Practice Advisory: Utility of surgical decompression for treatment of diabetic neuropathy

Surgical decompression at the site of anatomic narrowing has been promoted as an alternative treatment for patients with symptomatic diabetic neuropathy. Systematic review of the literature revealed only Class IV studies concerning the utility of this therapeutic approach. Given the current evidence available, this treatment alternative should be considered unproven (Level U). Prospective randomized controlled trials with standard definitions and outcome measures are necessary to determine the value of this therapeutic intervention. NEUROLOGY 2006;66:1805–1808 Diabetic peripheral neuropathy (DPN) is a common complication of diabetes. Population-based cohort studies have shown that 66% of type I and 59% of type 2 diabetics have objective evidence of peripheral neuropathy.1 Complications of DPN are a major cause for hospitalization among people with diabetes, and neuropathy ranks third in lifetime expenditures associated with the complications of diabetes, behind macrovascular disease and nephropathy.2 Several evidence-based reviews for treatment modalities for DPN are available.3-7 Surgical decompression of multiple peripheral nerves is being utilized as an alternative approach to treatment of symptomatic diabetic neuropathy.8-15 This is based on the hypothesis that diabetic nerves are more vulnerable to compressive injury at potential sites for entrapment.16-18 This forms the “double crush” or “double pathology” hypothesis,19 a term originally coined for increased susceptibility of nerves with proximal and distal compressive lesions.17 The metabolic stress of diabetes is the first crush, and compression of the nerve at the potential site of entrapment will cause the second crush. According to this hypothesis, most patients remain asymptomatic despite having diabetic nerve disease. Only when the second pathology occurs (compression of the nerves at entrapment sites) will the patients become symptomatic. Thus it has been hypothesized that symptoms in diabetic sensorimotor neuropathy may be due, in part, to compression of multiple peripheral nerves.19 Although this hypothesis has some experimental support,17,20-22 evidence to the contrary showing resistance to axonal degeneration after nerve compression also exists.23 More than 240 surgeons in 41 states in the United States and in 15 different countries have been trained to perform the decompressive surgery.24 As of January 31, 2006, 1,280 surgeries on 990 patients by 34 surgeons have been registered in the International Neuropathy Decompression Registry sponsored by the Diabetic Neuropathy Foundation of the Southwest (http://www.neuropathyregistry.com/). The public interest about this subject has generated several communications both to individuals and to organizations to develop a statement on this topic. Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of