[Abstract
OBJECTIVE: To investigate the efficacy of peripheral nerve release in the treatment of diabetic peripheral neuropathy.
METHODS: Fifty-seven patients with diabetic peripheral neuropathy with clinical manifestations of symmetrical pain, numbness and sensory abnormalities in both lower limbs were treated with three peripheral nerve release operations on the common peroneal nerve, deep peroneal nerve and posterior tibial nerve, and were followed up for 3 to 7 months.
RESULTS: After surgery, 71.9% (41 cases) of patients had significant relief of lower limb numbness, 21.1% (12 cases) had remission, and 7.0% (4 cases) had no change. Postoperative lower limb pain symptoms were significantly relieved in 42.1% (24 cases), relieved in 52.6% (30 cases), and no change in 5.3% (3 cases). Short-term follow-up showed stable efficacy and no recurrence of symptoms.
Conclusion: The application of peripheral nerve release can effectively help patients with diabetic peripheral neuropathy to restore sensation and relieve pain.
Key words] peripheral nerve release, diabetic peripheral neuropathy
Diabetic peripheral neuropathy (DPN) is the most common chronic complication of diabetes mellitus, with an incidence of 60% to 90%. Its pathogenesis is not fully understood and there is no way to prevent its occurrence, and it is also a major cause of foot ulcers, infections and amputations. At present, there is no specific treatment method with satisfactory efficacy other than strict control of blood sugar. In our hospital, 57 cases of DPN patients were treated by peripheral nerve release since 2004 with obvious results, which are reported below.
Data and methods
I. Subjects
The patients were inpatients of neurosurgery from Peking Union Medical College Hospital from November 2004 to May 2005. There were 11 patients with type 1 diabetes mellitus and 46 patients with type 2 diabetes mellitus. 7 of the patients with type 1 diabetes mellitus were male and 4 were female. The average age was 25.8 years (17-35 years), and the duration of the disease was 2 months to 3 years, with an average of 10 months; among type 2 diabetic patients, 21 were male and 25 were female. The average age was 58.6 years (46-78 years), and the duration of disease was 4 months to 15 years, with an average of 4.5 years. The patients had good glycemic control before admission and had been stable for one month (HbA1c <9%). And other causes of neuropathy were excluded.
1.Clinical manifestations: all patients had symmetrical numbness and sensory disturbance below both knees and spontaneous neuralgia.
2.Laboratory examination: Neuropack2 neuropotential evoking instrument manufactured by Nihon Kohden, Japan was applied. Forty-three of the 57 patients showed peripheral neurogenic damage in both lower extremities and slowed nerve conduction velocity. 49 patients had abnormal two-point discrimination below the knees.
II. Methods
1.Surgical method: In this group of 57 patients, three peripheral nerve release operations were performed on the common peroneal nerve, deep peroneal nerve and posterior tibial nerve of the lower limbs. During the operation, lumbar plexus and sciatic nerve block anesthesia was performed, the patient was placed in a supine position, a 3-cm long oblique incision was made 2 cm below the small head of the fibula, the skin was cut in full layer, subcutaneously, the common peroneal nerve was separated next to the long peroneal tendon, and the common peroneal nerve was released by cutting part of the tendon at the nerve insertion, and the nerve bundle was released along the surface of the common peroneal nerve to the distant and near. Then, a longitudinal surgical incision of approximately 3 cm in length was made between the first two toes on the dorsum of the foot, and the deep peroneal nerve was released by cutting the skin subcutaneously, and the bundle of the deep peroneal nerve was released distally and proximally throughout. Finally, a curved incision of approximately 6 cm in length was made at the tarsal canal, and the posterior tibial artery and vein and its branches were separated and protected by subcutaneous incision of the skin and flexor support band, and the posterior tibial nerve was separated under it. The posterior tibial nerve was separated underneath. The nerve bundle was released in the direction of the nerve alignment. The incision was closed with intradermal sutures and reinforced with interrupted sutures.
2. Efficacy assessment: numbness is graded as absent, mild (occasional), moderate (persistent but not obvious after distraction) and severe (persistent at all times). The efficacy is evaluated by the change in the degree of numbness after treatment. A decrease in grade >2 was considered significant relief, >1 was considered remission, 0 was considered ineffective, and an increase was considered worsening. Pain was assessed using a visual analog scale (VAS). The pain level gradually increased from 0 to 10, and the efficacy was assessed by the degree of VAS decrease before and after surgery. ≥80% of VAS decrease was considered significant relief, 20-80% was considered remission, Q20% was no change, and those with rising VAS were considered worsening. At the same time, we also compared the changes in the two points of discrimination in the lower limbs of patients.
3. Follow-up: All 57 patients were followed up after surgery for 3-7 months, and nerve conduction velocity was rechecked at the 3-month follow-up.
III. Results
1.Surgical effect: 71.9% (41 cases) of patients with lower extremity numbness were significantly relieved, 21.1% (12 cases) were relieved, and 7.0% (4 cases) had no change after surgery. The VAS score decreased from 7.5±1.5 before surgery to 2.1±0.9. There was a significant difference (P<0.05) between before and after treatment. 38 patients had improved 2-point discrimination compared with the preoperative period. 57 patients had no peripheral nerve injury after surgery, and 8 patients had delayed incision healing. The incision healing was delayed in 8 patients.
2. Follow-up effect: The 3-month postoperative outpatient follow-up showed that all patients with symptom relief were stable, with no recurrence or aggravation of symptoms; tibial nerve conduction velocity was 32.4±4.6m/s before treatment and 40.7±3.9m/s after treatment, with a significant difference in conduction velocity compared with that before treatment (P<0.05), and peroneal nerve conduction velocity was 35.9±3.7 before treatment and 43.3±4.2m/s after treatment. The conduction velocity of the peroneal nerve was 35.9±3.7 before treatment and 43.3±4.2m/s after treatment, with a significant difference in conduction velocity compared with that before treatment (P<0.05). There were 15 patients with a postoperative follow-up of 7 months with stable surgical efficacy.
