SLR - December 2023 - Pixton
Title: Does Lower Extremity Nerve Decompression Surgery Improve Quality of Life?Reference: Fakkel TM, Rinkel WD, Henk Coert J. Does Lower Extremity Nerve Decompression Surgery Improve Quality of Life? Plast Reconstr Surg. 2022 Dec 1;150(6):1351-1360. doi: 10.1097/PRS.0000000000009699. Epub 2022 Sep 27. PMID: 36161790.
Level of evidence: 3 Therapeutic
Reviewed by: Alexandra Pixton, DPM
Residency program: University Hospitals Regionals, Chardon, OH
Podiatric relevance: Significant morbidity and mortality is associated with peripheral neuropathy and sequelae of neuropathic ulcerations. Nerve entrapments can mimic not only neuropathic symptoms in the diabetic patient, but can also contribute to greater level of disease burden in patients with diabetic sensorimotor polyneuropathy.
Methods: A level III prospective study analyzing the outcomes of lower extremity nerve decompression (LEND) in 60 patients (15 bilateral and 45 unilateral). All patients exhibited a positive Tinel’s sign at the common peroneal nerve, superficial peroneal nerve, deep peroneal nerve, soleal sling, tibial nerve, and/or tarsal tunnel. Both short and long term results were evaluated to assess quality of life, incidence of surgical site problems, and predictors of outcomes. Norfolk Quality of Life Diabetic Neuropathy questionnaire (Norfolk QOL-DN), Michigan Neuropathy Screening Instrument score (MNSI), and the Rotterdam Diabetic Foot Study Test Battery were used for data collection and subsequent statistical analysis.
Results: Statistical analysis was performed in a 30 patient cohort with long term follow up data. Reduction in both Norfolk QOL-DN and MNSI scores, representative of symptom improvement, was observed in both median (6 mo.) and long term (>12 mo.) follow up. The decline in the MNSI score reported during the long term follow up was deemed statistically insignificant, and the authors attributed results to the objective nature of the MNSI and patient acclimatization to symptoms. Hypertension was correlated with worsening Norfolk QOL-DN scores following LEND. Wound complications were present in 10.9% of patients, and included simple surgical site infections or dehiscence. Quality of life outcomes were negligible between unilateral and bilateral cases.
Conclusions: Quality of life measures demonstrated improvement following lower extremity nerve decompression. Utilization of LEND, both in the setting of isolated nerve entrapments as well as in nerve entrapments compounded by diabetic sensorimotor polyneuropathy, increases patient quality of life. Prior LEND studies have excluded patients with non-palpable peripheral artery pulses and reported wound complication rates of 4.8%. Inclusion of the non-palpable patients correlates with the increased wound complication rate of 10.9% relative to prior LEND studies. Further investigation of modifiable risk factors, such as hypertension, is warranted to help guide appropriate patient selection. Following verification of entrapment, adequate perfusion, and addressing modifiable risk factors; I intend to employee LEND procedures in the managements of neuropathic patients. Preventing the formation of neuropathic ulceration is paramount in preventing amputation and preserving quality of life.