Procedures:

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Peripheral Nerve Disorder Symptoms and Treatment

Introduction:

Peripheral Neuropathy is estimated to affect about 50% of all Diabetics at some point, as well as many non-diabetics.  It has a variety of causes and symptoms, from mildly irritating to disabling.  Peripheral Neuropathy is often a progressive disease that can lead to serious complications and amputations in some, if not treated.  In fact, Peripheral Neuropathy is the number one cause of amputations in the United State, estimated to account for almost 100,000 amputations annually (U.S.).  There is no known medical treatment available that is generally agreed by physicians to halt the progression of the disease, once it starts.  However, in the large percentage of patients where symptoms are due to or complicated by a Nerve Entrapment / Nerve Compression (as explained in detail below in this section),  there is a minor outpatient surgical procedure called “Nerve Decompression” that  has proven highly effective to halt the progression of the disease, and in fact in reverse the problematic symptoms (especially pain and loss of sensation) associated with  Peripheral Neuropathy.

Background:

The locations of nerves in the human anatomy are generally classified into two separate categories: 

1. The Central Nervous System (“CNS”); which includes nerves located in the Brain and the Spine;
2. The Peripheral Nervous System (“PNS”); which generally includes the nerves located outside of the Central Nervous System, specifically nerves that emerge from the spinal cord..

For instance, the long nerve fibers that run between your spine and your feet / toes or your spine and your hands / fingers are called Peripheral Nerves, based on their location outside of the CNS.

Broadly speaking these nerves can be classified into two groups:
sensory nerves or motor nerves, based upon their respective functions:

1. A Sensory Nerve  is generally a nerve in which a stimulus creates a signal that travels along the nerve back towards the Central Nervous System, such as when you touch a hot stove (stimulus), a pain signal would travel from your finger, along your sensory peripheral nerves, back to your spine and up to your brain (CNS) where the signal is recognized as pain;
2. A Motor Nerve on the other hand is generally a nerve in which a signal generated in your Brain or Spine travels outward (away from the CNS) along a peripheral nerve  to control a muscle, effecting some sort of action in response to the original stimulus.  For example, once your brain receives and processed the signal from the sensory nerve that you have touched a hot stove; a message is sent via the motor nerves to pull your hand away from the hot stove.

Common Symptoms and Complaints involving the Peripheral Nervous System

Disorders of the Peripheral Nervous System affecting it’s function are referred to as Peripheral Neuropathy. This may be a result of injury or systemic disease.    There are well over a 100 known causes of Peripheral Neuropathy, including (but not limited to) arthritis, chemo therapy, radiation, sports injury, thyroid disorders, vitamin deficiencies, heavy metal toxicity, alcoholism and side effects from drugs. When the cause is not known, it is referred to as “idiopathic” peripheral neuropathy. One of the more common causes of Peripheral Neuropathy at this time associated with the current epidemic of diabetes is Diabetes Neuropathy. It is estimated to account for about 50% of all cases. 

Whether caused by diabetes or not, different parts of the body may be affected by peripheral neuropathy, based on which peripheral nerve(s) are involved. Symptoms of Peripheral Neuropathy may include one or more of the following (or similar symptoms) in the affected body part(s):

1. Numbness and tingling in one or both feet;
2. Pain, burning or shooting pain in one or both feet;
3. Cramping in the feet, curling of the toes;
4. Many people have similar complaints in their hands;
5. In late cases there may be weakness or loss of control or power  in the hands or legs.

If you have any of the above symptoms on an ongoing basis, it is important to be evaluated and treated by a physician specializing in Peripheral Nerve Conditions, because left untreated, many patients will progress to more severe symptoms including:

1. Ulcers & Amputations: For those with Peripheral Neuropathy involving the feet, as they begin to loose feeling the risk of ulceration is real, especially for diabetics.  One in six will develop a ulcer or open wound on the foot. Once chronic infection develops it can be difficult or even impossible to heal.  It is estimated that one in six people with such an ulcer or wound will require amputation.
   
   Peripheral Neuropathy is the leading cause of amputation in the U.S., accounting for almost 100,000 annually in this country alone.
   
