What is Diabetic Neuropathy?
Neuropathies are forms of nervous system disease, which results in impaired sensation to the ghands and feet. Diabetic neuropathy is the direct result of advanced glycosylated end products (AGE). AGE essentially causes the havoc played on the fascia by uncontrolled sugar (glucose) levels. The fascia is literally coated with the end products, making them narrower. This reaction is called the Maillard reaction. Due to uncontrolled glucose levels, there is nerve swelling. Swollen nerves and tighter fascia in the three "tunnels" affected in the lower extremity cause the symptoms of burning, tingling and pain. These tunnels are the tarsal, fibular and anterior tarsal.
"Diabetic neuropathy has always been thought to be an irreversible disease, and when the patient suffered damage to the nerve there was nothing that could be done to reverse it," says Jacoby — "this is true to a certain extent because as long as a patient is diabetic, they are susceptible." Although it is true that the underlying metabolic abnormalities of diabetes make the peripheral nerves most susceptible to chronic nerve compression, today there is a truly revolutionary procedure that is changing the lives of diabetic patients, The Dellon Procedure.
The Dellon Procedure involves decompressing multiple nerves of the lower extremities. Decompressing means to create a bigger opening in the fascia, so that the nerves are no longer compressed. A. Lee Dellon, M.D., is a plastic surgeon/hand surgeon who had been operating on his diabetic patients for carpal tunnel syndrom for a number of years. Many of this patients had asked repeatedly if he couldn't do something for their feet and legs. This led him to seek answers and to check the research in this field. After much research, he developed his technique to decompress the leg "tunnels," just as he had for their carpal tunnels. He translated the techniques for the median, ulnar and radial decompression in the hands, to those comparable sites in the feet. He and his patients soon found that the pain symptoms went away, and that sensation that had been lost in the legs and feet, now returned. Basically the surgery decompresses the tunnels by making them bigger, thus restoring the function of the nerves. Once the pressure is off the nerves, the nerve function is restored. Also, the risk for ulceration and amputation is now lessened.
Basically there are two types of diabetic patients suffering from neuropathy that are seen by Dr. Jacoby. The early stage, where they have extreme pain, and the later-stage patients, who have lost sensation and are prone to ulceration and gangrene. Of the patients that Dr. Jacoby sees, 50 percent are diabetic, 25 percent are prediabetic, Syndrom X, and the other 25 percent have neuropathy of idiopathic origins. Some of these patients may have elevated cholesterol, elevated BMI or have symptomology due to environmental toxins. The later-stage patients whose pain are masked by medications, may have their bodies' alarm systems altered and may undergo amputations as a result of ulceration. In their case, the neuropathy is advancing, and the pain or lack of pain, which is a barometer of how the disease is advancing, is masked. Neuropathy actually precedes frank diabetes. Patients will complain of tingling, numbness and burning. Some of Dr. Jacoby's patients are unaware that they are diabetic, and the other group knows they are, and have pain and are on medications to relieve the pain.
The Scottsdale Neuropathy Institute is dedicated to the care of neuropathic pain of the lower extremity, both medically and surgically. Dr. Jacoby believes that the patient history and physical is of primordial importance. The institute's testing modalities, which are "quantitative sensory testing," include the PSSD, and the nerve conduction velocity equipment, a computer-assisted device. Both testing modalities are noninvasive and painless, which makes the office visit a happier one for the patient.
The Controlled Diabetic Patient
The Scottsdale Neuropathy Institute strives to help patients control their disease by advocating better nutritional regimens and will guide patients to seek nutritional advice in order to better maintain their health. Nutritional supplementation for small fiber neuropathies has been shown to assist patients in gaining better health. All avenues of better lifestyle are advocated. It is precisely the controlled diabetic who shows positive Tinel sign over the tibial nerve in the tarsal tunnel, good PSSD results and a positive provocative sign who makes the ideal candidate for The Dellon Procedure. The PSSD, pressure specified sensory device, is the most efficient tool for finding sensory deficits in the lower extremities. It not only quantifies, but records specific peripheral nerve threshold levels and peripheral nerve innervation density. PSSD testing can note pathology at sub-clinical levels. Nerve conduction velocity equipment can differentiate between radiculopathy, distal motor/sensory neuropathy and lower back pathology.
Dr. Jacoby has been practicing for more than 30 years and finds most challenging not only the daily patient load, but also that cohort of patients who has multiple comorbidities, such as kidney and cardiac disease. It is this cohort that needs special attention and work-up to get them ready for surgery. Unfortunately, even though many could benefit from this surgery, they cannot undergo it due to their comorbidities.
The Scottsdale Neuropathy Institute is conducting multiple studies on neuropathy, diabetes and neuromas at present. The institute has found that neuroma pain may be an initial indicator of prediabetes. Appropriate and quick action in the prediabetic stage can preclude the patient from becoming diabetic.
Dr. Jacoby has been associated with the Scottsdale Memorial Wound Care Center for more than 5 years. Working with the diabetic population, he was dissatisfied with the results he wanted for his patients. After reading about the Dellon technique, he enrolled in the course at Johns Hopkins. After five years of using this surgical technique and 700 patients later, Dr. Jacoby says, "We are achieving over 85 percent excellent results, with no amputations for my patients. One of the most profound things we are doing is treating a disease that was considered not treatable."
There are 250 Dellon trained surgeons who have trained with Dr. Dellon at Johns Hopkins, and Dr. Jacoby is one of them. Only these peripheral nerve surgeons are specially trained in the Dellon technique, and only these surgeons may register their patients on the International Neuropathy Decompression Register.
Dr. Jacoby has been affiliated with the Scottsdale Family Practice Residency Program. For almost 25 years, residents have rotated through his practice, and now they are being exposed to this revolutionary new surgical technique. Future practitioners are learning how to save limbs and enhance quality of life for these patients.
Knowledge of the Dellon viewpoint is a most powerful tool. "We were taught never to operate on a diabetic patient, but they actually heal quite well. Of course, we take extra precautions," says Jacoby. "And the rewards for the patients and myself are dramatic." One of his first patients came to the office in a wheelchair. After the surgery, she was walking so well that her husband took her to Hawaii for a vacation. She fell on a lava bed and hurt her arm. Her arm was in a sling for her follow-up visit, but she walked in. There are 700 patient success stories "walking" in the community, instead of being attached to their wheelchairs. There will be more every day.