Diabetic Peripheral Neuropathy

Diabetes is one of the most prevalent conditions in American society.   The stigmata of this disease are many.  Diabetic peripheral neuropathy will affect half of all patients with diabetes.  Peripheral neuropathy causes numbness in the feet leading to unrecognized trauma, ulceration, and often amputation.  Numbness also leads to balance issues, contributing to falls.

As with any other emerging treatment, the pendulum continues to swing regarding surgery for lower extremity neuropathy.  Initial excitement regarding decompression surgery in the leg led many providers to operate routinely.  Unfortunately, candidates for lower extremity decompression are not as common as those with upper extremity neuropathy (e.g. carpal tunnel syndrome).  Overtreatment with surgery has led to decrease trust in the community.  Thus, the pendulum has now swung to non-operative treatments, and less neurologists and primary care providers believe in surgical management. 

Surgery can help some patients. 

Those with numbness symptoms, well-controlled blood sugar, positive nerve conduction studies and with Tinel sign (nerve tenderness) will benefit from surgery in the majority of cases.  All four of these factors are very important, thus, not all patients meet criteria.  Those with elevated A1C need better control to optimize nerve function prior to surgery.  Those with no Tinel sign are much less likely to benefit from surgery, likely because their nerves are too damaged to recover.  Similarly, nerve studies may indicate nerve damage that is too far along.

Peripheral neuropathy will always be a challenge to treat.  Surgery is part of the algorithm, but isn’t for every patient.  We have successes and failures; thus, we must approach the problem humbly and be judicious in patient selection.  I would love to hear comments from any patients and colleagues!