Dellon triple peripheral nerve decompression surgery
1.What is Dellon triple peripheral nerve decompression surgery?
Dellon triple decompression nerve surgery was invented in the 1980s by Professor Dellon, former president of the American Association for Peripheral Neurosurgery and professor of neurosurgery and orthopedic surgery at Hopkins University School of Medicine, as a procedure to target nerve lesions in the lower or upper extremities. For patients with lower extremity, dorsal foot, plantar and toe numbness, pain, and foot drop, a triple procedure is often used to release the common peroneal nerve, deep peroneal nerve, and tibial nerve; for patients with hand numbness, a triple procedure is used to decompress the median nerve, ulnar nerve, and sensory branch of the radial nerve. The above procedures are called peripheral nerve triple decompression surgery.
2.Efficacy of Dellon triple decompression nerve surgery
In a study conducted in multiple medical centers around the world, patients with diabetic peripheral neuropathy had 70-90% relief or improvement of sensory disorders and 80-90% relief of lower extremity weakness; the relief rate of the above symptoms in the drug control group was 30%; in the 4 and 5 years follow-up, it was found that there were no skin ulcers and amputations in the surgical group; while the control group had ulcers and amputations. In the four- and five-year follow-up, there were no skin ulcers or amputations in the surgical group, while the rate of ulcers and amputations in the control group was 30%.
Peripheral nerve decompression surgery is the most effective means of preventing amputation in patients with diabetic peripheral neuropathy. A positive nerve stimulation sign (Tinel’s sign) is an important predictor of surgical outcome. It refers to a positive patient who can induce limb numbness by tapping or touching a point in the nerve alignment location, and the chance of surgical relief of symptoms is at least 80%. Domestic and foreign case reports efficiency summary analysis: 464 patients, a total of 516 nerve surgery, pain relief rate in 88%, the recovery rate of sensory impairment in 79%.
3. Why diabetic and other neuropathies are prone to multiple nerve entrapment
Diabetic peripheral neuropathy is prone to nerve entrapment because of dual factors. Glucose provides energy to the nerve, generating nerve impulses that provide information upward to the brain and downward to the sensory finger or toe information. When glucose enters the nerve, it is converted to sorbitol, which pulls water into the nerve, causing the nerve itself to swell; as the swollen nerve passes through the narrow, hard lumen, the nerve is subjected to additional pressure, causing nerve entrapment. The pressure inside the nerve increases, the blood flow rate decreases, reducing the oxygen supply, and the limb feels numbness and ankylosis; over time, the nerve fibers will die, and the thicker nerves will be more easily compressed. Another factor is that the sugar in diabetic patients binds to the connective tissue around the nerve, which makes the nerve stiffer, less flexible, and easier to be strained; finally, the nerve’s ability to repair itself after compression is reduced.
In the Dellon triple nerve decompression procedure, this metabolic process is not altered, but rather the hard, narrow gap around the nerve is widened. Not all patients are suitable for surgery; patients with nerve entrapment present are the patients for whom surgery is indicated.
(1) Idiopathic neuropathy: Many neuropathies, without an obvious etiology, are present. For patients with combined neurological large nerve fiber lesions, nerve decompression surgery can also be performed to relieve symptoms.
(2) Neurological drug neuropathy: The chemical drugs used to treat the tumor may remain inside the nerve and the nerve is prone to seizure, for which nerve decompression surgery is still appropriate.
(3) Metal neurotoxic neuropathy: Heavy metals can attach to the cells of blood vessels, and when the fluid leaks out of the blood vessels and into the nerve, it causes swelling of the nerve and makes it easy for nerve compression to occur. As with diabetes, nerve decompression surgery is equally effective.
(4) Wind disease: patients with leprosy often have nerve damage, and nerve decompression surgery is also effective for some patients.
4. Which patients with peripheral neuropathy are suitable for peripheral nerve decompression surgery
After the diagnosis of diabetic peripheral neuropathy, systematic drug treatment should be used. For those who have poor results with drug treatment, surgery should be actively taken to improve patients’ quality of life, prevent diabetic foot and avoid amputation.
