Methods for tissue perfusion assessment after Dellon decompression of tarsal tunnels in diabetic neuropathy: key to effective management-a narrative review

Abstract

Background and objective: Diabetic neuropathy significantly elevates the risk of foot ulceration and lower-limb amputation, underscoring the need for precise assessment of tissue perfusion to optimize management. This narrative review explores the intricate relationship between sympathetic nerves and tissue perfusion in diabetic neuropathy, highlighting the important role of autonomic neuropathy in blood flow dynamics and subsequent compromises in tissue perfusion. The consequences extend to the development of diabetic peripheral neuropathy and related foot complications. By analyzing both non-invasive diagnostic methods and surgical interventions, such as tarsal tunnel decompression, the paper seeks to highlight their effectiveness in improving tissue perfusion, preventing ulcers, and reducing the risk of amputations in patients with diabetic peripheral neuropathy.

Methods: We reviewed current literature on both non-invasive diagnostic tools and surgical techniques for assessing and improving tissue perfusion in diabetic neuropathy. Methods discussed include transcutaneous oxygen pressure (TcPO₂), Doppler ultrasound, Tissue-Muscle Perfusion Scintigraphy with ^99mTc-MIBI, and the SPY Laser Angiographic System.

Key content and findings: Emphasizing the critical importance of surgical interventions, such as tarsal tunnel decompression and neurolysis of the posterior tibial nerve, the article underscores their efficacy in enhancing tissue perfusion and preventing ulcers and amputations. Additionally, it addresses the significance of precise blood flow measurement and timely intervention in the management of diabetic neuropathy and foot ulcers. The non-invasive techniques for assessing tissue perfusion and blood flow in diabetic neuropathy such as TcPO₂, Doppler ultrasound and Tissue-Muscle Perfusion Scintigraphy with ^99mTc-MIBI are explained. Also, this review introduces the SPY Laser Angiographic System, which employs near-infrared fluorescence imaging to assess blood flow and perfusion in tissues. This advanced tool generates real-time microvascular blood flow images and proves instrumental in diagnosing and monitoring diabetic foot ulcers.

Conclusions: In conclusion, surgical interventions, both vascular and peripheral nerve are pivotal for optimizing patient care. Early identification of foot ulcers and peripheral arterial disease is imperative, and an understanding of blood flow dynamics, combined with effective surgical techniques, constitutes key elements in managing diabetic neuropathy, healing and preventing ulcers, and limb salvage.

Keywords: Diabetic neuropathy; blood flow assessment; diabetic foot ulcers (DFU); tissue perfusion.

Figure 1

The sympathetic innervation of the tibial artery enters by these branches from the tibial nerve, shown beneath the scissors, in patient having tarsal tunnel decompression. Photo courtesy of A Lee Dellon, MD, PhD.

Figure 2

Doppler ultrasound of posterior tibial artery (A) before and (B) after Dellon Tarsal Tunnel decompression in patient with diabetic neuropathy.

Figure 3

Scintigraphic finding of a patient with diabetic neuropathy with greater tissue perfusion in the left foot in both studies—“rest” and “stress”, after Dellon four medial ankle tunnels decompression.

Figure 4

Comparison of pre- and postoperative condition in a neuropathic patient who underwent tarsal tunnels decompression surgery: (A) preoperative ulcer size, (B) postoperative photo showing completely healed ulcer.