Surgical treatment of superimposed, lower extremity, peripheral nerve entrapments with diabetic and idiopathic neuropathy.

BACKGROUND: Although it is recognized that people with peripheral neuropathy have an increased prevalence of chronic nerve entrapment, controversy still exists over their management. The present report details the evaluation, surgical approach, and outcome of a large cohort of people with diabetic and with idiopathic neuropathy. METHODS: A retrospective review of 158 consecutive patients, 96 with diabetic and 62 with idiopathic neuropathy, was done to analyze the results of neurolysis of multiple sites of chronic nerve compression in the lower extremity. Of these patients, 50 had a contralateral limb decompressed for a total of 208 limbs included in the study. Outcomes included visual analog scale (VAS) for pain in the 109 patients who had pain level greater than 8.0, measurement of the cutaneous pressure threshold for sensibility, self-reported change in pain medication usage, and self-reported change in balance. RESULTS: With a minimum follow-up of 1 year, 88% of patients with preoperative numbness reported improvement in sensation (P < 0.001). Of the 84 patients with impaired balance, 81% reported improvement in balance. Of those whose VAS was greater than 8, 83% reported an improvement in VAS (P < 0.001). There was a concomitant reduction in pain medication usage. There was no difference in outcomes between patients with diabetic versus idiopathic neuropathy in response to nerve decompression. CONCLUSIONS: Neurolysis of lower extremity chronic nerve compressions in patients with neuropathy and superimposed nerve compressions is an effective method for relieving pain, restoring sensation, and improving balance.

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy.

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

Salvage of sensation in a hallux-to-thumb transfer by nerve tube reconstruction.

We report a patient in whom, at 3 years after successful reconstruction of a right avulsed thumb with a microvascular hallux transfer, the insensate transfer had sensibility restored. The radial sensory and both volar digital nerves of the thumb were reconstructed using 2.3-mm-diameter bioabsorbable neural conduits. At 30 months after reconstruction, static 2-point discrimination of the hallux was 4 mm at 14.7 g/mm(2) in this now 42-year-old right-handed man. The cutaneous pressure threshold for 1-point static touch was 0.7 g/mm(2). There were no painful neuromas at the nerve reconstruction sites.

Denervation of the painful temporomandibular joint.

The successful management of temporomandibular joint (TMJ) pain remains elusive. Often the initial relief of pain is complicated by recurrence of the symptoms. This time frame suggests that the pain may be related to neuromas of the nerves that innervate the TMJ. In 2003, an anatomic description of the innervation of the TMJ suggested that denervation of this joint might be the appropriate treatment for pain resistant to traditional forms of therapy. In January, 2005, this approach was used to treat recalcitrant left TMJ pain in a 21-year-old woman with congenital hearing loss who had recurrent dislocations of her TMJ articular disc. She previously had two arthroscopic surgeries and one open attempt to treat her TMJ pain. The last failed TMJ surgery created a painful neuroma that prevented her from wearing her hearing aid. A medial and lateral denervation of the TMJ joint was done. The successful results of this surgery are presented at one-year follow-up. The technical considerations of this approach and risk to the facial nerve are discussed.

Prognostic ability of a good outcome to carpal tunnel release for decompression surgery in the lower extremity.

For years, patients who were treated successfully with carpal tunnel release were told there was nothing that could be done about their lower extremity symptoms. Now that lower extremity nerve decompression has been accepted as an option to treat appropriate patients, the authors looked for correlations between a successful outcome with carpal tunnel syndrome and its predictive value of success for lower extremity nerve decompression. Data from a recent study demonstrate that a good result from upper extremity peripheral nerve surgery predicts the outcome for lower extremity peripheral nerve surgery in 88% of patients, and is, therefore, information valuable for prognosis and clinical decision-making.

Surgical treatment of peripheral neuropathy: outcomes from 100 consecutive decompressions.

