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Page 2 of 15 Dellon. Plast Aesthet Res 2022;9:45 https://dx.doi.org/10.20517/2347-9264.2022.13

INTRODUCTION
Since about 50% of people with diabetes develop neuropathy , the worldwide explosion of diabetes
[3]
[1,2]
means that there will be an explosion of patients with diabetic neuropathy. About 50% of patients with
diabetic neuropathy have multiple chronic lower extremity nerve compressions [Figures 1 and 2] . In
[4,5]
1982, I began doing decompression of lower extremity nerves in diabetics and the results of this work were
reported in 1992 , demonstrating that 80% of patients with a positive Tinel sign of the tibial nerve in the
[6]
tarsal tunnel had improved sensation, and decreased pain. Subsequent studies demonstrated that there was
significantly less (P < 0.001) ulceration and amputation for a patient that had nerve decompression than the
“control” that did not have that surgery . In 2012, a multicenter prospective study of 38 surgeons, including
[7]
800 patients with a 3-year follow-up, demonstrated that 80% of patients had a significant (P < 0.001) relief of
pain by six months after surgery, sensation recovered in the feet, 0.3% vs. the expected 15% of patients
developed ulceration, 0.2% vs. the expected 15% had an amputation, and 0.6% vs. the expected 3.7% had a
hospitalization for foot infection .
[8]
There have been four independent basic science studies that demonstrate that rats with streptozotocin-
induced diabetes will not develop a neuropathic walking track pattern [9,10] , and will have improved lower
extremity motor function and improved perception of pain . These studies confirm experimentally the
[12]
[11]
hypothesis I proposed in 1988 [13,14] , that the double crush concept did apply to diabetes clinically: the
underlying pathophysiology of diabetes acts as the first crush, or site of compression, making the nerve
susceptible to more distal sites of compression.

Subsequently, 19 Level IV studies [6-8,15-29] , two systematic reviews [30,31] , and three Level I studies [32-34] have all
concluded that decompression of lower extremity nerves in diabetics relieves pain, improves sensation, and
prevents ulcers and amputations. There have been two economic cost-benefit analyses using the decision-
tree approach that concluded that the cost of surgical decompression is less than the cost of standard
medical care for the treatment of diabetic neuropathy [35,36] . The two most recent approaches, using the
highest form of analysis, Markov analysis, not only confirmed that the cost of surgical decompression is less
than the cost of standard medical care for the treatment of diabetic neuropathy, but also proved that
surgical decompression of lower extremity nerves improves the quality of life and even prolongs life [37,38] .

The results of the Markov cost-effectiveness studies are worth further comment. For example, from the
study from the Johns Hopkins School of Hygiene and Public Health : when compared to standard medical
[37]
“prevention” (treatment), for a patient population of 10,000, surgical decompression of lower extremity
nerves with the Dellon Approach prevented a total of 1447 ulcers and 409 amputations over a period of 5
years. The quality-adjusted incremental effectiveness (QALY) was 0.41. A QALY of 1.0 means a perfectly
healthy life without disability for 1 year. To put this increase of 0.41 into perspective, the QALY for a person
with diabetic neuropathy is 0.40, so that this surgery doubled the quality of life for the person who has
undergone surgery. In relation to survival, given the difference in death rates between the two prevention
strategies, medical vs. surgical, survival was 73% for those receiving medical prevention compared to 95%
for those undergoing surgery. The surgery-treated group lived longer because they had fewer ulcers, fewer
hospital admissions for infection, and fewer amputations.

THE DELLON APPROACH TO NERVE DECOMPRESSION IN THE DIABETIC
Making the diagnosis of neuropathy
What is the approach to the person who has any symptom of numbness, tingling, pain, or any combination
of these in the feet? If the symptoms are bilateral and include the dorsum and the plantar aspect of the foot,
we have little doubt that the diagnosis is neuropathy. As a Peripheral Nerve Surgeon, the person you are