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Scientific Publications

12/04	Changing the Natural History of Diabetic Neuropathy: Incidence of Ulcer/Amputation in the Contralateral Limb of Patients with a Unilateral Nerve Decompression Procedure. Abstract: The natural history of diabetic neuropathy is progressive and irreversible loss of sensibility in the feet, leading to ulceration and/or amputation in 15% of patients. The prevalence of neuropathy is more than 50% in those who have been diabetic for 20 years. Decompression of the tibial and peroneal nerves in those with diabetic neuropathy improves sensation in 70% of patients. The impact of this surgery on the development of ulcers and amputations in both the operated and the contralateral, non-operated limb was evaluated in a retrospective analysis of 50 diabetics a mean of 4.5 years (range 2 to 7 years) from the date of surgery. No ulcers or amputations occurred in the index limb of these patients. In contrast, there were 12 ulcers and 3 amputations in 15 different patients in contralateral limbs. This difference was significant at the p < .001 level. It is concluded that decompression of lower extremity nerves in diabetic neuropathy changes the natural history of this disease, representing a paradigm shift in health care costs.
12/04	Prognostic Ability of Tinel Sign in Determining Outcome for Decompression Surgery in Diabetic and Nondiabetic Neuropathy Abstract: During the past 12 years, 6 studies reported restoration of sensation and relief of pain in the foot by decompression of the tibial nerve and its distal branches in diabetic neuropathy. Although a positive Tinel sign related to favorable outcomes in some of the reports, this relationship was not evaluated specifically. In this study, the presence of the Tinel sign, positive or negative, over the tibial nerve was recorded in 46 patients with diabetic neuropathy and in 40 patients with idiopathic neuropathy. Outcomes were dichotomized into either a good/excellent or failure/poor category. Postoperative data were analyzed at 1 year. In diabetic neuropathy, the presence of a positive Tinel sign had a sensitivity of 88%, a specificity of 50%, and a positive predictive value of 88% in identifying patients who would have a good/excellent outcome. In idiopathic neuropathy, the presence of a positive Tinel sign had a sensitivity of 95%, a specificity of 56%, and a positive predictive value of 93% in identifying patients who would have a good/excellent outcome. It is concluded that a positive Tinel sign is a reliable indicator of successful outcome from decompression of the tibial nerve in patients with diabetes with symptomatic neuropathy, and in patients with symptomatic idiopathic neuropathy.
10/04	Measuring peripheral nerve function: electrodiagnostic versus neurosensory testing Abstract: The surgeon involved with the evaluation and treatment of peripheral nerve problems must be aware of the critical indications for the use of electrodiagnostic testing and its true and unfortunately common limitations in providing guidance for clinical care of these patients. The Pressure-Specified Sensory Device has been proven and documented by an increasing body of clinical evidence to be the functional equivalent of EDT for all clinical peripheral nerve problems with the exception of identifying radiculopathy and is superior to EDT for many peripheral nerve problems for which EDT is simply unable to provide the critical information necessary for patient care.
9/04	Diabetic Neuropathy: Review of Surgical Approach to Restore Sensation, Relieve Pain, and Prevent Ulceration and Amputation Abstract: Diabetic neuropathy occurs in a stocking and glove distribution consistent with a systemic metabolic disease. Historically, this concept led to the conclusion that the only role for surgery in a patient with diabetic neuropathy is for treatment of wounds, amputation, or reconstruction of a Charcot foot. This article reviews the basic scientific and clinical research that support the concepts that metabolic neuropathy renders the peripheral nerve susceptible to compression in patients with diabetes and that decompression of lower extremity peripheral nerves in these patients can relieve pain, restore sensation, and prevent ulceration and amputation.