(1) Stable diabetic condition: good glycemic control, preferably fasting blood sugar below 7 mmol/l, and normal blood sugar should be at least 2 weeks.
(2) After more than 3 months of systematic neurotrophic drugs and treatment to improve microcirculation, the pain and numbness symptoms are still not relieved.
(3) No significant stenosis or mild stenosis of the blood vessels of the lower limbs: those with severe stenosis or occlusion of the blood vessels of the lower limbs need vascular surgery first, and those with neurological symptoms still exist after the blood supply to the limbs is improved.
(4) Positive nerve Tinel’s sign: percussion of the nerve in the nerve walk, causing numbness and pain in the limb is positive.
(5) The patient does not have severe edema in the foot.
Chemotherapeutic drug peripheral neuropathy; metabolic disease peripheral neuropathy such as renal failure; leprosy; idiopathic peripheral neuropathy with positive nerve stimulation sign; various nerve entrapment diseases.
5, the purpose of peripheral nerve decompression surgery: to relieve pain; restore sensation; improve muscle strength; reduce skin ulcers and prevent amputation.
Why do diabetic patients have numbness in their hands and feet?
Diabetic patients often experience numbness and pain in their hands and feet after the onset of the disease for a period of time, or even burn because they cannot feel the temperature change when washing their feet, or worse, they do not even know that they have nails stuck in the soles of their feet, and finally form stubborn ulcers and have their limbs amputated. In fact, this is all due to a common complication of diabetes, called diabetic peripheral neuropathy.
1, why patients will have pain and numbness in the limbs and hands and feet
Pain and numbness is a normal response signal of the human body, produced by the stimulation of local nerves in the area of hands and feet and limbs, this signal is transmitted along the nerves to the spinal cord, from the spinal cord to the brain, once the pain or numbness signal suggests that you need to pay attention to your body.
Many people often wake up with numbness in the thighs and hands and forearms after sitting on a stool or sleeping on a table for a long period of time, which is a sign of abnormalities due to dysfunction caused by nerve compression for a short period of time. If the nerve receives compression for a long time, serious dysfunction will occur. Some people find that they cannot lift their wrists after waking up because of slumber, which is a dysfunction caused by prolonged compression of the radial nerve.
2.How is the nervous system composed and what is the relationship with pain
The nervous system includes the central nervous system and the peripheral nervous system.
The central nervous system includes the brain and spinal cord. Common lesions include brain tumors, brain hemorrhage, stroke, which often cause headache and partial loss of body function in patients, and can cause numbness in the body, but rarely cause pain in the upper and lower extremities or body.
The most common compression lesion is a herniated disc. The most common sciatica in the lower extremities is caused by a herniated disc in the lumbar spine, with pain radiating from the lower back to the outer thighs and even to the toes. The upper extremity is commonly characterized by herniated discs in cervical 5 and 6, causing pain in the neck and shoulders and radiating to the index finger. Routine X-rays, MRI and electromyography usually confirm the diagnosis. Most patients heal with conservative treatment, but sometimes surgery is required, which is usually done by a neurosurgeon or orthopedic surgeon.
The peripheral nervous system includes nerves that emanate from the brain and spinal cord: they are distributed to the upper extremities, lower extremities, face, chest and abdomen. The peripheral nervous system is a common cause of pain in the extremities.
3.How peripheral neuropathy causes pain in the extremities
Three types of peripheral nerve lesions: neuroma, nerve compression and neuropathy cause pain and numbness in the extremities and hands and feet. The local pain signals caused by these three lesions are transmitted to the brain. Pain can be relieved or cured if the signal transmission is blocked.
(1) Neuroma
After an injury to a peripheral nerve emanating from the spinal cord, the injured nerve has to grow back to its original site, called nerve regeneration. Nerve fibers are wrapped outside by Schwann’s cells, which release nerve growth factor after nerve injury to promote nerve growth to the distal end, growing about 1-3mm per day. When nerve injury is heavy, connective tissue around the nerve appears to grow faster than the nerve fibers, forming a scar at the broken end of the nerve fibers. If the nerve fibers grow into the scar tissue, a neuroma is formed, and nerve impulses are continuously transmitted from the scar to the spinal cord and brain, forming intractable pain.
