The role of peripheral nerve surgery in diabetic limb salvage

Background: Peripheral neuropathy is highly prevalent among patients with diabetes mellitus and demonstrates well-established consequences of limb loss following lower extremity ulceration, infection, and amputation and upper extremity loss of function. Symptomatic neuropathy is recognized by neuropathic pain, paresthesias, and the development of trophic limb changes. The objective of this review is to define the role of peripheral nerve surgery in the treatment of diabetic patients with upper or lower extremity symptomatic peripheral neuropathy and/or chronic postoperative pain. Methods: At locations of decreased anatomical cross-sectional area, compression points impinge on peripheral nerve fascicles, and because of a synergistic effect of the metabolic derangements of diabetes, these points of compression are implicated in nerve abnormality and dysfunction. The surgical outcomes literature following decompression is reviewed, and specific recommendations are made for appropriate surgical candidate selection. In addition, the operative techniques used in peripheral nerve surgery are outlined. Results: Peripheral nerve surgery for diabetic peripheral neuropathy is indicated when symptoms of pain, allodynia, or trophic changes persist despite optimization of medical management. Surgical treatment is considered an adjunct therapy to medical optimization and should be used when there is clinical and/or electrodiagnostic evidence of compression neuropathy or a postsurgical neuroma-related chronic pain syndrome that is refractory to conservative management. Conclusion: Review of available reports in the surgical literature demonstrates that the results of peripheral nerve surgery are promising for the prevention of limb loss in chronic diabetes mellitus, for diminishment of pain, and for restoration of sensory/motor function.