5/04	Relationship Between Loss of Pedal Sensibility, Balance, and Falls in Patients With Peripheral Neuropathy Abstract: The purpose of this study was to describe the relationship between balance and foot sensibility in a population of patients with impaired lower extremity sensation. The hypothesis was that increasing impairment of sensation correlates with impaired balance. To date, no report has investigated the relationship between loss of balance with the degree of sensibility in the foot in a population with neuropathy. Ten control subjects and 35 patients with sensory abnormalities and balance problems related to a neuropathy were evaluated. The MatScan Measurement System was used to measure their ability to stand still, maintaining their balance with their eyes open and then with their eyes shut. The degree to which the person moves while attempting to stand still is defined as "sway," which was recorded for normal and neuropathy patients. Sensibility of the foot was measured with the Pressure-Specified Sensory Device, which is noninvasive and nonpainful. The 1- and 2-point static touch thresholds are measured for the pulp of the big toe, medial heel, and the dorsum of the foot. Loss of 2- or 1-point sensation was recorded as sensibility score and compared with controls. Statistical analysis of data and their comparisons for the 2 groups was completed. There were 55% females in control and 64% in neuropathy patients, whereas average age was 50 and 62 years, respectively. Neuropathy was the result of diabetes in 64.5%, hypothyroidism in 19.3%, their combination in 13%, and of unknown etiology in the remaining 19% of patients. Controls had significantly lower mean sway than neuropathy patients (22.9 ± 9% vs. 189.5 ± 180%, P = 0.006). Likewise, sensibility score for normal and neuropathy patients was also significantly different (31.4 ± 9% vs. 232.8 ± 59%, P = 0.0001). When compared with the controls, 99% upper limit of confidence, sensibility in the neuropathy group at the hallux pulp was abnormal at a level consistent with axonal loss in 52% and was completely absent in the remaining 48%. Similarly, at the heel, sensibility was normal in 6.5%, abnormal at a level consistent with axonal loss in 71%, and absent in the remaining 22.5%. The correlation coefficient between sway and sensibility score was 0.36. The results of this investigation for the first time document the intuitive relationship between increasing loss of foot sensibility and increasing loss of balance. These measurements can now be used prospectively to evaluate whether restoration of sensation to patients with neuropathy, through peripheral nerve decompression, can improve balance and reduce falls/fractures in this patient population.
12/03	Frostbite and Diabetic Neuropathy Abstract: A 65-year-old African American man with diabetes presented by ambulance to the emergency room in February of 1993 for the treatment of frostbite to the toes of his right foot. He had been requiring insulin for 15 years. The frostbite occurred while the patient was outdoors shoveling snow. He could not feel either of his feet at the time of presentation. The physical examination demonstrated a superficial degree of frostbite, excellent posterior tibial and dorsalis pedis pulses, and positive Tinel signs over the tibial nerve in the tarsal tunnel, the deep peroneal nerve at the dorsum of the foot, and a tender common peroneal nerve at the fibular neck.
8/03	Chemotherapy-Induced Neuropathy: Treatment by Decompression of Peripheral Nerves Abstract: 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. Cisplatin and paclitaxel, 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 µ/g, whereas the cisplatin levels in the central nervous system were low, approximately 0.2 µ/g, because cisplatin does not cross through the blood-brain barrier. A similar mechanism in diabetes results in a susceptibility to chronic nerve compression that can be reversed by decompression of the peripheral nerve. Clinical success with this approach has resulted in restoration of sensation and relief of pain in 80 percent of patients, including both upper and lower extremity nerve compression sites. This subject has been reviewed recently. Similar success in the basic science model of cisplatin neuropathy in the rat provided a basis to apply this approach to patients with disabling symptoms of chemotherapy-induced neuropathy.
9/02	Documentation of Posttraumatic Nerve Compression in Patients with Normal Electrodiagnostic Studies Abstract: Electrodiagnostic evaluation may suggest the absence of posttraumatic nerve compression in the presence of patient symptoms. Computerassisted neurosensory testing documents peripheral nerve sensory impairment. In the setting of trauma, where there are often legal implications, documentation of peripheral nerve compression is important. This is highlighted in the diabetic, who may have neuropathy. A prospective study tracked trauma-related peripheral nerve problems in patients with "normal" electrodiagnostic studies, and for whom surgical care or legal outcome was determined by documentation of abnormalities by testing with the Pressure-Specified Sensory Device. Eight patients were identified, four of whom had diabetes. In all eight patients, neurosensory testing documented peripheral nerve problems, which was critical in obtaining approval from workers' compensation insurance carrier for decompression of the nerve and facilitating legal settlement. Neurosensory testing with the Pressure-Specified Sensory Device identifies peripheral nerve compression related to trauma, facilitating management of the patient, even in the presence of diabetic neuropathy.