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Liao C, Li S, Nie X, Tian Y, Zhang W. Triple-nerve decompression surgery for the treatment of painful diabetic peripheral neuropathy in lower extremities: A study protocol for a randomized controlled trial. Front Neurol 2022; 13:1067346. [PMID: 36588890 PMCID: PMC9794581 DOI: 10.3389/fneur.2022.1067346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives Painful diabetic peripheral neuropathy (DPN) is often refractory to conventional medications. Triple-nerve decompression was proposed for painful DPN due to the frequent involvement of multiple nerve entrapments in diabetes. However, the role of decompressive surgery remains controversial. This trial aims to assess the efficacy of triple-nerve decompression for patients with painful DPN suggestive of nerve entrapment using a randomized controlled trial (RCT) design. Methods and analysis This trial is a single-center RCT and will be conducted in Shanghai Ninth People's Hospital. Enrolled subjects (n = 74) with painful DPN due to nerve compression, which can be detected by nerve conduction studies, will be randomly allocated at a 1:1 ratio into surgical and non-surgical groups. The primary outcome will be measured by 50% responder rates, which is defined as the proportion of subjects with at least 50% reduction of the mean weekly visual analog score (VAS) of pain from baseline after 6 months of treatment. Mean weekly VAS will be additionally evaluated 1 week (W1), 1 month (M1), and 3 months (M3) after treatment to monitor the changes in pain intensity. The secondary outcomes include two-point discrimination (TPD), Toronto clinical scoring system (TCSS), electrophysiological indexes, hospital anxiety and depression scale (HADS), and the medical outcome study short-form 36-item questionnaire (SF-36). A quantitative analgesic questionnaire (QAQ) will be used as a secondary outcome to quantify the analgesic medication weekly. TPD and TCSS will be conducted at W1, M1, M3, and M6 after treatment. Electrophysiological tests, HADS, and SF-36 will be performed at M3 and M6. Ethics and dissemination Ethics approval has been obtained from the Ethics Committee of Shanghai Ninth People's Hospital (SH9H-2-21-T323-2). It was registered on the Chinese Clinical Trial Registry website (http://www.chictr.org.cn) on 16 August 2021 with the number ChiCTR2100050049. Written informed consent will be obtained from all participants. The results of this trial will be disseminated via peer-reviewed journals, mass media, and presentations at national and international academic conferences.
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Affiliation(s)
- Chenlong Liao
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuo Li
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Nie
- Biostatistics Laboratory of Clinical Research Unit, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yayuan Tian
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenchuan Zhang
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China,*Correspondence: Wenchuan Zhang
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Fakkel TM, Rinkel WD, Coert JH. Does Lower Extremity Nerve Decompression Surgery Improve Quality of Life? Plast Reconstr Surg 2022; 150:1351-1360. [PMID: 36161790 DOI: 10.1097/prs.0000000000009699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Entrapment neuropathies are more prevalent in patients with diabetes than in healthy patients. The aim of this study was to assess the effects of lower extremity nerve decompression surgery on quality of life and clarify predictors of this surgical outcome and the incidence of surgical site problems. METHODS Patients who underwent lower extremity nerve decompression surgery between September of 2017 and March of 2019 were followed prospectively at the outpatient clinic of University Medical Center Utrecht. The common, superficial, and deep peroneal nerve and tibial nerve at the tarsal tunnel and soleal sling were decompressed if an entrapment was diagnosed. The primary study outcome was quality of life as measured by the Norfolk Quality of Life-Diabetic Neuropathy questionnaire. Secondary outcomes of interest were change in Michigan Neuropathy Screening Instrument score, predictors of the Norfolk score at follow-up, and the occurrence of complications. RESULTS Sixty patients underwent surgery (45 unilateral, 15 bilateral), with a median postoperative follow-up of 13.0 months (interquartile range, 7.3 to 18.0 months). Quality of life improved significantly in this period of observation [baseline median, 46.0 (34.0 to 62.0) versus follow-up median, 37.0 (20.0 to 60.0); p = 0.011], as did Michigan Neuropathy Screening Instrument scores [7.0 (5.0 to 9.0) versus 3.0 (0.0 to 6.5); p < 0.01]. Predictors of quality of life were a higher baseline quality of life score [β, 0.59 ( p = 0.001)], longer follow-up time [β, 2.34 ( p < 0.001)], and hypertension [β, 16.38 ( p = 0.03)]. A total of 26.7 percent of patients had surgical site problems, including wound infections (18.3 percent). CONCLUSIONS Lower extremity nerve decompression surgery significantly improves quality of life by reducing neuropathy symptoms in patients with lower extremity nerve compressions. Attention should be given to lowering the risk of wound complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Tirzah M Fakkel
