Diabetic Foot Disease is defined as a syndrome in which peripheral neuropathy and peripheral vascular disease may result in foot ulceration, infection, deformity and or lower limb amputation in patients with diabetes.
Diabetic neuropathy is defined as the presence of symptoms and or signs of peripheral nerve dysfunction in people with diabetes and it is seen in up to 50 per cent of those with long-standing disease and pain is always the most common symptom.
According to Dr Nasser al Busaidy, Senior Consultant, Ministry of Health, (MoH), the incidence is up to 25 per cent. In Oman, amputation data from the Ministry of Health (MoH) indicate that diabetes is responsible for about 47 per cent of all lower limb amputations.
As a neurosurgeon based in Chennai, India and I often visit Oman as a consultant, where I focus on functional neurosurgery and do many surgeries including surgery for Parkinson’s disease, surgery for spasticity as in cerebral palsy or spinal cord injury, surgery for chronic pain, surgery for urine nerve problems.
Diabetic neuropathy pain, also known as neuropathic pain, is a symptom of nerve damage that can occur in people with diabetes.
It can feel like a burning, tingling, or sharp pain, and can be worse at night. It is caused by uncontrolled diabetes. High blood sugar can damage the blood supply to the legs, including the nerves of the legs and this causes severe pain (also called the cry of the drying nerves).
If untreated, the nerve damage causes loss of sensation in the legs.
This loss of sensation can lead to not caring small injuries (as no pain sensation) and end up in uncontrolled infection (drugs will not reach this part as no blood supply) and finally in amputation.
Many studies have shown that up to 25 per cent of patients with severe diabetic neuropathy and 31 per cent of them with foot ulcers end up having amputation. For people with healed diabetic foot ulcers, the 5-year cumulative rate of ulcer recurrence is 66 per cent and of amputation is 12 per cent.
The best treatment of diabetic neuropathy pain and ulceration is by prevention and proper foot care. Meticulous control of blood sugar is very important. There are several medications that can help treat pain, including duloxetine, amitriptyline, gabapentin or pregabalin and topical ointments like capsaicin cream. Lifestyle changes with diet and exercise can help.
Regular foot care, including toe nails is a must. Wear shoes that fit well and are comfortable. A combination of duloxetine and pregabalin is effective for pain relief but about 20 per cent of patients develop significant side effects and so stop the medication. Moreover, these drugs do not address the primary problem which is loss of blood supply.
In such cases, Spinal Cord Stimulation (SCS) is a good option. This involves stimulating the spinal cord to relieve pain and improve the blood supply. This is a simple surgery and the patient goes home within 24 hours.
SCS is usually reserved for treatment of pain in patients with neuropathic pain who have not responded to conventional treatment. Up to 70 per cent of these patients have reported pain relief one year after initiating treatment with SCS. Many studies have shown a good outcome with SCS. This surgery is approved by USFDA.
Dr Ramnarayan Ramachandran
The writer is a consultant functional neurosurgeon.
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