(2) Nerve entrapment
Peripheral nerve entrapment is a common condition. Common clinical cases include carpal tunnel syndrome, elbow tunnel syndrome, and ankle tunnel syndrome. Approximately 500,000 carpal tunnel syndrome surgeries are performed each year in the United States, with a prevalence rate of 125/100,000 Americans and an efficiency rate of 85% for surgery. The most significant symptom of carpal tunnel syndrome is often waking up at night because of numbness in the thumb, index finger and middle finger, and in severe cases, persistent numbness during the day. Chronic nerve entrapment is initially treated without surgery. Important treatment measures include avoiding excessive wrist flexion, oral mecobalamin tablets and non-steroidal anti-inflammatory drugs to reduce edema in the carpal tunnel; a brace can be worn during sleep at night to avoid wrist flexion. If these measures do not work, steroid hormones can be injected into the carpal tunnel to reduce edema. If all conservative treatment measures are ineffective, nerve decompression surgery is required.
(3) Neuropathy
Neuroma and nerve entrapment is a single nerve lesion, such as median nerve injury or entrapment, which can be unilateral or bilateral and presents as numbness in the ventral side of the thumb, index finger and middle finger. In contrast, when all the fingers of both hands are numb or painful, it is called a neuropathy.
The most common neuropathy is diabetic neuropathy. The second most common neuropathy is hypothyroidism. In hypothyroid patients, water will be deposited in the nerves, causing them to swell and become susceptible to compression at specific narrow passages, such as at the wrist or ankle. The next cause of neuropathy is autoimmune related diseases such as lupus erythematosus and rheumatoid arthritis vasculitis, which predispose the nerve to compression; other causes include heavy metal poisoning and chemotherapy drugs: such as arsenic, lead and mercury, where fluid leaks from the blood vessels into the nerve, predisposing it to compression. Chemotherapeutic drugs used to treat tumors, such as vincristine, paclitaxel, and cisplatin, cause a decrease in the rate of transport of some key substances within the nerve and make the nerve susceptible to compression.
Regardless of the cause of the neuropathy, the mechanisms that produce symptoms are similar to those of individual nerve entrapment. This gives us hope that most symptoms in patients with neuropathy may be due to nerve compression and that these symptoms constitute the clinical manifestations of neuropathy that can be relieved by nerve decompression surgery.
Peripheral nerve surgery can relieve or even cure the intractable pain caused by peripheral neuropathy in some patients, but usually peripheral nerve surgery is the last treatment option.
Nerves are very soft tissues that emanate from the spinal cord and travel through ligaments and bone and muscle tissue to distribute through the skin, joints and muscles. In some areas of the body, the ligaments, muscles and bones form narrow cavities, similar to caverns, through which the nerves pass. Nerves are easily compressed here. When a nerve is compressed, the pressure on the nerve increases, causing a decrease in blood flow within the nerve. When the blood flow decreases to a certain level, the nerve sends signals to the brain for help, and these signals manifest themselves as an ant-like sensation in the skin of the extremities, numbness, tingling, or numbness during sleep. This is like a chokehold on the neck, the brain lacks oxygen supply and the person faints and loses consciousness. When the nerves are not supplied with oxygen, they can no longer conduct normal nerve impulses. When this happens, it is like when the lights flicker in the house when the power is about to go out, and then the lights go out.
When you wake up at night because of numbness and an ankle sensation in your hand, the nerve is compressed at the wrist or elbow and the nerve lacks oxygen and sends a signal to wake you up.
When you sit on your legs and your big [finger] feels numb, it is because the nerve is compressed at the knee and the nerve sends a message to alert you to the problem. If the problem persists, the toes will gradually become weak and it will be difficult to lift the foot, making it difficult to walk up stairs and on uneven paths.
If the nerve compression is sudden and severe, it often manifests as pain and numbness in the skin. However, if the nerve compression is gradual and slow, lasting for a long time, up to several months, and no longer painful, but only recurrent numbness, the skin of the nerve will be continuously numb and with loss of sensation. This is a typical symptom of chronic nerve entrapment.