- From the Department of Plastic, Reconstructive, and Hand Surgery, Utrecht University Medical Center
| | - Willem D Rinkel
- From the Department of Plastic, Reconstructive, and Hand Surgery, Utrecht University Medical Center
| | - J Henk Coert
- From the Department of Plastic, Reconstructive, and Hand Surgery, Utrecht University Medical Center
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Lower Extremity Nerve Decompression for Diabetic Peripheral Neuropathy: A Systematic Review and Meta-analysis. Plast Reconstr Surg Glob Open 2022; 10:e4478. [PMID: 35999882 PMCID: PMC9390809 DOI: 10.1097/gox.0000000000004478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
Background: Diabetic peripheral neuropathy (DPN) is a leading cause of morbidity. This systematic review and meta-analysis evaluate the efficacy of lower extremity nerve decompression in reducing DPN symptoms and complications. Methods: A database search was performed using Medline, Embase, Google Scholar, and Cochrane Central Register of Controlled Trials. Articles addressing surgical decompression of lower limb peripheral nerves in patients with diabetes were screened for inclusion. Two independent reviewers undertook the assessment. Methodological quality measures were the Cochrane risk of bias and Newcastle-Ottawa scale. Results: The pooled sample size from 21 studies was 2169 patients. Meta-analysis of 16 observational studies showed significant improvement in the visual analog scale (VAS) (P < 0.00001) and two-point discrimination (P = 0.003), with strong reliability. Decompression of the tarsal tunnel region had the highest improvement in VAS [MD, 6.50 (95% CI, 3.56–9.44)]. A significant low-risk ratio (RR) of ulcer development and lower limb amputation was detected (P < 0.00001). Lowest RR of ulcer development was detected with tarsal tunnel release [RR, 0.04 (95% CI, 0.00–0.48)]. Improvements in VAS, two-point discrimination, and nerve conduction velocity were nonsignificant in the meta-analysis of five randomized controlled trials (RCTs). The RCT analysis was limited to only two studies for each outcome. Conclusions: Meta-analysis of observational studies highlights the efficacy of lower extremity nerve decompression in reducing DPN symptoms, ulcerations, and amputations. Releasing the tibial nerve in the tarsal tunnel region was the most effective observed procedure. Nevertheless, high-quality RCTs are required to support the utility of this intervention in DPN.
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Zhou H, Yang X, Liao C, Chen H, Wu Y, Xie B, Ma F, Zhang W. The Development of Mechanical Allodynia in Diabetic Rats Revealed by Single-Cell RNA-Seq. Front Mol Neurosci 2022; 15:856299. [PMID: 35668789 PMCID: PMC9165721 DOI: 10.3389/fnmol.2022.856299] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/14/2022] [Indexed: 01/14/2023] Open
Abstract
Mechanical allodynia (MA) is the main reason that patients with diabetic peripheral neuropathy (DPN) seek medical advice. It severely debilitates the quality of life. Investigating hyperglycemia-induced changes in neural transcription could provide fundamental insights into the complex pathogenesis of painful DPN (PDPN). Gene expression profiles of physiological dorsal root ganglia (DRG) have been studied. However, the transcriptomic changes in DRG neurons in PDPN remain largely unexplored. In this study, by single-cell RNA sequencing on dissociated rat DRG, we identified five physiological neuron types and a novel neuron type MAAC (Fxyd7+/Atp1b1+) in PDPN. The novel neuron type originated from peptidergic neuron cluster and was characterized by highly expressing genes related to neurofilament and cytoskeleton. Based on the inferred gene regulatory networks, we found that activated transcription factors Hobx7 and Larp1 in MAAC could enhance Atp1b1 expression. Moreover, we constructed the cellular communication network of MAAC and revealed its receptor-ligand pairs for transmitting signals with other cells. Our molecular investigation at single-cell resolution advances the understanding of the dynamic peripheral neuron changes and underlying molecular mechanisms during the development of PDPN.