IV. Discussion
In recent years, with the improvement of living standards, the incidence of diabetes has increased significantly in China, and according to the statistics of the Ministry of Health in 2004, 26 million patients were diagnosed with diabetes and 20 million patients with abnormal glucose tolerance nationwide. Among the many complications of diabetes, the most common is diabetic peripheral neuropathy (DPN), the incidence of which is as high as 60-90%.DPN first affects the foot and then the hand, with a glove and sock-like distribution area.The pathogenesis of DPN is complex and still unclear, but in recent years it is generally believed to be the result of a combination of factors, the main pathogenesis is related to metabolic and biochemical abnormalities, microangiopathy, immune factors and The main pathogenesis is related to metabolic and biochemical abnormalities, microangiopathy, immune factors and vitamin deficiency. At present, domestic and foreign treatment mostly adopts blood glucose control, metabolic regulation and improvement of microcirculation in order to correct neural ischemia and hypoxia and increase nerve conduction function. There are also antioxidant, nerve growth factor supplementation and immunosuppressant methods. However, there is a lack of clinically effective methods for the specific treatment of DPN. In this study, three peripheral nerve release procedures were applied to treat DPN, and significant efficacy was achieved, providing a new therapeutic avenue for the treatment of DPN.
The principles of peripheral nerve release for DPN are as follows: 1. Peripheral nerves in diabetic patients are susceptible to compression: peripheral nerves begin in the spinal cord and innervate the fingers and toes. In this pathway, there are multiple anatomical narrowings. For example, the ulnar nerve canal, the carpal tunnel, and the tarsal canal on the medial side of the ankle. Two factors may explain why peripheral nerves are susceptible to compression in diabetic patients.1 Swelling of peripheral nerves in diabetic patients. Normally, blood sugar enters the nerve to provide energy and is converted to fructose, and high blood sugar causes fructose to accumulate in the peripheral nerves of diabetic patients. The molecular formula of fructose determines that it binds water easily. Therefore, water is drawn into the nerve and causes swelling of the nerve. This phenomenon was confirmed in 1978. If nerve swelling occurs at an anatomically narrow site, the nerve becomes compressed and produces symptoms.2. Dysregulation of the intra-neural transmission system in diabetic patients. A variety of neurotransmitters within the nerve allow for the transmission of important chemical messages within the nerve. When a nerve is damaged such as by compression, its cell membrane needs to be rebuilt and these repair proteins need to be transmitted downstream along the microtubular proteins within the nerve. As early as 1979, it was reported that this cis-axoplasmic transport in the nerves of diabetic patients was dysfunctional. Therefore, damaged nerves in diabetic patients have difficulty repairing themselves and consequently produce symptoms.3. Relationship between neuropathy and nerve compression: The main symptom of DPN manifests as sensory loss in the distribution area of garter-like nerves, usually occurring symmetrically in the extremities, with symptoms often starting in the foot. In contrast, nerve compression is often a single nerve compression and is characterized by localized numbness of the limb. The difference between nerve compression-induced numbness and neuropathic numbness is one of the main factors why doctors used to believe that diabetic peripheral neuropathy was not caused by nerve compression. The numbness and tingling of peripheral nerve travel in multiple places of compression will occur in a glove and glove-like distribution. Therefore, the relationship between neuropathy and nerve compression is that metabolic abnormalities in diabetic patients can lead to neuropathy, and neuropathy can lead to nerve compression. At some stages of the disease process, neuropathy and nerve compression coexist, but the symptoms arise as a result of nerve compression.
Based on the above, this study uses peripheral nerve release surgery for DPN, which can be performed on the arms, hands, legs and feet to release the compressed areas of the nerve pathway by cutting through ligaments or fibrous tissue. The nerve compression is removed, the blood supply to the nerve is improved, and the nerve is allowed to glide with the movement of the adjacent joint. Peripheral nerve release does not resolve peripheral neuropathy caused by abnormalities in glucose metabolism. However, if peripheral nerve release is performed after nerve compression has occurred, blood flow to the nerve can be restored and symptoms of numbness and pain can be relieved or disappeared.
In this study, the efficiency rate (significant relief + relief) of lower extremity numbness in patients with type 1 and type 2 DPN after peripheral nerve release was 93% for the lower extremity. Postoperative lower extremity pain was 94.7%. The current short-term follow-up found that as postoperative nerve blood flow and nutrition improved, the patients’ symptom improvement progressed as regeneration after nerve injury. During the recovery process, patients may again develop sensory abnormalities, but the symptoms are mostly different from those before surgery. The above findings are similar to those of Dellon et al. in the United States, who showed that peripheral nerve release can relieve pain and restore sensation in about 85% of patients. Their clinical practice suggests that the earlier the treatment, the better the functional recovery and even complete recovery can be achieved for patients with diabetic peripheral neuropathy.
This study provides a new approach to the treatment of DPN. The results of this study show that peripheral nerve release surgery in patients with diabetic peripheral neuropathy can change the natural course of diabetic peripheral neuropathy, which is “progressive and irreversible”. The procedure is a minimally invasive microsurgery, which has the advantages of short operation time, few surgical complications, less patient pain, less cost and fast results. If promoted, it is believed that it will improve the quality of life of DPN patients and reduce the huge cost of DPN treatment applied to patients. At the same time, this study was conducted for a short period of time, and the longest postoperative patient was followed up for only 7 months. This paper is a preliminary report of the study, and the number of surgical cases and long-term follow-up time frame need to be increased to further determine the efficacy.