(4) How does the glove-like sensory disorder of numbness in the hands and feet develop?
Peripheral neuropathy usually begins with bilateral symmetrical foot involvement, with numbness and pain beginning at the toes and soles of the feet and gradually extending to the ankles, with the lesions resembling the shape of a pair of socks; in the upper extremities, the lesions appear in the shape of a glove.
In the upper extremity, if the ulnar nerve is jammed at the elbow (elbow canal syndrome), the radial nerve is jammed in the forearm (radial nerve sensory branch jamming) and the median nerve is jammed at the wrist (carpal tunnel syndrome), the resulting sensory deficit will resemble a glove. Whereas nerve entrapment symptoms can be relieved by decompression surgery, which relieves pain and numbness in most patients, the same applies to the lower leg and foot.
In the foot, the presence of both a common peroneal nerve at the knee (peroneal canal syndrome), a deep peroneal nerve entrapment at the front of the foot, and a tibial nerve and its branches at the ankle canal will produce a sensory disturbance similar to a sock, and nerve decompression surgery can relieve pain and numbness in most patients.
Diabetic peripheral neuropathy usually manifests as progressive worsening and continuous deterioration of the disease, culminating in amputation due to numbness and loss of sensation in the lower extremities and the formation of intractable ulcers in the limbs. For patients with poor drug therapy and persistent worsening of the disease, nerve decompression surgery can restore sensation in 80% of patients, and once sensation is restored, foot ulcers rarely reappear, thus avoiding amputation.
Professor Dellon has proposed a new theory of Ropathy. Some neuropathies are actually caused by the compression of multiple neuropathies, so it is possible to restore sensation and relieve pain by decompressing the patient’s nerves, which is a major breakthrough in the treatment of peripheral neuropathies.
Nerve entrapment disorders treated by peripheral nerve neurosurgery in hospitals: carpal tunnel syndrome, elbow tunnel syndrome, radial tunnel syndrome, thoracic outlet syndrome, ankle tunnel syndrome, foot drop, and heel pain.
What is Diabetic Peripheral Neuropathies (DPN): Diabetic peripheral neuropathy is the presence of symptoms and/or signs associated with peripheral nerve dysfunction in diabetic patients when other causes are excluded. Diabetic peripheral neuropathy is not a single condition, but rather a series of clinical syndromes by affecting specific parts of the The diabetic peripheral neuropathy is not a single condition, but rather a series of clinical syndromes by affecting specific parts of the nervous system. Common symptoms include numbness, pain, and limb weakness in the hands, feet, and lower legs. The disease is mostly progressive and insidious in its course.
Diabetic peripheral neuropathy is a common and distressing complication in diabetic patients, with a high rate of disability and mortality. Diabetic complications include vasculopathy and neuropathy. In developed countries, diabetes is the most common cause of peripheral neuropathy. Patients are rarely hospitalized for diabetes, but the hospitalization rate is higher because of diabetic peripheral neuropathy. The most dangerous and painful symptoms of diabetic peripheral neuropathy are: numbness and pain in the extremities, loss of sensation and amputation due to intractable ulcers, and DPN accounts for 50%-70% of non-traumatic amputations.
Diabetic peripheral neuropathy once the disease develops and its harm
1.How diabetic peripheral neuropathy develops
The development of diabetic peripheral neuropathy is often characterized by two types: one is the gradual progressive development of symptoms, gradually worsening and irreversible course; the second is the relatively sudden onset of disease and can be completely relieved.
The progression of distal symmetric neuropathy (DSPN) is associated with glycemic control in both type 1 and type 2 diabetes. Neurological deterioration is seen within 2-3 years of the onset of most type 1 diabetes; slowed nerve conduction velocity in type 2 diabetes is one of the earliest neurological abnormalities and can be present at the time of diagnosis. Nerve conduction velocity slowing after diagnosis usually decreases at a fixed rate of 1 m/s per year, and the degree of impairment is positively correlated with the duration of diabetes. In studies with long-term follow-up of type 2 diabetes, the prevalence of electrophysiological abnormalities in the lower extremities increased from 8% initially to 42% after 10 years, mainly due to axonal destruction and neuropathy.