   In over 2000 cases of Peripheral Neuropathy, where the patient had the decompression surgery (described below in this section) performed by Dr. Daniller or his colleagues, not one has reported developing an ulcer or has required amputation.
   
   
2. Balance Issues:  As you lose feeling and sensation in your feet, you may lose the ability to feel the gas / brake pedals in your automobile, thus losing your ability to operate a motor vehicle.  Additionally, such loss of balance may lead to falls, which often result in broken hips, broken wrists, etc.

Over 90% of those who have had the nerve decompression procedure performed by Dr. Daniller have had significant to complete relief of their pain and restoration of the lost sensation restored to their feet sufficiently to avoid any related balance or issues.

A Note about Chemotherapy:

Certain Chemotherapy drugs are known to cause peripheral neuropathy, including:  Vincristine, Cisplatin and others.  Often this can be successfully treated with decompression surgery if found on examination to be due to compression or entrapment of a nerve.

Nerve Compression / Entrapment

In many cases of Peripheral Neuropathy (regardless of the cause) the symptoms of pain, tingling and / or loss of sensation may be caused by a co-existing compression or entrapment of one or more nerve fibers.  These compression injuries to the nerves may be caused by sports injury, repeated irritation or low level stress injury occurring over time (continuous trauma), or many other causes.  Probably the most common cause of nerve compression is swelling or inflammation of the nerve or other associated structures such as tendons and their lubricating layer
as they pass together through a tight unyielding anatomical tunnel. These tunnels are typically found in the extremities where they bend. The commonest well known tunnel is referred to as the carpal canal or tunnel between the wrist and the hand.  Other tunnels are found at the elbow, the knee, and the ankle.

When the nerve or surrounding tissues become inflamed or swollen as it passes through one of these tunnels of fixed volume, the nerves become squeezed entrapped  or compressed. This leads to a choking or “ischemia” of the soft compressible nerve  in essence acting like a small tourniquet, depriving the nerve fibers of adequate blood flow and nourishment.  This ischemia which interferes with the adequate function of the nerve results in a pain signal. The pain signal which is interpreted by different people in different ways, is the body’s way of signaling that something is causing a problem interfering with the function of the organ ( in this case the nerves ) involved. Depending upon many factors such as severity of the signal and other factors the patient will interpret the signal as tingling, burning, overt pain, or similar symptoms. As the fibers slowly die off numbness will develop until the nerve finally dies at which point there is no feeling and often no further pain. It is obviously important to find adequate help before this point is reached.  Not all patients will report pain before numbness or loss of sensation.

How do you know which nerves are being compressed?
Each nerve conducts signals to specific parts of the body.  For instance, the median nerve supplies sensation to your thumb, index and middle and half of the ring finger.  The origin of the median nerve as it leaves the spine is an area between your neck and collar bones, known as the “brachial plexus”. While compression or injury to the nerve mentioned can occur at any point from where the nerve exits the spine to where it enters the hand, the commonest point is at the wrist in the carpal canal/tunnel. A different nerve called the Ulnar nerve  supplies the little finger and the other half of the ring finger and can also be squeezed/compressed in different areas This may lead not only to loss of feeling but fine finger function,  as it also supplies some very important small muscles in the hand that control fine finger motion/movement. The strong power muscles for hand gripping are actually in the forearm, and are not usually effected unless the entrapment occurs above the wrist.  A physician experienced in diagnosing and treating peripheral nerve compression/function can identify at which particular tunnel or site the nerve is being compressed / injured. This can often be identified clinically at time of examination by the physician gently tapping along the path of the nerve to elicit a signal known as the tinel sign (the same sensation you would feel as when you hit your funny bone).

Most of the bottom of the foot (including some of the heel) is supplied by the posterior Tibial Nerve.  This nerve is subject to compression (similar to the Carpel Tunnel Syndrome in the wrist) in a bony tunnel located on the inside of the ankle known as the Tarsal Tunnel.   Compression of the Posterior Tibial Nerve can result in numbness or tingling of the heel, the arch, the ball of the foot, and the bottom and tips of the toes. The loss of sensation in the feet can cause a loss of balance,  a feeling of unsteadiness, and cause you to fall.