Since 1992 it has been reported that patients with diabetes mellitus recover sensibility and obtain relief of pain from neuropathy symptoms by decompression of lower-extremity peripheral nerves. None of these reports included a series with more than 36 diabetic patients with lower-extremity nerves decompressed, and only recently has a single report appeared of the results of this approach in patients with nondiabetic neuropathy. No previous report has described a change in balance related to restoration of sensibility. A prospective study was conducted of 100 consecutive patients (60 with diabetes and 40 with idiopathic neuropathy) operated on by a single surgeon, other than the originator of this approach, and with the postoperative results reviewed by someone other than these two surgeons. Each patient had neurolysis of the peroneal nerve at the knee and the dorsum of the foot, and the tibial nerve released in the four medial ankle tunnels. After at least 1 year of follow-up, 87% of patients with preoperative numbness reported improved sensation, 92% with preoperative balance problems reported improved balance, and 86% whose pain level was 5 or greater on a visual analog scale from 0 (no pain) to 10 (the most severe pain) before surgery reported an improvement in pain. Decompression of compressed lower-extremity nerves improves sensation and decreases pain, and should be recommended for patients with neuropathy who have failed to improve with traditional medical treatment.

Accurate nomenclature for forefoot nerve entrapment: a historical perspective.

Current medical nomenclature is often based on the early history of the condition, when the true etiology of the disease or condition was not known. Sadly, this incorrect terminology can become inextricably woven into the lexicon of mainstream medicine. More important, when this is the case, the terminology itself can become integrated into current clinical decision making and ultimately into surgical intervention for the condition. "Morton's neuroma" is perhaps the most striking example of this nomenclature problem in foot and ankle surgery. We aimed to delineate the historical impetus for the terminology still being used today for this condition and to suggest appropriate terminology based on our current understanding of its pathogenesis. We concluded that this symptom complex should be given the diagnosis of nerve compression and be further distinguished by naming the involved nerve, such as compression of the interdigital nerve to the third web space or compression of the third common plantar digital nerve. Although the nomenclature becomes longer, the pathogenesis is correct, and treatment decisions can be made accordingly.

Painful foot neuromas after toe-to-thumb transfer.

Reconstruction of the thumb by transfer of a toe has evolved technically to the point that this complex procedure can result in a mobile, sensate, and aesthetically pleasing digit that contributes to an almost-normally functioning hand. Donor site deformity is well recognized, primarily as it relates to the appearance of the foot after transfer of the hallux to the thumb position and stiffness of the remaining portions of the big toe. The present report describes donor site disability related to painful neuromas of the superficial and deep peroneal nerves and the common plantar digital nerve to the first webspace. Salvage of the disabled donor foot is possible by applying techniques used to treat painful neuromas of the upper extremity, neuroma resection, and muscle implantation. The specific techniques used in treating this painful foot donor site after toe-to-thumb transfer are described.

Fibromyalgia and Tinel's sign in the foot.

In the physical examination of the patient suspected of having tarsal tunnel syndrome, the podiatric physician relies on Tinel's sign: tapping the posterior tibial nerve in the tarsal tunnel should produce a distally radiating sensation if the nerve is pathologically compressed at this location. The American College of Rheumatology recognizes fibromyalgia as a condition characterized by multiple "tender points" on physical examination. This report compares the locations of the 18 critical diagnostic fibromyalgia points with known sites of anatomical entrapment of peripheral nerves in the lower extremity. We also describe a patient with both fibromyalgia and tarsal tunnel syndrome. Tinel's sign in the lower extremity is a valid technique for assessing peripheral nerve compression in the patient with fibromyalgia.

Development and validation of a prediction model for strokes after coronary artery bypass grafting.

BACKGROUND: A prospective study of patients undergoing coronary artery bypass graft surgery (CABG) was conducted to identify patient and disease factors related to the development of a perioperative stroke. A preoperative risk prediction model was developed and validated based on regionally collected data. METHODS: We performed a regional observational study of 33,062 consecutive patients undergoing isolated CABG surgery in northern New England between 1992 and 2001. The regional stroke rate was 1.61% (532 strokes). We developed a preoperative stroke risk prediction model using logistic regression analysis, and validated the model using bootstrap resampling techniques. We assessed the model's fit, discrimination, and stability. RESULTS: The final regression model included the following variables: age, gender, presence of diabetes, presence of vascular disease, renal failure or creatinine greater than or equal to 2 mg/dL, ejection fraction less than 40%, and urgent or emergency. The model significantly predicted (chi(2) [14 d.f.] = 258.72, p < 0.0001) the occurrence of stroke. The correlation between the observed and expected strokes was 0.99. The risk prediction model discriminated well, with an area under the relative operating characteristic curve of 0.70 (95% CI, 0.67 to 0.72). In addition, the model had acceptable internal validity and stability as seen by bootstrap techniques. CONCLUSIONS: We developed a robust risk prediction model for stroke using seven readily obtainable preoperative variables. The risk prediction model performs well, and enables a clinician to estimate rapidly and accurately a CABG patient's preoperative risk of stroke.

