Christopher T. Maloney

Surgical treatment of peripheral neuropathy: outcomes from 100 consecutive decompressions.

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.

Free omental tissue transfer for extremity coverage and revascularization.

&NA; Microvascular transfer of the omentum has several unique advantages for the reconstruction and revascularization of extremity wounds. The omentum provides wellvascularized, malleable tissue for reconstruction of extensive soft‐tissue defects and has a long vascular pedicle (35 to 40 cm) with sizable vessels, which reduces some of the potential technical challenges of microsurgery. It can also be used for flow‐through revascularization of ischemic distal extremities. The unique properties of the omentum make it an ideal tissue for the reconstruction of difficult extremity defects, allowing simultaneous reconstruction and revascularization. Experience with six free omental tissue transfers for upper‐extremity and lower‐extremity reconstruction is described. Three of the cases involved distal anastomoses to take advantage of the flow‐through characteristics of the flap, providing distal arterial augmentation. All flaps accomplished the reconstructive goals of wound coverage and extremity revascularization. The omentum is a valuable, often overlooked tissue for the treatment of difficult extremity wounds. (Plast. Reconstr. Surg. 111: 1899, 2003.)

Surgical treatment of superimposed, lower extremity, peripheral nerve entrapments with diabetic and idiopathic neuropathy.

BackgroundAlthough it is recognized that people with peripheral neuropathy have an increased prevalence of chronic nerve entrapment, controversy still exists over their management. The present report details the evaluation, surgical approach, and outcome of a large cohort of people with diabetic and with idiopathic neuropathy. MethodsA retrospective review of 158 consecutive patients, 96 with diabetic and 62 with idiopathic neuropathy, was done to analyze the results of neurolysis of multiple sites of chronic nerve compression in the lower extremity. Of these patients, 50 had a contralateral limb decompressed for a total of 208 limbs included in the study. Outcomes included visual analog scale (VAS) for pain in the 109 patients who had pain level greater than 8.0, measurement of the cutaneous pressure threshold for sensibility, self-reported change in pain medication usage, and self-reported change in balance. ResultsWith a minimum follow-up of 1 year, 88% of patients with preoperative numbness reported improvement in sensation (P < 0.001). Of the 84 patients with impaired balance, 81% reported improvement in balance. Of those whose VAS was greater than 8, 83% reported an improvement in VAS (P < 0.001). There was a concomitant reduction in pain medication usage. There was no difference in outcomes between patients with diabetic versus idiopathic neuropathy in response to nerve decompression. ConclusionsNeurolysis of lower extremity chronic nerve compressions in patients with neuropathy and superimposed nerve compressions is an effective method for relieving pain, restoring sensation, and improving balance.

Sympathetic nerves in the tarsal tunnel: implications for blood flow in the diabetic foot.

Digital sympathectomy is a well-known and established treatment for medically refractory Raynaud’s disease, a vasospastic disorder thought to result from an overactive sympathetic nervous system. Morgan et al. first localized the sympathetic nerves in the hands and fingers.1 Subsequent prospective and retrospective studies showed that digital sympathectomy is effective for ulcer healing, and for ulcer and amputation prevention.2–4 Demonstrating sympathetic fibers within the tarsal tunnel would be a first step in providing a basis for applying these upper extremity concepts to the lower extremity. Lower extremity peripheral neuropathy with superimposed nerve compression has been treated successfully by decompression surgery.5–7 Aszmann et al. also demonstrated that tarsal tunnel decompression can change the natural history of lower extremity peripheral neuropathy by reducing the incidence of future ulceration and amputation. In their 50-patient cohort who had lower extremity nerves decompressed on only one extremity, none of the decompressed extremities went on to have any wound complications, whereas 12 ulcerations and three amputations occurred in 15 different patients in the contralateral limb over a 4.5-year follow-up period.8 These patients also had documented improvement in sensation to the feet of their operated legs; thus, one reason for this lack of wound problems is increased protective sensation. Other possibilities that have yet to be evaluated are enhanced blood flow sresulting from vessel dilatation, such as might occur with a “sympathectomy” performed with epineurectomy during decompression. To elucidate this potential mechanism, we first attempted to identify sympathetic nerve fibers in the tarsal tunnel using immunohistochemical methods.

13 SURGICAL TREATMENT OF PERIPHERAL ENTRAPMENT NEUROPATHY OF THE LOWER EXTREMITIES: OUTCOMES FROM 158 CONSECUTIVE SURGICAL CASES.

Objective We report the outcome of 158 patients with peripheral entrapment neuropathy treated surgically by multiple nerve decompressions of the peroneal and tibial system. This is a promising approach for the treatment of pain, numbness, and balance disturbance in diabetic and nondiabetic patients with peripheral nerve entrapment syndromes in the lower extremities. Methods Records of 158 consecutive patients with diabetic and nondiabetic neuropathy, treated surgically by multiple nerve decompression, were reviewed to document changes in the visual analogue scale, sensation improvement, reduction in pain medication requirement, and balance improvement. All patients underwent tarsal tunnel release and neurolysis of lower extremity nerves of the tibial and peroneal system as a concomitant part of the procedure. Patients offered surgical intervention met specific criteria including documented sensory abnormalities using neurosensory testing by the Pressure-Specified Sensory Device (PSSD) and a positive Tinels sign on examination over the involved nerve. Results Eighty-eight percent of the patients with preoperative numbness reported sensation improvement. Eighty-one percent of patients with balance disturbance reported improved balance after the procedure. From those patients who underwent the procedure mainly for pain relief, 83% reported an improvement in the visual analogue scale of more than 50% and 77% improved in more than 5 points of the scale. After the procedure, patients reported a decrease in their pain medication requirement (p ≥ .001), sensation improvement (p ≥ .001), and pain relief (p ≥ .001). Conclusion Similar to experiences found in the upper extremity, nerve decompression in the lower extremity is a safe and effective procedure to improve the quality of life of patients with peripheral neuropathy secondary to nerve compression. Documentation and staging of the severity of neuropathy with neurosensory testing and the presence of Tinels sign facilitate successful selection of surgical candidates. Decompression and neurolysis of compressed lower extremity nerves are associated with statistically significant improvement in the visual analogue scale and sensation. The great majority of patients are very satisfied with the results.