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STAGE AT WHICH REFERRED
Clinical DiagnosisClinical Diagnosis
 Detailed clinical history
 Assessment of arterial circulation
– Peripheral pulses
...
Clinical DiagnosisClinical Diagnosis
Neurological
– Autonomous
 Temperature
 Scaling of skin – nails – hair
 Sweating ...
ElectrodiagnosticElectrodiagnostic
Classification ofClassification of
Neuropathies inNeuropathies in
Diabetes MellitusDiab...
Electrodiagnostic Classification of Neuropathies in DMElectrodiagnostic Classification of Neuropathies in DM
DiscussionDis...
Section of a Normal Nerve withSection of a Normal Nerve with
Myelinated Fibres & GoodMyelinated Fibres & Good
VascularityV...
Diabetic Nerve Shows Thickening of theDiabetic Nerve Shows Thickening of the
Nerve Sheath As Well As of the VesselsNerve S...
Deformities
SKIN GRAFT STABLE 2YRS. POST-OP. BUT SHOWS
ULCERATION OF RIGHT FOOT .
Complete healing of ulcer.Complete healing of ulcer.
OPERATION TO IMPROVEOPERATION TO IMPROVE
BLOOD SUPPLY - BYPASSBLOOD SUPPLY - BYPASS
Releasing the tight constriction
from around nerves & blood
vessels
Preventive Surgery
•Relieves pain
•Protective
sensatio...
Nerves Released in Leg
• Tibial
• Common Peroneal
• Deep Peroneal
• Superficial Peroneal
Sites of Tibial
Nerve
compression in
region of ankle
and lower leg
Common
Peroneal n
Superficial
Peroneal n
Deep
Peroneal n
Entrapment
sites of
Peroneal Nerve
NEAR KNEE
FOOT
Tendon Lengthening
ANKLE
6.87.5
10 mths
POST
2.95.3PRE
At
amp
Ankle
amp
NCS
Lt Tibial
BC
L.FOOT HEALED FOLLOWING DECOMPRESSION BUT
R . FOOT DEVELOPED SEVERE BURNS
INJURY
DECOMPRESSION
OFFERED BETTER
SENSATIONS AS
WELL AS HELPED
HEALING OF THE
ULCER
IMPROVEMENT IN
THE NERVE
CONDUCTION AFTER
A PERIOD OF
9 MONTHS.
DM
Rec Site Amp
2-4mV
La ms Date
AH 1.2 5.00 26/02/01
AH 1...
YEAR
TOTAL CASES
TREATED
FEMALE NEUROLYSED
2000 20 4 7
2001 25 4 7
2002 15 3 1
2003 22 5 5
2004 23 4 3
2005 22 4 4
2006 10...
Patients neurolysed 25
Male 17
Female 8
Nerves total 28
Bilateral release 3
Ulcerated side neurolysed 9
Died 5
Age
group
3...
ID NAME
M
/F
AG
E
DIAG CLINICAL
DATE
NEUROLYSI
S
NEUROLY
SIS
1 SP F 56 rt dmf
Rt great toe
gangrene
28/01/2000 Lt
2
JA M 4...
ID NAME
GEND
ER
AGE DIAG CLINICAL
DATE
NEUROLY
SIS
NEUR
OLYSI
S
8 NB M 50 lt dmf Lt 5th
toe gangrene 24/02/2001 Rt
9 MG M ...
ID NAME M/F AGE DIAG CLINICAL
DATE
NEUROLYS
IS
NEUROL
YSIS
16 GS M 53 lt dmf
Lt tation of 1st
2nd toes ampu;
raw areas
07/...
ID NAME M/F AGE DIAG CLINICAL
DATE
NEUROLYS
IS
NEUROL
YSIS
23 FA F 67 Rt dmf Rt charcot 22/01/04 Lt
24 FA F 67 Rt dmf Rt c...
Planned incision
Upper limit of stocking sensory loss
Tinel’s Sign
Extent of release Incision sutured
GS
Tibial nerve at ankle
Tibial nerve going under soleus
Upper limit
GS
7th
Nov 2003
PRE-OP upper limit of ‘stocking’ anesthesia
28th
Nov 2003
21 DAYS POST-OP line of hyperesthesia
GS
SS
Tinel’s
sign
B
A
C
D
SS
Compression like rungs of ladder
Severe Fibrosis
SS
6W POST
NEUROLYSIS
PRE-NEUROLYSIS
Nerve Site Rec Site
Amp Lat
Pre
6w
Post
Pre
6w
post
R
Tibial
Below ankle AH 2.0 2.0 4.35 3.65
At ankle AH 0.9 1.9 5,70 4.8...