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Affiliation(s)
- Han Zhou
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaosheng Yang
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenlong Liao
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongjin Chen
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiwei Wu
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Binran Xie
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fukai Ma
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - WenChuan Zhang
- Department of Neurosurgery, Ninth People Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Jack MM, Smith BW, Spinner RJ. Neurosurgery for the Neurologist: Peripheral Nerve Injury and Compression (What can be Fixed?). Neurol Clin 2022; 40:283-295. [DOI: 10.1016/j.ncl.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Xu L, Sun Z, Casserly E, Nasr C, Cheng J, Xu J. Advances in Interventional Therapies for Painful Diabetic Neuropathy: A Systematic Review. Anesth Analg 2022; 134:1215-1228. [PMID: 35051958 DOI: 10.1213/ane.0000000000005860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Painful diabetic neuropathy (PDN) is one of the major complications of diabetes mellitus. It is often debilitating and refractory to pharmaceutical therapies. Our goal was to systematically review and evaluate the strength of evidence of interventional management options for PDN and make evidence-based recommendations for clinical practice. METHODS We searched PubMed, Scopus, Google Scholar, and Cochrane Llibrary and systematically reviewed all types of clinical studies on interventional management modalities for PDN. RESULTS We identified and analyzed 10 relevant randomized clinical trials (RCTs), 8 systematic reviews/meta-analyses, and 5 observational studies of interventional modalities for PDN using pain as primary outcome. We assessed the risk of bias in grading of evidence and found that there is moderate to strong evidence to support the use of dorsal column spinal cord stimulation (SCS) in treating PDN in the lower extremities (evidence level: 1B+), while studies investigating its efficacy in the upper extremities are lacking. Evidence exists that acupuncture and injection of botulinum toxin-A provide relief in pain or muscle cramps due to PDN with minimal side effects (2B+/1B+). Similar level of evidence supports surgical decompression of lower limb peripheral nerves in patients with intractable PDN and superimposed nerve compression (2B±/1B+). Evidence for sympathetic blocks or neurolysis and dorsal root ganglion (DRG) stimulation is limited to case series (2C+). CONCLUSIONS Moderate to strong evidence exists to support the use of SCS in managing lower extremity pain in patients who have failed conventional medical management for PDN. Acupuncture or injection of botulinum toxin-A can be considered as an adjunctive therapy for PDN. Surgical decompression of peripheral nerves may be considered in patients with PDN superimposed with nerve compression. High-quality studies are warranted to further evaluate the safety, efficacy, and cost-effectiveness of interventional therapies for PDN.
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Affiliation(s)
- Li Xu
- From the Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Zhuo Sun
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | | | | | - Jianguo Cheng
- Department of Pain Management, Anesthesiology Institute.,Department of Neuroscience, Lerner Research Institute
| | - Jijun Xu
- Department of Pain Management, Anesthesiology Institute.,Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Rodríguez-Merchán EC, Moracia-Ochagavía I. Tarsal tunnel syndrome: current rationale, indications and results. EFORT Open Rev 2021; 6:1140-1147. [PMID: 35839088 PMCID: PMC8693231 DOI: 10.1302/2058-5241.6.210031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches. It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic. There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG). A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma. Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema). Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment. Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%. Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible. A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression. Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology. Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031
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Affiliation(s)
- E. Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
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Nagpal AS, Leet J, Egan K, Garza R. Diabetic Neuropathy: a Critical, Narrative Review of Published Data from 2019. Curr Pain Headache Rep 2021; 25:15. [PMID: 33630186 DOI: 10.1007/s11916-020-00928-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This manuscript is a systematic, narrative review that compiles and describes all data available from 2019 related to epidemiologic, diagnostic, and therapeutic advances in diabetic neuropathy (DN). RECENT FINDINGS Epidemiology of DN is discussed. Diagnostic modalities include predictive models, electrodiagnostics, imaging, and biomarkers. A majority of studies on the treatment of diabetic peripheral neuropathy (DPN) involve pharmacotherapy, but complementary and alternative medicine, exercise, modalities, psychological, interventional, and surgical options are also explored. DN is a highly prevalent and debilitating consequence of diabetes that can present challenges to the clinician as the assessment is largely subjective with different phenotypic presentations among patients. Treatment of DN is largely symptomatic as the pathogenesis of DN is not fully understood and is likely multifactorial. It is evident from the broad range of treatments that too often provide unsatisfactory relief that there is no consensus about a single most effective treatment for DN, and monotherapy rarely proves to be successful.
