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• W3147468613 abstract "To the Editor: We thank Dr Liao for his response1 to our review.2 We agree that the practice advisory published by the American Academy of Neurology stated that decompressive surgery for diabetic peripheral neuropathy (DPN) is unproven,3 but appear to differ on the implications of this assessment. When the risk of an intervention is clear but its benefit is not, the fundamental principle of “primum non nocere” should prevail, especially in patients with diabetes, in whom the incidence of perioperative complications is increased4 and wound healing is impaired.5 Dr Liao suggests that observational studies showing the involvement of aldose reductase pathways, oxidative stress, and advanced glycation end products in diabetic neuropathy provide evidence for the utility of decompressive surgery, but to our knowledge there is no evidence that surgery affects any of these processes. In fact, historical experience with aldose reductase inhibitors admonishes against inferring clinical efficacy from basic scientific research: the clinical effects of aldose reductase inhibitors have been disappointing and they are not used for treatment today.6 Importantly, the inclusion criteria for decompressive surgery remain unclear: proponents state that it should only be considered in patients with DPN and superimposed focal nerve entrapment. Dr Liao states that confirmation with electrophysiological testing is required for a diagnosis of superimposed nerve entrapment, although his paper on decompressive surgery did not mention abnormal nerve conduction studies as an inclusion criterion.7 As in other studies on decompressive surgery, the authors relied solely on a combination of clinical findings and the presence of a Tinel sign at sites of potential entrapment for a diagnosis of nerve compression. However, a positive Tinel sign has no diagnostic value for nerve compression in the legs.8 While we sympathize with the notion “where there is compression, there should be decompression,” we feel that this requires proof of compression as well as proof that patients benefit clinically from decompression. In our view, surgical decompression in patients with diabetes should be restricted to focal nerve entrapment based on solid diagnostic criteria. Finally, it worries us that many surgeons subject thousands of patients to an unproven procedure when clear proof of its efficacy could be obtained with a small clinical trial on as few as 22 patients.2 Fortunately, a randomized sham-controlled clinical trial is now underway at the University of Texas. The results are eagerly anticipated. If this trial provides solid evidence that decompressive surgery causes a significant, long-term reduction in pain compared to the placebo control (the sham-operated leg), we will revise our position. Until then, we prefer to do no harm. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article." @default.
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• W3147468613 date "2017-05-03" @default.
• W3147468613 modified "2023-10-17" @default.
• W3147468613 title "In Reply: Decompressive Surgery for Diabetic Neuropathy: Waiting for Incontrovertible Proof" @default.
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• W3147468613 doi "https://doi.org/10.1093/neuros/nyx193" @default.
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