Decompression nerve surgery for diabetic neuropathy: a structured review of published clinical trials
Authors Albers JW, Jacobson R
Received 2 May 2018
Accepted for publication 13 June 2018
Published 24 September 2018 Volume 2018:11 Pages 493—514
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 2
Editor who approved publication: Professor Ming-Hui Zou
James W Albers,1 Ryan Jacobson2
1Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA; 2Department of Neurology, Rush University Medical Center, Chicago, IL, USA
Aim: To assess lower extremity decompression nerve surgery (DNS) to treat the consequences of diabetic distal symmetric peripheral neuropathy (DPN).
Research design and methods: MEDLINE, PubMed, and related registries were searched through December 2017 to identify randomized, quasi-randomized or observational trials that evaluated the efficacy of lower extremity DNS on pain relief (primary outcome) or other secondary outcomes. Observational studies were included, given investigators’ reluctance to use sham surgery controls. Outcome effect size was estimated, and a weighted average was calculated.
Results: Eight of 23 studies evaluated pain relief, including a double-blind randomized controlled trial (with a sham surgery leg), an unblinded trial with a nonsurgical control leg, and 6 observational studies. All reported substantial pain relief post-DNS with average effect sizes between two and five. Unexpectedly, the double-blind trial showed improvement in the sham leg comparable to the DNS leg and exceeding the improvement observed in the nonsurgical leg in the unblinded study. Sensory testing showed generally favorable results supporting DNS, and nerve conduction velocities increased post-DNS relative to deterioration in controls. Ultrasound revealed fusiform nerve swelling near compression sites. Morphological results of DNS were generally favorable but inconsistent, whereas hemodynamic measures showed a positive effect on arterial parameters, as did transcutaneous oximetry (improved microcirculation). The incidence of initial and recurrent neuropathic diabetic foot ulcers appeared reduced post-DNS relative to the contralateral foot (borderline significant).
Conclusion: The data remain insufficient to recommend DNS for painful DPN, given conflicting and unexpectedly positive results involving sham surgery relative to unblinded controls. The generally supportive sensory and nerve conduction results are compromised by methodological issues, whereas more favorable results support DNS to prevent new or recurrent neuropathic foot ulcers. Future studies need to clarify subject selection vis-à-vis DPN vs superimposed compressed nerves, utilize appropriate validated instruments, and readdress use of sham surgical controls in light of recent results.
Keywords: diabetic neuropathy, painful neuropathy, neuropathy treatment
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