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Affiliation(s)
- Ameet S Nagpal
- Department of Anesthesiology, Joe R. & Thereza Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA.
| | - Jennifer Leet
- Department of Rehabilitation Medicine, Joe R. & Theresa Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Kaitlyn Egan
- Department of Rehabilitation Medicine, Joe R. & Theresa Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Rudy Garza
- Department of Anesthesiology, Joe R. & Thereza Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
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Agarwal P, Sharma D. Our experience of reinnervation of sole in diabetic sensorimotor polyneuropathy: A chance to change the natural history of disease. J Clin Orthop Trauma 2021; 17:25-29. [PMID: 33717968 PMCID: PMC7920140 DOI: 10.1016/j.jcot.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/05/2021] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy which leads to insensate sole, diabetic foot ulcers (DFU) and its complications. We share our experience in recovery of sensation in the sole after prophylactic surgery such as nerve decompression (ND) or sensory neurotization by nerve transfer (NT) in patients having Diabetic sensorimotor polyneuropathy DSPN. 32 patients (46 feet) were selected for either nerve decompression or sensory neurotization depending upon presence or absence of Tinel's sign at tarsal tunnel. At 6 month post-operatively perception of touch and pain recovered in all feet; temperature and pressure perception recovered in ∼95% feet; average vibration perception threshold returned to normal range and 2-Point Discrimination came down significantly. There were no ulcers or amputation in operated limbs during follow up period of 6 months. Prophylactic surgery in the form of ND and NT can be offered with minimal complications which significantly improve sensations in the sole in selected cases of DSPN. These have the potential to improve the quality of life of patient and change the natural course of disease.
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Affiliation(s)
- Pawan Agarwal
- Professor, and in Charge Plastic Surgery Unit, NSCB Government Medical College, Jabalpur MP, 482003, India
- Corresponding author. 292/293, Napier Town, Jabalpur, 482001, MP, India.
| | - Dhananjaya Sharma
- Professor and Head, Department of Surgery, NSCB Government Medical College, Jabalpur, MP, 482003, India
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Agarwal P, Sharma B, Sharma D. Tarsal tunnel release restores sensations in sole for diabetic sensorimotor polyneuropathy. J Clin Orthop Trauma 2020; 11:442-447. [PMID: 32405206 PMCID: PMC7211905 DOI: 10.1016/j.jcot.2019.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy. Loss of sensations in sole leads to diabetic foot ulcers (DFU) and its complications. Surgical decompression has been used in the treatment of diabetic peripheral neuropathy, however; its effectiveness has been questioned.Purpose of this study was to evaluate the sensory recovery in sole after tarsal tunnel decompression (TTD) in patients having DSPN. METHODS Thirteen patients (Age28-70 years, average 35.57 years; 7 Males, 6 Females; 20 feet) with DSPN and positive Tinel's sign over the tarsal tunnel were included in the study. Pre and post-operative sensory tests performed on the sole included tests for touch, pain, temperature, pressure, vibration perception threshold (VPT) and two-point discrimination (2-PD). Results were classified as per British Medical Research Council (MRC) scoring system. RESULTS -Sixteen feet were followed-up for 6 months. In all feet perception of touch, pain and pressure recovered. Temperature perception recovered in 75% feet. VPT came to normal range (16.81V) from 40.37 V and 2-PD came down to average of 6.0 mm from preoperative average of11.2 mm.MRC scale improved from S0 in 5 feet and S2 in 15 feet to S3+ in all 16 feet.There were no ulcers or amputation in operated limbs during follow up period of 6 months. CONCLUSIONS TTD improves plantar sensations in diabetic neuropathy and prevents ulcers and its related complications.
