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Approximately 21 million Americans suffer from Peripheral Neuropathy or
damage to the peripheral nerves. There are over 100 causes for this
condition, with Diabetes and
chemotherapy being the most common previously incurable causes in the
US. Twenty percent of all senior citizens experience Peripheral Neuropathy
which is often of an unknown cause.
Symptoms in the hands and feet range from constant, severe tooth
ache-type pain, intermittent burning or tingling and sometimes complete
numbness resulting in loss of balance. The implications on healthcare in the
U.S. are profound, when considering the related chronic pain, chronic
wounds, infections, amputations, fractures, and deformities that must be
treated, all of which are largely a result of Peripheral Neuropathy.
The reason for these devastating effects is simply that historically there
have been no successful treatment options for Peripheral Neuropathy.
Therefore, patients were instructed to pay special attention to their feet,
cleaning and inspecting them daily, to take pain killers, and to report
immediately to their foot specialist when infections developed. However,
recent advancements in the diagnosis and treatment of Peripheral Neuropathy
are offering a new sense of hope for people afflicted with this condition.
Dr. Kyle Kinmon, through his comprehensive approach to the diagnosis and
treatment of Peripheral Neuropathy, is able to offer hopes of both restoring
sensation and decreasing pain related to this previously untreatable
condition.
Treatment for Peripheral Neuropathy is designed to relieve pain and to
restore strength and sensation. Accomplishing these goals leads to a
decrease in the need for pain medication, less deformities, ulcerations,
infections, and amputations, as well as fewer injuries due to falls. At
Orthopaedic Surgery Associates, Inc., Dr. Kinmon emphasizes an attempt to
achieve these results without dependence on powerful drugs by employing
non-surgical or surgical means. Unique to South Florida, Dr. Kinmon is able
to offer both scientifically proven methods of treatment through our
practice alone. Therefore, patients are provided the option to make an
educated, non-biased decision on their preference of treatment modality
based on their individual needs.
Decompression of Multiple Peripheral Nerves
Dr. Kyle J. Kinmon of Orthopaedic Surgery Associates, Inc. has studied on
several occasions with A. Lee Dellon, MD, a professor of neurological and
plastic surgery at Johns Hopkins University in Baltimore and founder of the
Institute for Peripheral Nerve Surgery. Dr. Dellon discovered that by
decompressing nerves in the upper extremity for carpal tunnel syndrome he
could restore strength and sensation to the hands. He then conducted
research on peripheral nerves in mice which confirmed these original
incidental findings (2). The theory confirmed in Dr. Dellon’s studies is
that the underlying metabolic changes which occur in certain types of
Peripheral Neuropathy lead to an increased susceptibility of the peripheral
nerve to compression. This is based on research conducted in 1973 by Upton
and McComas which confirmed that once a peripheral nerve is insulted, the
remaining distal portion of the nerve becomes more vulnerable to
compression. (3.). they termed this phenomenon the “Double Crush Syndrome”.
The original insult may either consist of a direct compression at a proximal
level, or some metabolic abnormality manifesting a systemic problem such as
diabetes or drug toxicity.
In the case of
Diabetic Peripheral Neuropathy,
sorbitol, a breakdown product of glucose accumulates in the peripheral
nerve. Water then enters the nerve in order to maintain an isotonic
environment, resulting in actual swelling of the nerve. Therefore, in tight
anatomical tunnels which do not expand in the healthy patient, and much less
in patients whose tissues are glycosylated, the nerves are compressed. The
result of this compression is a decrease in the rate of axoplasmic flow, the
inability of the nerve to heal itself distally, demyelination of the axons,
and therefore the symptoms of neuropathy. It was proven first in mice, and
later in humans, that when these nerves are decompressed in time they will
regenerate, thereby relieving the painful manifestations of nerve
compression and restoring sensation.
Additional underlying causes of neuropathy also result in swelling of
nerves and compression in these tight anatomical tunnels. An example of a
common clinical presentation of this is
Chemotherapy Induced Peripheral
Neuropathy, often associated with drugs such as Cisplatin and
Vincristine. Many former cancer patients who have been successfully treated
with these drugs suffer from severe pain in the extremities. These drugs
cause peripheral neuropathy through a mechanism similar to that of lead
poisoning, whereby the tight junctions of the capillaries in the epineurium
are loosened, allowing fluid to leak into the perineurial space, and the
nerve to swell. Again, axoplasmic flow is affected distally and peripheral
neuropathy is the result. As of today, the results of nerve decompression in
post chemotherapy patients have yet to be published. However, personal
correspondence with Dr. Dellon boasts a 100% success rate with these
patients for relieving pain in 14 cases so far.
The operative procedures which were developed by Dr. Dellon, and personally
instructed to Dr. Kinmon, include decompression of peripheral nerves at
three sites in the lower extremity. The sites were identified in studies
conducted on cadavers by tracing the courses of nerves which innervate the
foot. The common peroneal nerve
is released at the fibular tunnel, just below the outside of the knee. The
deep peroneal nerve is decompressed on the top of the foot where it is
trapped between the tendon of the extensor digitorum brevis and the lateral
aspect of the first metatarsal. The posterior tibial, medial plantar,
lateral plantar and medial calcaneal nerves are decompressed about the
inside of the ankle in the region of the tarsal tunnel and distally through
a single incision.
Intra-operatively, the nerves
commonly demonstrate a visible indention at the sites of compression and the
distal portions are noted to be thinner and unhealthy in appearance relative
to the proximal portions. Immediately post-operatively in the recovery room,
many patients are able to feel light touch in areas of their feet that were
previously numb. Also many patients report an immediate decrease in burning,
tingling, and pain. However, there are a number of patients who will
experience an increase in pain as the nerves regenerate distally. If
present, this pain will occur for a period of time relative to the amount of
preoperative nerve damage, predictable based on the fact that nerves
regenerate at a rate of 1 millimeter per day or roughly 1 inch per month.
Published studies indicate that of the patients who underwent this surgery,
90% report a significant decrease in pain and 80% a restoration of
sensation. Also, at 4 year follow up of 44 neuropathic patients who
underwent unilateral nerve decompression of the lower extremity, 0% of the
operated extremities had reulcerated, while 9 of the non-operated limb had.
(Submitted for publication)
Summary
Peripheral Neuropathy is a common, previously incurable condition imparting
devastating effects on many people worldwide. Although a percentage of these
patients remain without a cure, recent advancements offer hope that they all
may live a significantly more enjoyable life.
The physicians of Orthopaedic Surgery Associates, Inc. are the first in
South Florida to offer this comprehensive specialized approach to the
treatment of Lower Extremity Peripheral Neuropathy. Please contact our
office to schedule an appointment.
Kyle J. Kinmon, MS,DPM,FACFAS
Foot and Ankle Surgery
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