STAGE AT WHICH REFERRED

Clinical DiagnosisClinical Diagnosis Detailed clinical history Assessment of arterial circulation

– Peripheral pulses Assessment of venous circulation

– Resting & standing venous filling– Varicosities– Skin colour

Vascular study– MRI angiography, Doppler– Invasive angiography

Clinical DiagnosisClinical DiagnosisNeurological

– Autonomous Temperature Scaling of skin – nails – hair Sweating & dryness of skin Return of circulation on release of pressure

– Sensory [EMG] Hyperaesthesia Anaesthesia

– Motor Muscle weakness, paralysis -- deformities

Electrodiagnostic Electrodiagnostic Classification of Classification of Neuropathies in Neuropathies in

Diabetes MellitusDiabetes Mellitus

Dr. Bhavna Doshi, Dr. Bhavna Doshi, Dr. K. A. Dr. K. A.

Mansukhani, Tejas Mansukhani, Tejas BhojrajBhojraj

Electrodiagnostic Classification of Neuropathies in DMElectrodiagnostic Classification of Neuropathies in DM DiscussionDiscussion

Diabetic Neuropathy referrals formed only 7.3% of the total referrals which is surprising as type 2 Diabetes Mellitus has a prevalence of about 12 to 18% in the age group 25 to 75 years, and about 17 to 19.1% of them have diabetic neuropathy.

64% of the study group had moderately severe and chronic sensory-motor peripheral neuropathy and were undergoing electrodiagnostic examination for the first time. This suggests that diabetic neuropathy is under-diagnosed or under-investigated.

Section of a Normal Nerve with Section of a Normal Nerve with Myelinated Fibres & Good Myelinated Fibres & Good

VascularityVascularity

Diabetic Nerve Shows Thickening of the Diabetic Nerve Shows Thickening of the Nerve Sheath As Well As of the Vessels Nerve Sheath As Well As of the Vessels

With Demyelination of the Nerves at With Demyelination of the Nerves at PlacesPlaces

Deformities

SKIN GRAFT STABLE 2YRS. POST-OP. BUT SHOWS ULCERATION OF RIGHT FOOT .

Complete healing of ulcer.Complete healing of ulcer.

OPERATION TO IMPROVE OPERATION TO IMPROVE BLOOD SUPPLY - BYPASSBLOOD SUPPLY - BYPASS

Releasing the tight constriction from around nerves & blood vessels

Preventive Surgery

•Relieves pain •Protective sensation returns

Nerves Released in Leg• Tibial • Common Peroneal• Deep Peroneal• Superficial Peroneal

Sites of Tibial Nerve

compression in region of ankle and lower leg

Common Peroneal n

Superficial Peroneal n

DeepPeroneal n

Entrapment sites of

Peroneal Nerve

NEAR KNEE

FOOT

Tendon Lengthening

ANKLE

6.87.510 mths

POST

2.95.3PRE

At amp

Ankle amp

NCS Lt Tibial

BC

L.FOOT HEALED FOLLOWING DECOMPRESSION BUT R . FOOT DEVELOPED SEVERE BURNS

INJURY

DECOMPRESSION

OFFERED BETTER

SENSATIONS AS

WELL AS HELPED

HEALING OF THE

ULCER

IMPROVEMENT IN THE NERVE

CONDUCTION AFTER A PERIOD OF

9 MONTHS.

DM

Rec Site Amp2-4mV

La ms Date

AH 1.2 5.00 26/02/01

AH 15.2 4.35 22/11/01

YEAR TOTAL CASES TREATED FEMALE NEUROLYSED

2000 20 4 7

2001 25 4 7

2002 15 3 1

2003 22 5 5

2004 23 4 32005 22 4 4

2006 10 2 1

Patients neurolysed 25Male 17Female 8 Nerves total 28Bilateral release 3Ulcerated side neurolysed 9Died 5

