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

BACKGROUND: A triad of metabolic abnormalities are known that render the peripheral nerve in diabetes mellitus susceptible to chronic compression: conversion of glucose to sorbitol increases the intraneural water content, slowing of axoplasmic transport of proteins hinders structural repair, glycosylation of endoneurial collagen reduces perineurial gliding. In the early 1990s, Dellon et al demonstrated that removal of a site of anatomic narrowing of the tibial nerve in the rat model prevented neuropathic walking. METHOD: Scientific literature related to this concept was reviewed. Through the end of 2006, there have been 15 peer-reviewed studies that used the inclusion criteria of (1) presence of symptomatic neuropathy, (2) positive Tinel sign over the tarsal tunnel demonstrating a site of compression, (3) no previous history of ulcer or amputation and (4) used the Dellon Triple Decompression technique (neurolysis of the peroneal nerve at the knee and the dorsum of the foot, and neurolysis of the tibial nerve in the four medial ankle tunnels). FINDINGS: These studies demonstrated relief of pain in 88% and restoration of sensation in 79% of patients. One study demonstrated that the natural history of diabetic neuropathy can be changed by observing no ulcers/amputations in the operated leg of 50 diabetics followed for a mean of 4.5 years, while 12 ulcers and 3 amputations occurred in the non-operated contralateral limb (p < 0.001). Results of a multi-centered prospective study are available at NeuropathyRegistry.com, demonstrating a reduction in the prevalence of ulceration in 665 diabetics at 2.5 years from 15 to 0.6% in those diabetics without a previous history of ulceration and from 50 to 2.2% in 44 patients with a previous history of ulceration. CONCLUSIONS: Decompression of superimposed nerve compressions in the patient with symptomatic neuropathy reliably relieves pain, restores sensation, and thereby prevents ulceration and amputation.