KJ
Release of the Vessels
Cross compression due to the perforators
AS
Release of the Artery
Extent of Release of the Nerve
Level of stocking anaesthesia
Benefits of DecompressionBenefits of Decompression
Early onset of feeling of improved
sensation
Improvement of circulati...
Pirate Amputation
AmputationDiabetes ≠
=
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
1362574057 dr. s. tambwekar
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1362574057 dr. s. tambwekar

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1362574057 dr. s. tambwekar

  1. 1. STAGE AT WHICH REFERRED
  2. 2. Clinical DiagnosisClinical Diagnosis  Detailed clinical history  Assessment of arterial circulation – Peripheral pulses  Assessment of venous circulation – Resting & standing venous filling – Varicosities – Skin colour  Vascular study – MRI angiography, Doppler – Invasive angiography
  3. 3. Clinical DiagnosisClinical Diagnosis Neurological – Autonomous  Temperature  Scaling of skin – nails – hair  Sweating & dryness of skin  Return of circulation on release of pressure – Sensory [EMG]  Hyperaesthesia  Anaesthesia – Motor  Muscle weakness, paralysis -- deformities
  4. 4. ElectrodiagnosticElectrodiagnostic Classification ofClassification of Neuropathies inNeuropathies in Diabetes MellitusDiabetes Mellitus Dr. Bhavna Doshi,Dr. Bhavna Doshi, Dr. K. A.Dr. K. A. Mansukhani, TejasMansukhani, Tejas BhojrajBhojraj
  5. 5. Electrodiagnostic Classification of Neuropathies in DMElectrodiagnostic Classification of Neuropathies in DM DiscussionDiscussion  Diabetic Neuropathy referrals formed only 7.3% of the total referrals which is surprising as type 2 Diabetes Mellitus has a prevalence of about 12 to 18% in the age group 25 to 75 years, and about 17 to 19.1% of them have diabetic neuropathy.  64% of the study group had moderately severe and chronic sensory-motor peripheral neuropathy and were undergoing electrodiagnostic examination for the first time. This suggests that diabetic neuropathy is under- diagnosed or under-investigated.
  6. 6. Section of a Normal Nerve withSection of a Normal Nerve with Myelinated Fibres & GoodMyelinated Fibres & Good VascularityVascularity
  7. 7. Diabetic Nerve Shows Thickening of theDiabetic Nerve Shows Thickening of the Nerve Sheath As Well As of the VesselsNerve Sheath As Well As of the Vessels With Demyelination of the Nerves atWith Demyelination of the Nerves at PlacesPlaces
  8. 8. Deformities
  9. 9. SKIN GRAFT STABLE 2YRS. POST-OP. BUT SHOWS ULCERATION OF RIGHT FOOT .
  10. 10. Complete healing of ulcer.Complete healing of ulcer.
  11. 11. OPERATION TO IMPROVEOPERATION TO IMPROVE BLOOD SUPPLY - BYPASSBLOOD SUPPLY - BYPASS
  12. 12. Releasing the tight constriction from around nerves & blood vessels Preventive Surgery •Relieves pain •Protective sensation returns
  13. 13. Nerves Released in Leg • Tibial • Common Peroneal • Deep Peroneal • Superficial Peroneal
  14. 14. Sites of Tibial Nerve compression in region of ankle and lower leg
  15. 15. Common Peroneal n Superficial Peroneal n Deep Peroneal n Entrapment sites of Peroneal Nerve
  16. 16. NEAR KNEE FOOT Tendon Lengthening ANKLE
  17. 17. 6.87.5 10 mths POST 2.95.3PRE At amp Ankle amp NCS Lt Tibial BC
  18. 18. L.FOOT HEALED FOLLOWING DECOMPRESSION BUT R . FOOT DEVELOPED SEVERE BURNS INJURY