Age group

35-45 446-55 756-65 866-85 6

ID NAME M/F

AGE DIAG CLINICAL

DATE NEUROLYSI

S

NEUROLYSIS

1 SP F 56 rt dmf Rt great toe gangrene 28/01/2000 Lt

2JA M 44 b/l dmf b/l neuropathic

Daibetic feet

21/07/2000 Lt

3 18/08/2000 Rt

4 TS F 70 rt dmf Rt plantar ulcer 25/08/2000 Lt

5DT M 50 lt dmf Lt plantar

aspect necrosis

02/09/2000 Rt

6 08/09/2000 Lt

7 KB F 45 lt dmf 2 plantar ulcers L foot 15/09/2000 Lt

NEUROLYSED

ID NAME GENDER AGE DIAG CLINICAL

DATE NEUROLY

SIS

NEUROLYSI

S

8 NB M 50 lt dmf Lt 5th toe gangrene 24/02/2001 Rt

9 MG M 60 rt dmf rt leg necrotizing fasciitis 02/03/2001 Lt

10 BK M 55 rt dmf rt great toe ulcer 08/03/2001 Lt

11 YV M 60 rt dmf 24/03/2001 Lt

12 LG M 58 rt dmf Neuropathic pain 13/07/2001 Lt

13 MN F 35 lt dmf Lt foot blackened skin 14/09/2001 Rt

14 NS F 75 28/12/2001 Rt

15 AS M 67 rt dmfrt 1st mt ulcer,, 2nd

3rd toes tips ischaemic

13/09/2002 Rt

ID NAME M/F AGE DIAG CLINICALDATE

NEUROLYSIS

NEUROLYSIS

16 GS M 53 lt dmfLt tation of 1st 2nd toes ampu;

raw areas 07/11/2003 Rt

17 PR M 43 lt dmf Lt cellulitis upto thigh 14/11/2003 Rt

18 SP M 69 lt dmf Lt dmf lt knee raw area 15/11/2003 Rt

19 MD F 60 rt dmf rt foot heel ulcer 29/11/2003 Rt

20 NK M 63 lt dmf abscess lt foot; 26/12/2003 Rt

21 KJ M 53 b/l dmf chronic callosities both 1st MPJs 07/02/2004 Rt

22 SS F 60 b/l dmf 1st mt head ulcers 08/10/2004 Rt

ID NAME M/F AGE DIAG CLINICALDATE

NEUROLYSIS

NEUROLYSIS

23 FA F 67 Rt dmf Rt charcot 22/01/04 Lt

24 FA F 67 Rt dmf Rt charcot 2/03/05 Rt

25 BC M 55 Lt dmf Lt gr toe amp 7/03/05 Lt

26 BJ 52 Lt dmf Lt nec fascii 28/10/05 Rt

27 SB 63 Lt dmf Lt forefoot plantar necrosis 16/7/05 Rt

28 TR 82 Bil dmf Gr toe pl ulcer 12/5/06 Rt

Planned incision

Upper limit of stocking sensory loss

Tinel’s Sign

Extent of release Incision sutured

GS

Tibial nerve at ankle

Tibial nerve going under soleus

Upper limit

GS

7th Nov 2003

PRE-OP upper limit of ‘stocking’ anesthesia

28th Nov 2003

21 DAYS POST-OP line of hyperesthesia

GS

SS

Tinel’s sign

B

A

CD

SSCompression like rungs of ladder

Severe Fibrosis

SS

6W POST NEUROLYSIS

PRE-NEUROLYSIS

Nerve Site Rec SiteAmp Lat

Pre 6w Post Pre 6w

post

R Tibial

Below ankle AH 2.0 2.0 4.35 3.65At ankle AH 0.9 1.9 5,70 4.85

Knee AH 0.6 1.8 16.25 14.4

PRE-RELEASE

6wk POST

KJ Release of the Vessels

Cross compression due to the perforators

AS

Release of the ArteryExtent of Release of the Nerve

Level of stocking anaesthesia

Benefits of DecompressionBenefits of DecompressionEarly onset of feeling of improved

sensationImprovement of circulationEase of walking Reduction of tirednessFreedom from crampsHealing of ulcers, absence of recurrence

Pirate Amputation

Amputation Diabetes ≠=