Decompressive Surgery for Diabetic Neuropathy: Waiting for Incontrovertible Proof

Abstract

Abstract Triple decompression surgery has been advocated as a treatment for diabetic peripheral neuropathy (DPN). A practice advisory published in 2006 by the American Academy of Neurology concluded that “this treatment alternative should be considered unproven.” Since then, multiple cohort studies involving several thousands of patients and 1 nonblind, randomized, controlled trial have been published, suggesting that surgical treatment of DPN has become commonplace in many centers globally. The results of these observational studies suggest that decompressive surgery could result in a substantial reduction of pain and the restoration of sensation in patients with DPN. However, as these studies are all observational in design, the utility of surgery remains unproven. Furthermore, the selection of patients for surgery is based on the incorrect assumption that the presence of a Tinel sign at sites of potential entrapment indicates nerve compression. The utility of surgery could be determined through a randomized, double-blind, sham-controlled trial in which 1 leg is treated with surgical decompression and the other with sham surgery. This design would eliminate a large number of possible confounders and would therefore require only a small number of patients. Such a trial is currently being performed at the University of Texas. The true beneficiaries will be patients with DPN: either decompressive surgery will be established as an evidence-based treatment for millions of patients or they will be spared from potentially harmful surgery with no significant benefit.