The Common Peroneal Nerve can be compressed at a tunnel located on the outside of the knee at the head of the fibula bone. And finally the deep Peroneal Nerve can become compressed at the dorsum (top) of the foot.  The compression of these Peroneal Nerves can cause symptoms of pain and / or loss of sensation at the top of the foot.  Recent studies indicate that the main nerve to the foot, called the Tibial Nerve, can also be compressed / entrapped behind the knee

In diabetics, due to swelling of the nerves (described in further detail below),  it is more common than not for multiple nerves to be compressed at multiple locations, often resulting in what has been described as a “stocking and glove” distribution of pain and / or loss of sensation, etc.   

Only a physician experienced in diagnosing nerve compression / entrapment can determine what particular nerves are involved and if decompression surgery is indicated.  An examination by such a physician will be necessary prior to the procedure to help you determine if such a procedure makes sense for you, and if so, what particular nerves will need decompressing. Electrodiagnostic tests while useful in the upper limb are at this time often not deemed sensitive enough to clearly record entrapment or compression in the lower limb.

Why is Nerve Compression more frequent in Diabetics than Non-Diabetics?
A common complication of Diabetes is referred to as Peripheral Neuropathy. Despite efforts to keep blood sugar good control, symptoms of Peripheral Neuropathy will still occur in about 50% of diabetics at some point.  Once the symptoms begin, they almost always get worse.  Currently, the exact cause of the presenting clinical symptoms commonly referred to as Diabetic Neuropathy  is controversial among medical scientists. There are several pain medications available for the pain and burning associated with peripheral neuropathy. Unfortunately they are often ineffective, must be taken in high doses or have undesirable side effects. There is general agreement that there is no known reliable medical treatment to prevent the progression of the symptoms once loss of sensation has started. It is at this point that it becomes especially important to be evaluated by a surgeon experienced in what we know is actually happening to the nerve and mostly responsible for the symptoms of pain. tingling, burning but more importantly LOSS OF SENSATION.

The reason it is so important to prevent or treat LOSS OF SENSATION is because when you loose the ability to feel your feet, balance issues may occur, which can lead to falls and broken bones / hips, etc.  Additionally, if you can’t feel your feet, you may not be able to feel the gas / break pedals in your automobile.  Additionally, most amputations in this country are a result of this loss of sensation leading to open wounds and ulcers of the foot and leg, which then get infected.   In most cases, there is no known way of returning sensation once lost other than by decompression.

The Peripheral Nerves that extend from your spinal cord to your fingers and toes pass through several anatomic areas of narrowing (or “tunnels”) along the way.   Among them, in your arm, these exist at the elbow (“funny bone”) and at the wrist there is the carpel tunnel; in the leg these tunnels occur at the fibular head (outside of the knee), at the inside of your ankle (known as the “tarsal tunnel”) and at the top of the foot.  Normally, these tunnels protect the nerves and hold them in place as they pass through these areas of the body that flex and extend back and forth.  Some people (both diabetic and non-diabetic) are born with anatomical structures i.e. tunnels that are too narrow, and therefore more likely to cause compression of nerves passing through them if some swelling or other space occupying structure such as swelling or a cyst develops requiring more space than what is available in the relatively narrow tunnel/tube.  However in the diabetic, there are additional factors that make the nerves even more likely to be compressed.

Basic science studies have strongly suggested that the most important factor is that Increased levels of glucose circulating in the diabetic also result in an increased uptake of this sugar into the nerves.  Aldose Reductase, an enzyme inside the nerve , converts the glucose into two smaller sugar molecules:  sorbitol and fructose.  These smaller sugar molecules are “hydrophilic”, meaning they attract water molecules, thus causing the nerves to swell.  Once the nerves become swollen (which at some point seems to become irreversible), they expand themselves within the tunnels, in essence, these nerves are being compressed or “choked” by the tunnel due to the increase size of the nerves within the narrow tunnels that due to their rigid walls are unable to expand to accommodate the increased volume of structures now running through them.

