dr. s. tambwekar

8. STAGE AT WHICH REFERRED

9. 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

10. Clinical DiagnosisClinical Diagnosis
Neurological
– 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

11. ElectrodiagnosticElectrodiagnostic
Classification ofClassification of
Neuropathies inNeuropathies in
Diabetes MellitusDiabetes Mellitus
Dr. Bhavna Doshi,Dr. Bhavna Doshi,
Dr. K. A.Dr. K. A.
Mansukhani, TejasMansukhani, Tejas
BhojrajBhojraj

13. 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.

14. Section of a Normal Nerve withSection of a Normal Nerve with
Myelinated Fibres & GoodMyelinated Fibres & Good
VascularityVascularity

15. Diabetic Nerve Shows Thickening of theDiabetic Nerve Shows Thickening of the
Nerve Sheath As Well As of the VesselsNerve Sheath As Well As of the Vessels
With Demyelination of the Nerves atWith Demyelination of the Nerves at
PlacesPlaces

16. Deformities

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

29. Complete healing of ulcer.Complete healing of ulcer.

31. OPERATION TO IMPROVEOPERATION TO IMPROVE
BLOOD SUPPLY - BYPASSBLOOD SUPPLY - BYPASS

33. Releasing the tight constriction
from around nerves & blood
vessels
Preventive Surgery
•Relieves pain
•Protective
sensation returns

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

35. Sites of Tibial
Nerve
compression in
region of ankle
and lower leg

36. Common
Peroneal n
Superficial
Peroneal n
Deep
Peroneal n
Entrapment
sites of
Peroneal Nerve

37. NEAR KNEE
FOOT
Tendon Lengthening
ANKLE

38. 6.87.5
10 mths
POST
2.95.3PRE
At
amp
Ankle
amp
NCS
Lt Tibial
BC

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

47. DECOMPRESSION
OFFERED BETTER
SENSATIONS AS
WELL AS HELPED
HEALING OF THE
ULCER

55. IMPROVEMENT IN
THE NERVE
CONDUCTION AFTER
A PERIOD OF
9 MONTHS.
DM
Rec Site Amp
2-4mV
La ms Date
AH 1.2 5.00 26/02/01
AH 15.2 4.35 22/11/01

56. 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 3
2005 22 4 4
2006 10 2 1

57. Patients neurolysed 25
Male 17
Female 8
Nerves total 28
Bilateral release 3
Ulcerated side neurolysed 9
Died 5
Age
group
35-45 4
46-55 7
56-65 8
66-85 6

58. ID NAME
M
/F
AG
E
DIAG CLINICAL
DATE
NEUROLYSI
S
NEUROLY
SIS
1 SP F 56 rt dmf
Rt great toe
gangrene
28/01/2000 Lt
2
JA 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
5
DT 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

59. ID NAME
GEND
ER
AGE DIAG CLINICAL
DATE
NEUROLY
SIS
NEUR
OLYSI
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 dmf
rt 1st
mt ulcer,, 2nd
3rd toes tips
ischaemic
13/09/2002 Rt

60. ID NAME M/F AGE DIAG CLINICAL
DATE
NEUROLYS
IS
NEUROL
YSIS
16 GS M 53 lt dmf
Lt 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

61. ID NAME M/F AGE DIAG CLINICAL
DATE
NEUROLYS
IS
NEUROL
YSIS
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

62. Planned incision
Upper limit of stocking sensory loss
Tinel’s Sign
Extent of release Incision sutured
GS

63. Tibial nerve at ankle
Tibial nerve going under soleus
Upper limit
GS

64. 7th
Nov 2003
PRE-OP upper limit of ‘stocking’ anesthesia
28th
Nov 2003
21 DAYS POST-OP line of hyperesthesia
GS

65. SS
Tinel’s
sign

66. B
A
C
D
SS
Compression like rungs of ladder
Severe Fibrosis

67. SS
6W POST
NEUROLYSIS
PRE-NEUROLYSIS

68. Nerve Site Rec Site
Amp Lat
Pre
6w
Post
Pre
6w
post
R
Tibial
Below ankle AH 2.0 2.0 4.35 3.65
At ankle AH 0.9 1.9 5,70 4.85
Knee AH 0.6 1.8 16.25 14.4
PRE-RELEASE
6wk POST

69. KJ
Release of the Vessels
Cross compression due to the perforators

70. AS
Release of the Artery
Extent of Release of the Nerve
Level of stocking anaesthesia

71. Benefits of DecompressionBenefits of Decompression
Early onset of feeling of improved
sensation
Improvement of circulation
Ease of walking
Reduction of tiredness
Freedom from cramps
Healing of ulcers, absence of recurrence

72. Pirate Amputation
AmputationDiabetes ≠
=