Dr. Vincent Giacalone
Podiatric Medicine & Surgery
466 Hook Rd., Suite 24D, Emerson, NJ 07630
Peripheral Nerve Decompression and Neuropathy
What is “Diabetic Neuropathy”?
Diabetic Neuropathy is a complication of diabetes, which results in a reduced or complete lack of sensation and the ability to feel pain in the feet, and sometimes hands. There are two types of neuropathy, painful and painless. In a majority of patients, neuropathy develops painlessly and you may be unaware of the lost in ability to feel pain. This becomes dangerous due to the fact that if a blister, cut or irritation from a shoe or other type of trauma occurs, it may be unnoticed for some time. The delay in feeling the injury may be enough time for it to become infected and much more serious. A minority of patients develop the “painful” type of neuropathy. This causes a host of painful sensations, ranging from a mild tingling to a severe burning of the feet. Most patients develop the painless type, where the nerves are being damaged without warning. Many patients with neuropathy also have balance and muscle strength problems, resulting in a greater risk of tripping and falling.
The nerves in your feet connect to the brain similar to an extension cord brining electricity to a lamp. If the extension cord gets damaged and develops cracks and you touch it, you get a shock. This is similar to the “painful” type of neuropathy where the nerve becomes damaged and gives you pain or “shocks”. Sometimes, if the extension cord damage is bad enough, it blows a fuse or trips the circuit breaker and no electricity flows through the cord. The same is true for neuropathy, if allowed to progress the nerve may stop working, resulting in no feeling in the feet at all. In the painless type the circuit breaker trips or the fuse blows, very often without any symptoms.
What causes neuropathy?
Diabetic neuropathy, also called diabetic peripheral sensory neuropathy, is basically caused by prolonged elevation in blood glucose levels over time, although the exact cause of diabetic neuropathy has yet to be proven with 100% accuracy. This may be due to the fact that the cause is slightly different for each patient. However it has been well established that diabetes causes two distinct problems for the nerve. One is the fact that the increased blood glucose causes the nerves to swell. The second is that it causes ligaments and tendons to shrink or tighten. There are three areas in each leg and foot where a nerve, which looks like a wire, travels under or through a tunnel made up of ligament type tissue. Normally when we walk the nerve is free to move easily within the tunnel. Imaging now that the combination of the nerve swelling and the tunnel shrinking will cause a choking of the nerve, or nerve compression. This is similar to wrapping a rubber band around your finger, pinching or choking the blood vessels and nerves.
Each person is different in as far as the length of time it will take or the level of blood glucose elevation before neuropathy may begin to develop. However the longer high blood glucose levels are allowed to continue, the greater the chance damage to the nerve and compression will begin. Neuropathy usually will not develop overnight; however can come on quickly, within a matter of months in some cases.
How do I know if I have neuropathy?
Most patient begin to develop neuropathy are unaware of the nerve damage being done, because in most patients it happens painlessly, with no symptoms at all. Therefore it is very important to have your feet checked by Dr. Giacalone at least annually. If he determines that you have neuropathy, more frequent visits may be recommended. You may however see several sign on the foot indicating you have injured your foot painlessly. Noticing a blood blister, dark discoloration (dried blood) within a corn or callus or blood under a toenail, without associated pain, is often a significant clue in detecting neuropathy. In addition, you may see the rapid development of hammertoes or bunions or other changes in the foot’s shape. Some patients who develop neuropathy will begin to experience symptoms such as tingling, burning or a sensation of heaviness, stiffness or tightness in the feet. Generally these sensations begin to develop prior to a reduction or permanent lack of sensation, although the two may occur together. If properly treated and blood glucose is brought under tight control, at this point the risk of permanent sensation loss can be reduced.
Is having diabetic neuropathy dangerous?
