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Losing Your Nerve?
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With triple decompression surgery, some diabetic neuropathy may
be reversed
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By John McIntosh
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Diabetes Focus Second Quarter 2006
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Many peripheral nerves that have been damaged by chronically high levels of glucose can be surgically treated, allowing them to regenerate, relieving pain and restoring sensation in up to 90 percent of patients.
That statement is true. And the reasons are as simple as A, B, C:
Diabetic neuropathy occurs when chronic high blood sugar causes damage—such as swelling and stiffness—in the peripheral nerves that are typically located in the hands and feet. This results in pain, a decrease in motor skills, numbness and even paralysis.
Peripheral nerves—the nerves that branch out from the central nervous system of the brain and spine into the arms and legs—can be repaired. These nerves have the ability to recover from injury.
By using a technique called decompression surgery, doctors are able to reduce pressure on peripheral nerves in the extremities, alleviating a great amount of physical discomfort.
“What’s been shown,” says Michael Rose, M.D., a board-certified plastic and reconstructive surgeon and partner at the Plastic Surgery Center in Shrews- bury, NJ, “is that once you release the pressure on a peripheral nerve, a significant amount of regeneration happens. That is starkly different from the central nerves of the spine. The nerves of the peripheral nervous system regenerate all the time.”
Until recently, Dr. Rose didn’t think it was possible to treat any kind of diabetes-related nerve damage surgically. But about three years ago he accidentally fixed a patient’sneuropathy when he operated on one of her nerves. After she got better, he looked into the pheno-menon. He found a doctor who had been successfully treating
neuropathy with surgery for about 15 years—A. Lee Dellon, M.D., professor of plastic surgery and neurosurgery at Johns Hopkins University in Baltimore and director of the Dellon Institutes for Peripheral Nerve Surgery.
“Dr. Dellon is responsible for figuring out all of this,” says Dr. Rose. “He identified these tunnels in the arms and legs where pressure develops, and he was able to relieve symptoms of diabetic neuropathy. He expanded our understanding of nerve entrapment syndromes.”
So Dr. Rose called Dr. Dellon and went to his clinic. There he was able to learn Dr. Dellon’s techniques. “Now I lecture at his annual scientific meeting and am slated to assist him with the courses that he teaches for other surgeons,” says Dr. Rose. “Our whole thing is that we have seen people turn their lives around after having this surgery, and we are trying very hard to get the word out.”
Dr. Rose has done over 100 of these procedures, and he says Dr. Dellon has done nearly 1,000. Currently there are approximately 200 doctors in the United States who perform this surgery.
Decompression surgery is a procedure that relieves pressure on the peripheral nerves as they pass through three different (hence “triple”) passageways or tunnels on their way to each extremity.
The procedure is probably best explained by using as an example the tunnel that most people are familiar with: the carpal tunnel. It is found in the palm of the hand and is the tunnel through which the peripheral nerve passes as it extends from the forearm to the wrist and into the hand. High glucose levels may cause that nerve to swell and stiffen, which in turn causes pressure inside the carpal tunnel. Dr. Dellon found that opening up the tunnel alleviates pressure on the nerve, and sensation in the hands, as well as range of motion, can be restored. “The surgery is relatively straightforward,” says Dr. Rose. “It takes about an hour and fifteen minutes. It’s done on an outpatient basis and can be done under either local or general anesthesia.
“Essentially what we do is open up the skin at the different compression points in order to get to the tunnels where a nerve is sandwiched between a ligament and a bone. We cut away the roof of the tunnel, releasing the swollen, damaged nerve. The nerve has room to ‘breathe’ and is no longer compressed.”
To be a candidate for this surgery:
- You must have neuropathy, a diagnosis that is confirmed by a diabetes specialist.
- You must have good circulation in your extremities.
- You must be able to undergo an operation. People on certain medications, or who have other complications, may not be able to have the surgery.
The three compression points in the lower extremities are known as: the fibular tunnel (located toward the outside of the leg just below the knee); the tarsal tunnel (located just below the bone that is on the inside of the ankle where the nerves enter the foot); and what Dr. Rose calls the dorsal foot tunnel. “It doesn’t really have a name,” he says, “but it’s on the top of the foot. Unlike all the rest, this one is actually a compression between a tendon and a bone, not between a ligament and a bone.” The three compression points in the upper extremities are known as: the cubital tunnel (located on the back and on the inside of the elbow); the radial tunnel (located in the forearm); and the carpal tunnel (located in the palm of the hand).
Decompression surgery has been performed for about 15 years on a regular basis. Among well-selected individuals, Dr. Rose estimates that about 80 to 90 percent will have relief of pain, and about 70 percent who have had their legs operated on will have a significant improvement in sensation on the bottom of their feet. Recurrence of neuropathic complications following decompression surgery is rare. Dr. Rose notes, “Some scar tissue may occur, but the recurrence rate has been very, very low, probably on the order of 5 percent. There have also been many encouraging reports of people who, 15 years after surgery, still have relief from their symptoms.” One study followed 49 patients who had a leg operated on. Five years later, no patient had gotten an ulcer on the side that was operated on, but 14 had gotten an ulcer on the leg which had not been treated. This surgery reduces the future occurrence of ulcers or amputations to nearly zero, says Dr. Rose: “It seems to be around a percent or two at most.“
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