This results in the nerve being compressed thereby interfering with it’s adequate blood supply -- resulting in symptoms of pain, tingling burning and / or loss of sensation.  The pain is a signal sent by your body screaming for help because the nerves are not getting the nutrients and oxygen they need in order to function properly.  The “pins and needles”, loss of sensation, numbness and other similar symptoms are a result of these deprived sensory nerves losing their ability to function and send sensory messages back to the Central Nervous System (spine and brain).  Any loss of muscle function may be a result of the deprived motor nerves losing their ability to send messages from the Central Nervous system to the outlying portions of the body but only tend to develop relatively late in the process. Once this atrophy develops as in the muscles to the hand it is unlikely that the muscles will regenerate even if pressure is removed from the nerve.

If there are no known medical treatments available that can prevent the symptoms of Nerve Compression or stop its progression to more serious consequences, is there a surgical approach that is safe and effective?
There is a surgical approach to reverse the symptoms of nerve compression/entrapment and neuropathy that has proved safe and effective for many.

The most common of these types of nerve decompression surgeries is the well known “Carpal Tunnel Procedure” which can be performed in diabetics and non-diabetics alike.  It is among the most common hand surgeries in the U.S. and chances are that you may know someone who has had this procedure.

It is the successful experience obtained over many years in relieving the symptoms of nerve compression by decompression of nerves in the upper limb that has led to an understanding that the same process occurs in the lower limb and that decompression in the lower limb can similarly relieve symptoms of compression/entrapment.  It is part of the same peripheral nerve system and responds the same and with similar results.

The surgery in the upper limb commonly performed is best know as carpal tunnel surgery done for symptoms of Carpal tunnel syndrome once all medical attempts at helping have failed to take care of the problem.

These types of surgeries open the narrow tunnels constricting the peripheral nerves (thereby relieving the “choking” of the nerve) by making a small incision across a fibrous band or ligament that is constricting the nerve. This increases the space through which the nerve and or accompanying structures pass relieving the compression/constriction ring that the nerve is exposed to.

How Does This Type of Surgery Help the Nerve? 
According to Lee Dellon, professor of Neurosurgery at Johns Hopkins Medical School, who is considered an early pioneer in nerve decompression,

“Decompression of a peripheral nerve in a person with diabetes can alter the natural course or history of diabetic neuropathy by removing the tight areas along the length of the nerve that are symptom-producing regions of friction. "

Lee Dellon, M.D., Ph.D.  professor of Neurosurgery at Johns Hopkins medical school explains the benefits of the Nerve Decompression procedure he helped to develope on CNN.

The surgery to decompress the nerve does not change the basic, underlying metabolic (diabetic) neuropathy that made the nerve susceptible to compression in the first place. When the surgical decompression is done early in the course of nerve compression, restoration of blood flow to the nerve will stop the numbness and tingling, and permit strength to recover.    When the decompression is done later in the course of nerve compression, and nerve fibers have begun to die, decompression of the nerve will permit the diabetic nerve to regenerate…..Of course, if you wait too long to decompress the nerve, recovery may not be possible. If you already have ulcerations on your feet, or have lost toes, then very little sensation may be recovered because the damage to the nerve has become irreversible.”

When should Someone be Evaluated for Decompression Surgery?
The purpose of the Nerve Decompression Surgery is to reverse the symptoms and prevent further damage caused by Nerve Compression / Entrapment in both the diabetic and non-diabetic alike. In the Diabetic they may still have Diabetic Neuropathy (damage to the nerve itself caused by the diabetes);  but a significant percentage of the symptoms that cause the pain etc. and LOSS OF SENSATION have been shown to be due to a co-existing compression / entrapment as discussed. This is why it is important to be examined by a physician/surgeon experienced in diagnosing or treating this particular cause of the problem.

 There is a greater chance of completely reversing symptoms the sooner you come in for evaluation after you begin experiencing symptoms. (numbness and tingling in the hands or feet, or you notice any unexplained pain, weakness, loss of balance or loss of control of muscles in the hands or feet that persist.)  The patients that generally do the best are ones who come in before the hands or feet go completely numb and before any ulceration or amputation has developed.  The sooner one comes in for evaluation; the better the chances are to reverse the damage to the nerves caused by compression.

A Note for Diabetics -- It is important that you work with your primary care physician, your endocrinologist and diabetes care team to make sure that your diabetes is as well controlled as possible.  If the symptoms of neuropathy / nerve compression are not relieved by having your diabetes under good control, then surgery may be your only good alternative for halting or reversing the pain and or loss of sensation, which may lead to open wounds, ulcers, infection and amputation in some.

