropathy (24.0 versus 12.0 mm2). Our study highlights the value of newer ultrasound imaging techniques in identifying a morphological change in the tibial nerve and confirms that the tibial nerve in the tarsal tunnel is swollen, consistent with chronic compression, in diabetic patients with neuropathy. (J Am Podiatr Med Assoc 95(5): 433-437, 2005)
Surgical Decompression in Lower-Extremity Diabetic Peripheral Neuropathy
Andrew J. Rader, DPM Patoka Valley Podiatry, PC, Jasper, IN; Center for Wound Healing, 1900 Medical Arts Dr, St Joseph's Hospital, Huntingburg, IN 47542.
Peripheral neuropathy can be a devastating complication of diabetes mellitus. This article describes surgical decompression as a means of restoring sensation and relieving painful neuropathy symptoms. A prospective study was performed involving patients diagnosed as having type 1 or type 2 diabetes with lower-extremity peripheral neuropathy. The neuropathy diagnosis was confirmed using quantitative sensory testing. Visual analog scales were used for subjective assessment before and after surgery. Treatment consisted of external and as-needed internal neurolysis of the common peroneal, deep peroneal, tibial, medial plantar, lateral plantar, and calcaneal nerves. Subjective pain perception and objective sensibility were significantly improved in most patients who underwent the described decompression. Surgical decompression of multiple peripheral nerves in the lower extremities is a valid and effective method of providing symptomatic relief of neuropathy pain and restoring sensation.
(J Am Podiatr Med Assoc 95(5): 446-450, 2005)
The concept of nerve compression induced by separate pathology was extended to chemotherapy-induced neuropathy based upon a rat model of cisplatin neuropathy in 2001,30 and reported for the first time in patients with chemotherapy-induced neuropathy due to cisplatin and taxol in 2004.31 This first report contains just eight patients. They have had relief of pain and recovery of sensation from decompression of upper and lower extremity nerves. Chemotherapy regimens that contain vincristine, platin compounds, such as cisplatin or carboplatin, taxol, or thalidomide are known to cause a sensory neuropathy that is typically distal and symmetrical like diabetic neuropathy. This neuropathy is often painful. For cisplatin and taxol, the mechanism that renders the peripheral nerve susceptible to compression is that binding of the chemotherapeutic agent to tubulin within the nerve's axoplasm, resulting in a decrease in the slow component of anterograde transport. The pain may be severe enough for the patient to stop chemotherapy, at which time nerve decompression would be appropriate. For other patients, the neuropathy symptoms, which for each drug are dose-related, may improve the following cessation of chemotherapy. If the symptoms persist and are disabling, a positive Tinel sign identifies the location of the peripheral nerve compression site. Operative procedures in the lower extremity for chemotherapy-induced neuropathy are the same as those for diabetic neuropathy patients.
Chemotherapy-Induced Neuropathy: Treatment by Decompression of Peripheral Nerves
Dellon, A. Lee M.D.; Swier, Patrick M.D.; Maloney, Chris T. Jr. M.D.; Livengood, Melvin S. D.P.M., M.P.H.; Werner, Scott D.P.M.
Baltimore, Md.; Tucson, Ariz.; Greensboro, N.C.; and Myrtle Beach, S.C.
From the Divisions of Plastic Surgery and Neurosurgery, Johns Hopkins University; Department of Surgery, University of Arizona; Guilford Foot Center; and Coastal Podiatry.
Plastic surgeons encounter clinical problems related to cisplatin and tactual chemotherapy most often related to soft-tissue injury resulting from extravasation of the drug during intravenous infusion therapy. 1,2 Cisplatin 3-5 and paclitaxel, 6-8 however, each cause a painful chemotherapy-induced neuropathy resulting from their binding to tubulin in the axoplasm. This results in a decrease in the slow component of anterograde axoplasmic transport that makes the peripheral nerve susceptible to chronic nerve compression. In a study from 1984, postmortem histological examination demonstrated concentrations of cisplatin in the peripheral nerve at the same level as in the tumor, approximately 3 Î¼g/g, whereas the cisplatin levels in the central nervous system were low, approximately 0.2 Î¼g/g, because cisplatin does not cross through the blood-brain barrier. 3 A similar mechanism in diabetes results in a susceptibility to chronic nerve compression 9,10 that can be reversed by decompression of the peripheral nerve. 11 Clinical success with this approach has resulted in the restoration of sensation and relief of pain in 80 percent of patients, including both upper and lower extremity nerve compression sites. 12-15 This subject has been reviewed recently. 16 Similar success in the basic science model of cisplatin neuropathy in the rat 17 provided a basis to apply this approach to patients with disabling symptoms of chemotherapy-induced neuropathy.
Plastic and Reconstructive Surgery: Volume 114 (2) August 2004 pp 478-483