Free omental tissue transfer for extremity coverage and revascularization.

Microvascular transfer of the omentum has several unique advantages for the reconstruction and revascularization of extremity wounds. The omentum provides well-vascularized, malleable tissue for reconstruction of extensive soft-tissue defects and has a long vascular pedicle (35 to 40 cm) with sizable vessels, which reduces some of the potential technical challenges of microsurgery. It can also be used for flow-through revascularization of ischemic distal extremities. The unique properties of the omentum make it an ideal tissue for the reconstruction of difficult extremity defects, allowing simultaneous reconstruction and revascularization. Experience with six free omental tissue transfers for upper-extremity and lower-extremity reconstruction is described. Three of the cases involved distal anastomoses to take advantage of the flow-through characteristics of the flap, providing distal arterial augmentation. All flaps accomplished the reconstructive goals of wound coverage and extremity revascularization. The omentum is a valuable, often overlooked tissue for the treatment of difficult extremity wounds.

Brachial gradient in cardiac surgical patients.

BACKGROUND: Review of the clinical and therapeutic implications of difference in arm blood pressure detected preoperatively in patients having heart surgery. METHODS AND RESULTS: Prospective study of 53 patients (Group 1) with gradient and comparison with a group of 175 patients without gradient (Group 2). All patients had preoperative carotid duplex interrogation and operative epiaortic scanning. There was no statistical difference regarding age, sex, status, redo, diabetes, ejection fraction, prior myocardial infarct, hyperlipidemia, or creatinine level. Risks factors for Group 1 included peripheral vascular disease (P<0.0001) and cerebrovascular symptoms (P=0.0196). Severe carotid disease (>80% stenosis) was seen in 41.5% of Group 1 and 13.7% of Group 2 (P<0.0001) patients. Severe atherosclerotic proximal aortic disease was found in 39.6% of Group 1 and 10.8% of Group 2 (P<0.0001) patients. There were 7 patients with strokes in Group 1 (13.20%) and 9 in Group 2 (5.14%; P=0.06). Four patients died in Group 1 (7.54%) and 10 died in Group 2 (5.71%; P=0.74). CONCLUSION: Brachial gradient is a marker for increased carotid and proximal atherosclerotic aortic disease. Preoperative arch study at the time of catheterization is strongly recommended, as well as preoperative carotid Doppler and operative epiaortic ultrasound.

Increased incidence of proximal aortic atherosclerotic disease in patients with internal carotid occlusion.

BACKGROUND: Atherosclerotic involvement of the proximal aorta is a major cause of embolic operative stroke in cardiac surgery. Its incidence is less well known in patients with severe carotid disease. METHODS: We reviewed the incidence of proximal atherosclerotic aortic disease in patients with internal carotid occlusion (group 1) and then compared it to a group of patients with normal carotids undergoing cardiac surgery (group 2). Both groups had preoperative carotid Doppler and epiaortic ultrasound analysis at the time of surgery. RESULTS: Epiaortic ultrasound results showed that the degree of atherosclerosis in group 1 was normal in 9 patients (10.2%), mild in 34 (38.6%), moderate in 29 (33%), and severe in 16 (18.2%). In group 2, the degree of atherosclerosis was normal in 70 patients (9.3%), mild in 466 (61.8%), moderate in 150 (19.9%), and severe in 68 (9.0%). Stroke rate was higher in group 1 at 4.5% versus 1.1% for group 2 (P =.029). No difference in surgical mortality was found. CONCLUSIONS: Patients with internal carotid occlusions undergoing heart surgery have a higher incidence of proximal aortic atherosclerotic disease. Epiaortic ultrasound examination is strongly recommended.