Having diabetic neuropathy places you at a higher risk of developing a diabetes related foot complication, such as an ulcer (sore), infection or amputation. Loosing feeling also places you at a greater risk for falling. The lack of feeling or ability to feel pain can allow a problem, such as a blister, sore, ingrown toenail, cut, etc., to persist for a long enough period of time to become a more serious complication, prior to being noticed. Pain usually alerts us that there is a problem, however with neuropathy there is no such warning and the problem gets worse. If unrecognized and left untreated, even for 24 hours, a seemingly small problem, (a swollen toe or a cut) can quickly become a very serious infection. Having diabetes also increased your risk of infection and slow healing. If you couple a cut, which is unnoticed for a day or so, with an increased potential towards infection and slow healing, the result can be disastrous. Learning how to use your eyes every day to check for problems, and not relying on pain to tell you something is wrong, becomes very important.
If I have neuropathy, can it be treated?
Yes. A procedure called Peripheral Nerve Decompression is the only treatment which targets the cause of neuropathy and reverses the condition in patient who meet the surgical criteria. Oral medication may help with the pain and abnormal sensations, however do not address the actual cause.
What is the Peripheral Nerve Decompression Procedure?
This is an out-patient (same day surgery) surgical procedure, which is performed in the hospital or surgery center to decompress the three nerves, one just below the knee, one at the inner ankle and the last one on the top of the foot. The procedure is performed under general or spinal anesthesia and takes approximately one and one half hours to complete. The basis of the procedure is to open the tunnel in which the nerve is being compressed, similar to cutting the rubber band wrapped around your finger. The nerve itself is not operated on. This procedure is performed using special visual instruments called loupes, which allows Dr. Giacalone to see the nerves very clearly.
How do I know if I am a candidate for the procedure?
Most patient on whom the procedure is performed have either painful neuropathy, loss of feeling or numbness and or balance problems with or without difficulty walking. If you have any of these symptoms, Dr. Giacalone will perform a series of simple test in order to determine if you are a good candidate for the surgery. Additionally your circulation and diabetes control will also be evaluated and play an important role in Dr. Giacalone’s decision.
What do I need to do prior to the surgery?
Before you can have this procedure you must see your primary care doctor for medical clearance. This may include a physical examination, blood tests, chest x-ray and EKG. Dr. Giacalone will be in contact with your medical doctor to discuss your surgery.
Can both legs and feet be operated on at the same time?
No, only one leg and foot can be operated on at a time, allowing at least three months before the other leg/foot can be operated on.
What can I expect after the surgery?
You may go home within several hours after the procedure and will be allowed to walk on your leg and foot. You do not need crutches or a cast. Dr. Giacalone will discus just how much weight you may put on your foot and how much walking you can do. Some patients may need to use a walker or cane for a week or so. You will return to see Dr. Giacalone approximately 3 days after the procedure and again 10-14 days later when the stitches are removed. Due to neuropathy, most patients have minimal pain following the surgery. Pain relief and sensation recovery can take up to 6 months to reach maximum benefit. Nerves recover and regenerate slowly, which is why patients improve slowly over the course of 6 months.
What is the success rate of the procedure?
Generally, in patients who meet certain criteria, the success rate is approximately 80% by the end of the 6th month. Dr. Giacalone can share with you his personal results as well as those of published medical studies.
How was the procedure developed?
The procedure was first developed in the late 1980 by a Johns Hopkins University plastic and hand surgeon, Lee Dellon, MD. Dr. Dellon has refined and performed this procedure on thousands of patients over the years with excellent results. Dr. Giacalone has been personally trained by Dr. Dellon to perform this surgery at his hospital in Baltimore. To date there are approximately 220 surgeons nationally, like Dr. Giacalone, trained to perform this procedure.
Dr. Giacalone has been trained specifically and extensively in the diagnosis and medical and surgical treatment of foot disorders. He has been specially trained in the nerve decompression procedure by Dr. Lee Dellon of Johns Hopkins University, who developed the procedure. Dr. Giacalone has been board certified by The American Board of Podiatric Orthopedics and The American Board of Podiatric Surgery since 1993 and is a Fellow of the American College of Foot and Ankle Surgeons. He also practiced at the Hospital for Joint Diseases in New York City. Dr. Giacalone performs surgery at Hackensack University Medical Center (HUMC) in Hackensack and HUMC @ Pascack Valley in Westwood and Surgicare Surgical Center in Oradell.