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Page 4 of 15 Dellon. Plast Aesthet Res 2022;9:45 https://dx.doi.org/10.20517/2347-9264.2022.13

seeing may not have been evaluated appropriately for the presence of a medically treatable etiology of
neuropathy. Before assuming the patient has diabetic neuropathy, it is critical to do a two-hour oral glucose
tolerance test (OGTT). All too often, a patient will see me who has been told they have “idiopathic
neuropathy”, meaning the usual tests for serum folate/B12 levels, autoimmune disease, heavy metal toxicity,
hypothyroid, HbA1c and serum glucose are normal, yet they have not had this OGTT, a stress test. Up to
56% of idiopathic neuropathy patients will have an abnormal OGTT, meaning that they have impaired
glucose tolerance . Whether their medical doctor will or will not tell them they have diabetes, their
[39]
peripheral nerves are subjected to a hyperosmolar condition related to excess serum glucose, causing the
nerve to swell. This swelling, in the presence of a known site of anatomic narrowing, like the tarsal tunnel
region or the fibular tunnel, is the usual cause of chronic compression.

Of course, the history is important too in making the diagnosis. For example, chemotherapy-induced
neuropathy, today usually due to treatment with a “platin” or “taxol” drug that binds to tubulin in the
axoplasm of the nerve, can cause neuropathy. The results of lower extremity nerve decompression for the
treatment of chemotherapy-induced neuropathy, neuropathy that persists for more than six months after
the cessation of chemotherapy, can be as successful as for the treatment of diabetic neuropathy. This has
been proven experimentally and clinically . Indeed, the Dellon Approach is as successful in the
[40]
[41]
treatment of idiopathic neuropathy as it is in treating diabetic neuropathy [27,42] . Furthermore, once the
patient with Leprosy has received triple antibiotic therapy and is no longer infectious, but has a disability
related to the immune-mediated swelling along the course of superficial peripheral nerves, like branches of
the peroneal nerve at the knee (fibular tunnel), leg (superficial peroneal nerve) or foot dorsum (deep
peroneal nerve), then neurolysis of these lower extremity nerves can also be successful [42,43] .

Electrodiagnostic testing will most likely have been done prior to the patient ever seeing the surgeon, and is
quite successful at identifying a symmetrical neuropathy, especially if there is decreased number of axons
present. However, electrodiagnostic testing, even in the upper extremity, where it is most sensitive, is often
unable to identify a chronic nerve compression in a person who does not have neuropathy and is very
unlikely to identify a superimposed chronic nerve compression in the presence of an underlying neuropathy
due to the inherent nature of the neuropathy upon the axons [44-46] . Similar reasoning applies to the lower
extremity, where 50% of asymptomatic people over the age of 55 have no medial plantar response and have
motor fasciculations [47-49] .

MAKING THE DIAGNOSIS OF CHRONIC NERVE COMPRESSION
If the electrodiagnostic testing has demonstrated a superimposed chronic nerve compression at a known
site of anatomic narrowing, then the diagnosis has been confirmed objectively. Jules Tinel, MD, a
Neurologist in France, and Paul Hoffman, PhD, a Physiologist in Germany, both described, independently,
in 1915, the tingling sign that results from a peripheral nerve regenerating distally . Beginning with
[50]
Phalen’s description of carpal tunnel syndrome in 1966, the Hoffman-Tinel sign (hereinafter referred to as
the Tinel sign) has been accepted as identifying the site of a nerve compression along the course of a
[51]
peripheral nerve . In my experience, this sign is sufficient if the site of compression is close to the target
skin territory, like the dorsum of big toe/1st web space when the deep peroneal nerve is lightly tapped at the
junction of the first and second metatarsal and the cuneiform bone, or the tibial nerve in the tarsal tunnel.
However, for the common peroneal nerve at the fibular neck, there is often NOT a distally radiating
perception, but just tenderness of the nerve or proximal radiation of the tingling. This sign, described by
[52]
Francoise Louise Isidore Valleix, MD, in 1841 , has been proven to be valid in my clinical experience at
localizing a site of nerve compression for the common peroneal nerve at the fibular neck.