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Improvement of Blood Flow in Patients with Diabetic Neuropathy by Decompression of the Sympathetic Fibers within the Tibial Nerve
Sofija Pejkova, MD PhD1; Sofija Tusheva, MD1; Blagoja Srbov, MD1; Bisera Nikolovska, MD PhD1; Savetka Paljoskovska, MD2; Stefania Azmanova Mladenovska, MD1; Gordana Georgieva, MD1
1University Clinic for Plastic and Reconstructive Surgery, Medical Faculty, University "St.Cyril and Methodius", Skopje, Macedonia, The former Yugoslav Republic of; 2University Clinic for Cardiology,Medical Faculty, University "St.Cyril and Methodius", Skopje, Macedonia, The former Yugoslav Republic of

Purpose: It has been shown that the tibial nerve in the tarsal tunnel contains sympathetic fibers. It is known that decompression of the tibial nerve in the four medial ankle tunnels can improve sensation, relieve pain and prevent ulcers and amputation. The hypothesis of this research is that decompression of the tibial nerve will improve sympathetic nerve function in the diabetic foot as demonstrated by improved blood flow. Method: Twelve patients with diabetic neuropathy had blood flow to their feet evaluated by Doppler ultrasonography of the posterior tibial artery. The Doppler used was GE Vivid7, 10 MHz, performed by an experienced vascular specialist. The average time of onset of diabetes in our study group was 64 months (range 42-96 months. The average age of the patients was 56.8 years (range 37-65 years). Preoperatively sensory symptoms were evaluated with Michigan Neuropathy Screening Instrument (MNSI) and sensibility evaluated using two-point discrimination, measured in the big and little toe pulp, and medial heal. Surgery, was a “Dellon Decompression” of the four medial ankle tunnels, meaning the tibial nerve and its branches. The follow-up period ranged 3 to 5 months. At the time of follow-up, the blood flow was measured again as well as the MNSI and evaluation of sensibility. Statistically, pre-operative and post-operative measurements in the same subject, as well as comparison of the operative decompressed and non-operative control legs values were considered to be matched pairs. Results: The MNSI and two point discrimination were taken as evidence that the surgical decompression had been successful for the sensory component of the tibial nerve. The neuropathy symptoms evaluated by MNSI were significantly reduced from mean score 12.5 pre-operatively to 7.7 post-operatively (p<0.0001). Furthermore, by comparison of the peripheral nerves’ sensory function (Medical Research Council grading) in the operative vs. control foot, of the same patient, statistically significant differences were identified regarding the medial plantar nerve and lateral plantar nerve, as well as the calcaneal nerve (p=0.002). This confirmed that the tibial nerve sensory decompression was successful. For blood flow, the results revealed that flow evaluated by Doppler ultrasonography in the posterior tibial artery improved significantly from mean value 38.5 to 61.8 cm/s after decompression of the tibial nerve (p<0.0001), confirming improved sympathetic nerve function. Conclusion: By decompressing the sympathetic fibers within the tibial nerve at the ankle, blood flow can be improved in patients with diabetic neuropathy and superimposed chronic nerve compression.


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