2. The main hazards of diabetic peripheral neuropathy (DPN)
(1) Pain.
Pain in the hands and feet and/or extremities, initially in the toes and fingers, gradually progressing upward to involve the back of the feet, soles of the feet and palms of the hands; pain is heavier at night, unable to touch the sheets and other objects, waking up in pain many times due to severe and sudden irritating pain, seriously affecting the quality of life.
(2) Sensory numbness.
Numbness in the toes or fingers, inability to feel the shape of objects, hot and cold, and pressure. The numbness gradually goes upward and involves the back of the feet, soles of the feet and palms of the hands and backs of the hands; the patient is often prone to skin burns when bathing with hot water or washing the feet, and they do not heal for a long time; even if a nail is stuck in the foot, the patient cannot feel it; eventually, the patient loses balance, has difficulty walking at night, and needs to hold something when walking to walk smoothly, otherwise he is prone to fall. This is due to deep sensory impairment caused by neuropathy.
Limb weakness: Patients easily break their feet, the big [fingers and dorsum of the feet are not lifted up, and walk with drag, especially when walking upstairs and on uneven roads with great effort.
Intractable ulcers: Patients lose protective functions due to sensory numbness, while neuropathy causes impaired microcirculation in the foot skin, poor blood supply, and long-lasting ulcers due to small trauma.
Amputation: DPN patients have a 1.7-fold increased risk of amputation, a 12-fold increased risk if they already have a foot deformity, and a 36-fold increased risk of amputation with a history of previous foot ulcers. Fifty to 75 percent of non-traumatic amputations are in patients with diabetic peripheral neuropathy. About 85,000 people in the United States have amputations due to this disease every year, with an average of 1 amputation every 2 minutes.
3.The severity of diabetic peripheral neuropathy in China
At present, there are nearly 90 million diabetic patients in China. An analysis of 24,496 cases of DM patients by the Chinese Medical Association’s Division of Diabetes from January 1991 to December 2000 found that diabetic neuropathy accounted for 60.3%.
The onset of clinically significant diabetic peripheral neuropathy is often evident within 10 years after the diagnosis of diabetes, and its prevalence is correlated with the course of the disease; neurological function tests reveal that 60%-90% of patients have varying degrees of neuropathy, of which 30%-40% are asymptomatic.
4. The main risk factors for diabetic peripheral neuropathy are: smoking; age over 40 years; and poor glycemic control.
Theoretical basis for the treatment of diabetic and other neuropathies
1.Traditional theory of neuropathy treatment
Diabetic neuropathy is the most common type of neuropathy. 10 years after the onset of diabetes, about 50% of patients will develop neuropathy. 1/6 of patients with diabetic neuropathy will develop foot ulcers, and 1/6 of them will have their limbs amputated. half of patients with unilateral amputation will also need to have their opposite limbs amputated, and patients with amputation on both sides will die after three years.
Conventional theory considers neuropathy to be a progressive, irreversible lesion. Doctors often give nerve-nourishing and pain-relieving medications for diagnosed neuropathy, such as diabetic neuropathy; for patients with diminished or lost sensation, the foot is treated with intensive care and special protective footwear. However, doctors usually do not check whether the patient has nerve entrapment, and the treatment for nerve entrapment with or without the condition is usually the same.
2.Modern view of neuropathy treatment
Recent research from the Dellon Neurological Institute in the United States has concluded that common neuropathies are known to predispose the nerve to entrapment and that neurological entrapment is the primary cause of the patient’s symptoms.
Nerve decompression surgery can restore sensation, relieve pain, improve strength, avoid ulcers, and prevent amputation. The most common loss of muscle function is caused by a lesion of the common peroneal nerve near the knee joint, which prevents lifting of the large [finger, inability to lift the foot, and difficulty walking up stairs. As the lesion prolongs, the innervated muscle will gradually necrotize and eventually become fibrous tissue, and surgery must be performed before the muscle degenerates and dies.