Evaluation

Prior to your examination, you may be screened on the telephone by a member of our staff to determine if there is a reasonable possibility that you may have a treatable peripheral nerve compression.  Most of the patients that pass this screening do turn out to have a treatable nerve compression, and they are offered surgery. The results of the surgery are good to excellent for most patients.

An examination by a physician specially trained in nerve decompression work is essential to determine if surgery is likely to benefit you and give you sufficient relief from your symptoms.

Not all persons who have Peripheral Neuropathy will be deemed eligible for the decompression procedure. You will not be offered the surgery unless;

1. the physician conducting the exam thinks there is sufficient evidence of a correctable nerve compression or entrapment,
2. that it is likely that the surgery will result in substantial or complete reversal of symptoms (pain and / or loss of sensation, etc.), and;             
3. your primary care physician and the surgeon agree that your general medical condition is of sufficient status to safely allow for the surgery.

Will I need to stay in the Hospital Overnight?
The surgery generally takes about two hours of operating room time plus about one hour in the recovery room.  Generally the procedure is done on an outpatient basis and the patient goes home the same day of the surgery.  Rarely, some patients may have a pre-existing condition or other medical reasons why it will be best and safer to stay one night in the hospital, such as to receive intravenous antibiotics, or to receive proper care for your heart or kidneys.

Does the Procedure Require Anesthesia?
General Anesthesia, in which you are put to sleep for the length of the operation, is most often easier for the patient.  On the legs, it may possible to have spinal anesthesia if you cannot tolerate general anesthesia, where just your legs would be put to sleep.  Occasionally, if there are medical reasons for you not to have general anesthesia, a local anesthesia may be used on a case by case basis.

What Should I bring For My Consultation with You?
It is helpful to have a letter of referral sent by your doctor. If you have diabetes, that letter should state how long you have had diabetes and what your current medications are, including your dose schedule for insulin or other medications you may be on, if any.  It is also helpful for diabetics to know the results of their most recent Hemoglobin A1c  test.

You do not need to bring x-rays with you.

If you have a nerve conduction test (EMG or NCV), you should bring a copy of the electrodiagnostic test with you, however, it is not necessary to have this test before your consultation.

What are the risks of the Surgery?
The published results of the Nerve Decompression Surgery for the treatment of the symptoms of neuropathy due to a co-existent nerve compression offer the best chance for the resolution of your symptoms.  The complication rate of this procedure is low. They will be carefully explained to you at time of evaluation and all questions answered including what can be expected in the period after surgery.

The biggest risk of the surgery is the risk of anesthesia, which with modern techniques is extremely low. Although very rare, severe complications are theoretically possible. This is why your past medical history is so important to us in selecting the safest anesthesia for your surgery and in selecting the appropriate type of medical facility in which you should have your surgery.

With any surgery, there is always the risk of bleeding, infection, scar formation, the unpredictable nature of the healing process and failure of the procedure to achieve its desired goal.

As of the writing of this page (January 1, 2009) there have been no major or persisting complications from any patient who has undergone the decompression surgery at NISC.

What is the Success Rate of the Procedure?

Over the past fifteen years, the results of this type of surgery have been carefully evaluated. Separate studies have been done, and reported between 1992 and 2000. These studies reached the same conclusion:

In a recent national study, about 80% of those diabetic patients who have had a nerve decompressed, have had decreased pain and improved sensory and motor function with improvement in balance.  At NISC, over 90% of our patients achieve good to excellent results (this is probably due to the superior training of our staff which includes extensive experience in micro surgery and the performance of nerve surgery).

The presence of ulcerations or previous toe amputation does not mean you are passed the point where you can be helped. Only a consultation can determine this.

A postoperative patient survey has shown that over the period of time that this surgery has been done; none of the patients had been admitted to the hospital for treatment of foot infection or ulceration. No patient has had an amputation.

While these results in no way guarantee that you will achieve an excellent outcome, they are suggestive of what can be achieved by this approach.

For More Information Please Call
(818) 758-0200