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Operative Nervendekompression an der unteren Extremität bei diabetischer Polyneuropathie

Surgical decompression of the lower leg in painful diabetic polyneuropathy

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Zusammenfassung

Operationsziel

Schmerzreduktion, ggf. Einsparung von Schmerzmedikation, Verbesserung der Sensibilität, Verbesserung der Balance mit Stand- und Gangsicherheit, Verhinderung von Ulzerationen und Amputationen durch Dekompression der Nerven der unteren Extremität bei diabetischer Polyneuropathie.

Indikationen

Schmerzhafte Sensibilitätsstörungen bei diabetischer Polyneuropathie mit positiven Hoffmann-Tinel-Zeichen über dem Tarsaltunnel und einem Knöchel-Arm-Index >0,7.

Kontraindikationen

Diabetische Polyneuropathie ohne Schmerzen und Sensibilitätsstörungen. Fehlendes Hoffmann-Tinel-Zeichen über dem Tarsaltunnel, Arm-Knöchel-Index <0,7. Körpergewicht >140 kg. Relative Kontraindikation: venöse Stase und postthrombotisches Syndrom.

Operationstechnik

In Allgemein- oder Spinalnarkose erfolgt in Blutleere die Dekompression der Nerven der unteren Extremität an drei Lokalisationen: (1) N. peronaeus communis am Fibulaköpfchen mit Einkerbung des M. peronaeus longus und mikrochirurgischer Dekompression bis zur Aufteilung in den N. peronaeus superficialis und profundus. (2) N. tibialis in vier Höhen: (a) im Tarsaltunnel, (b) N. plantaris medialis im medialen plantaren Tunnel, (c) N. plantaris lateralis im lateralen plantaren Tunnel, (d) Rr. calcanei im calcanearen Tunnel. (3) N. peronaeus profundus am Fußrücken mit Resektion des M. extensor hallucis brevis.

Weiterbehandlung

Entlastung des Fußes für 3 Wochen, Ziehen der Fäden nach 3 Wochen, Aquagymnastik ab der 4. postoperativen Woche.

Ergebnisse

Bei insgesamt 12 der von uns operierten Patienten (Alter 64±9 Jahre; Operationsdauer 83±27 min; stationäre Verweildauer 6±2 Tage) erzielten wir nach durchschnittlich 12 Monaten (12±6) eine Schmerzreduktion nach der visuellen Analogskala von 7,1±1,2 präoperativ auf 3,3±2,4 postoperativ. Im Schulnotensystem war die Balance von Note 5±1 auf 2±1 verbessert, das Gefühl von 5±2 auf 3±1. Es traten keine Ulzerationen am dekomprimierten Bein auf. Amputationen waren nicht erforderlich. Zwei Wundheilungsstörungen am Fuß und eine Unterschenkelvenenthrombose zwei Wochen poststationär wurden konservativ behandelt.

Abstract

Objective

Surgical decompression of nerves of the lower leg should facilitate swelling-related pressure in diabetic polyneuropathic similar to carpal and cubital tunnel syndrome. Pain reduction, reduced need for pain medication, improved pedal sensitivity, improved balance and proprioception, and potential prevention of ulcerations and amputations are the objectives of the operation.

Indications

Diabetic polyneuropathy with positive Hoffmann-Tinel sign over the tarsal tunnel and an ankle-brachial index >0.7

Contraindications

No Hoffmann-Tinel sign over the tarsal tunnel, no pain, no sensibility disorders, ankle-brachial index <0.7, body weight >140 kg. Relative contraindication: venous stasis and postthromobitic syndrome.

Surgical technique

Under general or spinal anesthesia, tourniquet, decompression of nerves of the lower leg in three locations: (1) common peroneal nerve at the fibula head with incision of the peroneus longus muscle, (2) tarsal tunnel with its four tunnels: (a) tibial nerve in the tarsal tunnel, (b) medial plantar nerve in the medial plantar tunnel, (c) lateral plantar nerve in the lateral plantar tunnel, (d) Rr. calcaneare in the calcaneal tunnel, (3) dorsum of the foot with decompression of the peroneus profundus nerve with excision of the extensor hallucis brevis muscle.

Postoperative management

No weight bearing for up to 3 weeks, suture removal after 3 weeks, water aerobics starting postoperative week 4.

Results

A total of 12 patients (64±9 years) were operated and were followed up for 12±6 months. Procedure time was 83±27 min. Pain reduction on a visual analogue scale improved from 7.1±1.2 preoperatively to 3.3±2.4 postoperatively. Balance improved on a Likert scale (1=best, 6=worst) from 5±1 to 2±1, while sensory impairment improved from 5±2 to 3±1. There were no ulcerations or amputations. Two secondary wound healing problems at the ankle and one lower leg venous thrombosis 2 weeks following discharge were managed conservatively.

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  1. Plastische Hand- und Wiederherstellungschirurgie, Med. Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    K. Knobloch FACS, A. Gohritz & P.M. Vogt

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  1. K. Knobloch FACS
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  2. A. Gohritz
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  3. P.M. Vogt
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Correspondence to K. Knobloch FACS.

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Knobloch, K., Gohritz, A. & Vogt, P. Operative Nervendekompression an der unteren Extremität bei diabetischer Polyneuropathie. Oper Orthop Traumatol 24, 74–79 (2012). https://doi.org/10.1007/s00064-011-0096-9

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  • DOI: https://doi.org/10.1007/s00064-011-0096-9

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