  19. 19. DECOMPRESSION OFFERED BETTER SENSATIONS AS WELL AS HELPED HEALING OF THE ULCER
  20. 20. IMPROVEMENT IN THE NERVE CONDUCTION AFTER A PERIOD OF 9 MONTHS. DM Rec Site Amp 2-4mV La ms Date AH 1.2 5.00 26/02/01 AH 15.2 4.35 22/11/01
  21. 21. YEAR TOTAL CASES TREATED FEMALE NEUROLYSED 2000 20 4 7 2001 25 4 7 2002 15 3 1 2003 22 5 5 2004 23 4 3 2005 22 4 4 2006 10 2 1
  22. 22. Patients neurolysed 25 Male 17 Female 8 Nerves total 28 Bilateral release 3 Ulcerated side neurolysed 9 Died 5 Age group 35-45 4 46-55 7 56-65 8 66-85 6
  23. 23. ID NAME M /F AG E DIAG CLINICAL DATE NEUROLYSI S NEUROLY SIS 1 SP F 56 rt dmf Rt great toe gangrene 28/01/2000 Lt 2 JA M 44 b/l dmf b/l neuropathic Daibetic feet 21/07/2000 Lt 3 18/08/2000 Rt 4 TS F 70 rt dmf Rt plantar ulcer 25/08/2000 Lt 5 DT M 50 lt dmf Lt plantar aspect necrosis 02/09/2000 Rt 6 08/09/2000 Lt 7 KB F 45 lt dmf 2 plantar ulcers L foot 15/09/2000 Lt NEUROLYSED
  24. 24. ID NAME GEND ER AGE DIAG CLINICAL DATE NEUROLY SIS NEUR OLYSI S 8 NB M 50 lt dmf Lt 5th toe gangrene 24/02/2001 Rt 9 MG M 60 rt dmf rt leg necrotizing fasciitis 02/03/2001 Lt 10 BK M 55 rt dmf rt great toe ulcer 08/03/2001 Lt 11 YV M 60 rt dmf 24/03/2001 Lt 12 LG M 58 rt dmf Neuropathic pain 13/07/2001 Lt 13 MN F 35 lt dmf Lt foot blackened skin 14/09/2001 Rt 14 NS F 75 28/12/2001 Rt 15 AS M 67 rt dmf rt 1st mt ulcer,, 2nd 3rd toes tips ischaemic 13/09/2002 Rt
  25. 25. ID NAME M/F AGE DIAG CLINICAL DATE NEUROLYS IS NEUROL YSIS 16 GS M 53 lt dmf Lt tation of 1st 2nd toes ampu; raw areas 07/11/2003 Rt 17 PR M 43 lt dmf Lt cellulitis upto thigh 14/11/2003 Rt 18 SP M 69 lt dmf Lt dmf lt knee raw area 15/11/2003 Rt 19 MD F 60 rt dmf rt foot heel ulcer 29/11/2003 Rt 20 NK M 63 lt dmf abscess lt foot; 26/12/2003 Rt 21 KJ M 53 b/l dmf chronic callosities both 1st MPJs 07/02/2004 Rt 22 SS F 60 b/l dmf 1st mt head ulcers 08/10/2004 Rt
  26. 26. ID NAME M/F AGE DIAG CLINICAL DATE NEUROLYS IS NEUROL YSIS 23 FA F 67 Rt dmf Rt charcot 22/01/04 Lt 24 FA F 67 Rt dmf Rt charcot 2/03/05 Rt 25 BC M 55 Lt dmf Lt gr toe amp 7/03/05 Lt 26 BJ 52 Lt dmf Lt nec fascii 28/10/05 Rt 27 SB 63 Lt dmf Lt forefoot plantar necrosis 16/7/05 Rt 28 TR 82 Bil dmf Gr toe pl ulcer 12/5/06 Rt
  27. 27. Planned incision Upper limit of stocking sensory loss Tinel’s Sign Extent of release Incision sutured GS
  28. 28. Tibial nerve at ankle Tibial nerve going under soleus Upper limit GS
  29. 29. 7th Nov 2003 PRE-OP upper limit of ‘stocking’ anesthesia 28th Nov 2003 21 DAYS POST-OP line of hyperesthesia GS
  30. 30. SS Tinel’s sign
  31. 31. B A C D SS Compression like rungs of ladder Severe Fibrosis
  32. 32. SS 6W POST NEUROLYSIS PRE-NEUROLYSIS
  33. 33. Nerve Site Rec Site Amp Lat Pre 6w Post Pre 6w post R Tibial Below ankle AH 2.0 2.0 4.35 3.65 At ankle AH 0.9 1.9 5,70 4.85 Knee AH 0.6 1.8 16.25 14.4 PRE-RELEASE 6wk POST
  34. 34. KJ Release of the Vessels Cross compression due to the perforators
  35. 35. AS Release of the Artery Extent of Release of the Nerve Level of stocking anaesthesia
  36. 36. Benefits of DecompressionBenefits of Decompression Early onset of feeling of improved sensation Improvement of circulation Ease of walking Reduction of tiredness Freedom from cramps Healing of ulcers, absence of recurrence
  37. 37. Pirate Amputation AmputationDiabetes ≠ =

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