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Affiliation(s)
- Pawan Agarwal
- Charge Plastic Surgery Unit, Department of Surgery, NSCB Government Medical College, Jabalpur, MP, 482003, India
| | - Bashudev Sharma
- Resident Department of Surgery, NSCB Government Medical College, Jabalpur, MP, 482003, India
| | - Dhananjaya Sharma
- Department of Surgery, NSCB Government Medical College, Jabalpur, MP, 482003, India
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Rinkel WD, Fakkel TM, Castro Cabezas M, Birnie E, Coert JH. (Cost-)effectiveness of lower extremity nerve decompression surgery in subjects with diabetes: the DeCompression (DECO) trial-study protocol for a randomised controlled trial. BMJ Open 2020; 10:e035644. [PMID: 32341044 PMCID: PMC7204866 DOI: 10.1136/bmjopen-2019-035644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/21/2020] [Accepted: 04/07/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The peripheral nerves of patients with diabetes are often pathologically swollen, which results in entrapment at places of anatomical narrowing. This results in nerve dysfunction. Surgical treatment of compression neuropathies in the lower extremities (lower extremity nerve decompression (LEND)) results in relief of symptoms and gain in peripheral nerve function, which may lead to less sensory loss (short term) and less associated detrimental effects including foot ulceration and amputations, and lower costs (long term). The aim of the DeCompression trial is to evaluate the effectiveness and (cost-)effectiveness of surgical decompression of compressed lower extremity nerves (LEND surgery) compared with patients treated with conventional (non-surgical) care. METHODS AND ANALYSIS A stratified randomised (1 to 1) controlled trial comparing LEND surgery (intervention) with conventional non-surgical care (control strategy) in subjects with diabetes with problems of neuropathy due to compression neuropathies in the lower extremity. Randomisation is stratified for participating hospital (n=11) and gender. Patients and controls have the same follow-up at 1.5, 3, 6, 9, 12, 18, 24 and 48 months. Participants (n=344) will be recruited in 12 months and enrolled in all affiliated hospitals in which they receive both the intervention or conventional non-surgical care and follow-up. Outcome assessors are blinded to group assignment. PRIMARY OUTCOME disease-specific quality of life (Norfolk Quality of Life Questionnaire-Diabetic Neuropathy). SECONDARY OUTCOMES health-related quality of life (EuroQoL 5-dimension 5-level (EQ-5D5L), 36-item Short Form (SF-36)), plantar sensation (Rotterdam Diabetic Foot Test Battery), incidence of ulcerations/amputations, resource use and productivity loss (Medical Cost Questionnaire, Productivity Cost Questionnaire) during follow-up. The incremental cost-effectiveness ratio will be estimated on the basis of the collected empirical data and a cost-utility model. ETHICS AND DISSEMINATION Ethics approval has been granted by the Medical Research Ethics Committee of Utrecht University Medical Center (reference: NL68312.041.19v5, protocol number: 19-335/M). Dissemination of results will be via journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER NetherlandsTrial Registry NL7664.
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Affiliation(s)
- Willem D Rinkel
- Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Tirzah M Fakkel
- Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Manuel Castro Cabezas
- Department of Internal Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Erwin Birnie
- Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Genetics, University Medical Center Groningen, Groningen, The Netherlands
| | - J Henk Coert
- Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
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Rinkel WD, Castro Cabezas M, Birnie E, Coert JH. The natural history of tarsal tunnel syndrome in diabetic subjects. J Plast Reconstr Aesthet Surg 2020; 73:1482-1489. [PMID: 32276769 DOI: 10.1016/j.bjps.2020.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/11/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Tibial nerve entrapment is highly prevalent in diabetic subjects, resulting in significantly more neuropathic complaints and concomitant sensory disturbances. The study aim was to assess the impact of tarsal tunnel syndrome (TTS) and sensory loss at baseline on incident diabetic foot ulceration (DFU) in diabetic patients, since decompressing the tibial nerve might change the natural history of the disease. METHODS In this study, 113 subjects with TTS (69 bilateral, 23 left-sided and 21 right-sided) participating in the prospective Rotterdam Diabetic Foot Study were compared to 303 diabetic controls without TTS, regarding incident DFU. Kaplan-Meier analysis and Cox's regression analysis were used to determine the independent hazard of baseline variables for new DFU. RESULTS The median observation period was 836.5 days (IQR, 459-1077.8). In bilateral TTS, 17.4% (95% CI: 8.4-26.3%) of subjects experienced DFU versus 8.3% (95% CI: 5.1-11.6%) in controls (left or right) during follow-up (p = 0.0036). In left-sided TTS, no subjects versus 6.2% (95% CI: 3.4-9.0%) in controls had DFUs (p = 0.243). Incident ulceration was seen in 14.3% (95% CI: -0.7% to -29.3%) of right-sided TTS subjects versus 4.1% (95% CI: 1.5-6.3%) in controls (p = 0.034). Besides HbA1c, diminished sensation at the hallux independently increased the risk of ulceration, in patients with (HR: 4.692, p = 0.003) and without (HR: 2.307, p = 0.002) prior DFU. DISCUSSION Elevated sensory thresholds in TTS render diabetic patients at a higher risk for DFU. With effective surgery, TTS is likely to be an amenable factor to potentially prevent diabetic foot disease and thereby reduce amputation risk. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Willem D Rinkel
- Department of Plastic-, Reconstructive- and Hand Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, the Netherlands.
| | - Manuel Castro Cabezas
- Department of Internal Medicine/Centre for Diabetes, Endocrinology and Vascular Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Erwin Birnie
- Department of Statistics and Education, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J Henk Coert
- Department of Plastic-, Reconstructive- and Hand Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands; Department of Plastic-, Reconstructive- and Hand Surgery, Utrecht University Medical Center, Utrecht, the Netherlands
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