Acute Improvement in Intraoperative EMG Following Common Fibular Nerve Decompression in Patients with Symptomatic Diabetic Sensorimotor Peripheral Neuropathy: 1. EMG Results
Abstract:Electromyographic (EMG) recordings of the fibularis longus (FL) and tibialis anterior (TA) muscles were performed intraoperatively during common fibular nerve (CFN) nerve decompression (ND) in patients with symptomatic diabetic sensorimotor peripheral neuropathy (DSPN) and clinical nerve compression. Forty-six legs in 40 patients underwent surgical ND by external neurolysis; FL and TA muscles were monitored intraoperatively. Evoked EMGs were recorded just prior to and within 1 minute after ND. Thirty-eight leg… Show more
“…Anderson and Barrett et al [26,39] demonstrate acute improvement in evoked EMG potential in some DSPN cases within 1 minute of surgical external neurolysis for decompression of tarsal tunnel, medial and lateral plantar tunnels, as Figure 1 illustrates.Figure 1.NIM screenshot figure of 400% improvement of motor evoked potential in the 6-minute interval for ND of posterior tibial and plantar nerves.
…”
Section: Objective Outcomesmentioning
confidence: 94%
“…The bilateral pain relieving effect of unilateral decompression is confirmed in two Level 1 studies [19], although the mechanism is unknown. A retrospective study demonstrates intra-op EMG motor function improvement during ND [26]. RCT protocols confirm high expectation of pain relief with ND in comparison to disappointing benefits with pharmacology.…”
Section: The Skeptics Casementioning
confidence: 99%
“…Liao et al [33] found ND effective in both diffuse and focal DSPN pain for 300 cases with 2 year F/U vs a control, non-operated group. Anderson et al [26] found strong pain relief in a study of intra-operative EMG changes during ND.…”
Section: Subjective Outcomesmentioning
confidence: 99%
“…Acute intra-operative improvement in EMG motor evoked potentials of anterior and lateral compartment leg muscle can occur with decompression of the common peroneal nerve at the fibular neck [26,39]. Stimulation of CPN proximal to the fibular tunnel is followed by improved motor evoked potential response of peroneus longus and tibialis anterior after ND in most cases.…”
Section: Objective Outcomesmentioning
confidence: 99%
“…Nerve decompression appears to reduce the documented 25–30% annual DFU recurrence risk [51] by 80% or more [17,22–26], Figure 3 demonstrates one report. Trignano et al [52] reported 100% healing and 0/8 recurrences of neuro-ischemic DFU at 18 months after ND.Figure 3.A Kaplan Meier survival curve illustrates the ulcer-free survival of 42 cases with prior healed unilateral DFU and subsequent ND of that leg only.…”
External neurolysis of the nerve at fibro-osseous tunnels has been proprosed to treat or prevent signs, symptoms, and complications in the lower extremity of diabetes patients with sensorimotor polyneuropathy. Nerve decompression is justified in the presence of symptomatic compressed nerves in the several fibro-osseous tunnels of the extremities, which are known to be frequent in diabetes. Quite a body of literature has accumulated reporting results after such nerve decompression in the leg, describing pain relief and sensibility improvement, as well as balance recovery, diabetic foot ulcer prevention, curtailed ulcer recurrence risk, and amputation avoidance.Historical academic hesitance to endorse surgical treatments for pain and numbness in diabetes was based primarily on the early retrospective reports’ potential for bias and placebo effects, and that the hypothetical basis for surgery lies outside the traditional etiology paradigm of length-dependent axonopathy. This reticence is here critiqued in view of recent studies using objective, measured outcome protocols which nullify such potential confounders. Pain relief is now confirmed with Level 1 studies, and Level 2 prospective information suggests protection from initial diabetic foot ulceration and most neuropathic ulcer recurrences. In view of the potential for nerve decompression to be useful in addressing some of the more difficult, expensive, and life altering complications of diabetic neuropathy, this secondary compression thesis and operative treatment methodology may deserve reassessment.
“…Anderson and Barrett et al [26,39] demonstrate acute improvement in evoked EMG potential in some DSPN cases within 1 minute of surgical external neurolysis for decompression of tarsal tunnel, medial and lateral plantar tunnels, as Figure 1 illustrates.Figure 1.NIM screenshot figure of 400% improvement of motor evoked potential in the 6-minute interval for ND of posterior tibial and plantar nerves.
…”
Section: Objective Outcomesmentioning
confidence: 94%
“…The bilateral pain relieving effect of unilateral decompression is confirmed in two Level 1 studies [19], although the mechanism is unknown. A retrospective study demonstrates intra-op EMG motor function improvement during ND [26]. RCT protocols confirm high expectation of pain relief with ND in comparison to disappointing benefits with pharmacology.…”
Section: The Skeptics Casementioning
confidence: 99%
“…Liao et al [33] found ND effective in both diffuse and focal DSPN pain for 300 cases with 2 year F/U vs a control, non-operated group. Anderson et al [26] found strong pain relief in a study of intra-operative EMG changes during ND.…”
Section: Subjective Outcomesmentioning
confidence: 99%
“…Acute intra-operative improvement in EMG motor evoked potentials of anterior and lateral compartment leg muscle can occur with decompression of the common peroneal nerve at the fibular neck [26,39]. Stimulation of CPN proximal to the fibular tunnel is followed by improved motor evoked potential response of peroneus longus and tibialis anterior after ND in most cases.…”
Section: Objective Outcomesmentioning
confidence: 99%
“…Nerve decompression appears to reduce the documented 25–30% annual DFU recurrence risk [51] by 80% or more [17,22–26], Figure 3 demonstrates one report. Trignano et al [52] reported 100% healing and 0/8 recurrences of neuro-ischemic DFU at 18 months after ND.Figure 3.A Kaplan Meier survival curve illustrates the ulcer-free survival of 42 cases with prior healed unilateral DFU and subsequent ND of that leg only.…”
External neurolysis of the nerve at fibro-osseous tunnels has been proprosed to treat or prevent signs, symptoms, and complications in the lower extremity of diabetes patients with sensorimotor polyneuropathy. Nerve decompression is justified in the presence of symptomatic compressed nerves in the several fibro-osseous tunnels of the extremities, which are known to be frequent in diabetes. Quite a body of literature has accumulated reporting results after such nerve decompression in the leg, describing pain relief and sensibility improvement, as well as balance recovery, diabetic foot ulcer prevention, curtailed ulcer recurrence risk, and amputation avoidance.Historical academic hesitance to endorse surgical treatments for pain and numbness in diabetes was based primarily on the early retrospective reports’ potential for bias and placebo effects, and that the hypothetical basis for surgery lies outside the traditional etiology paradigm of length-dependent axonopathy. This reticence is here critiqued in view of recent studies using objective, measured outcome protocols which nullify such potential confounders. Pain relief is now confirmed with Level 1 studies, and Level 2 prospective information suggests protection from initial diabetic foot ulceration and most neuropathic ulcer recurrences. In view of the potential for nerve decompression to be useful in addressing some of the more difficult, expensive, and life altering complications of diabetic neuropathy, this secondary compression thesis and operative treatment methodology may deserve reassessment.
The IWGDF 2019 Updated Guidelines for prevention of foot ulcers in diabetes advise that nerve decompression surgery not be considered. This nerve decompression option has similar scientific supporting evidence to other surgeries which are recommended. The sanction ignores a large body of non‐Level 1 evidence demonstrating various beneficial outcomes of ND including pain relief, DFU prevention, and protection from recurrence and amputation.
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