A Neurosurgeon’s Thoughts on Diabetic Peripheral Neuropathy

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Editor’s Note: Painful diabetic peripheral neuropathy is a challenging pathology often presenting to podiatric practices. As with diabetes management as a whole, a multidisciplinary collaboration is often key in optimizing outcomes. In this piece, Betsy H. Grunch, MD, FAANS, FACS comments on this condition from a neurosurgical point of view, including the importance of patient education, and how spinal cord stimulation may play a role.
 
How does painful diabetic peripheral neuropathy play a role in your spine/neurosurgery practice?
 
Patients that present to a neurosurgery practice have a variety of comorbid health conditions, including diabetes. Up to 50% of patients with diabetes suffer from coexisting neuropathy.¹ Any type of neurological treatment/surgical recommendation requires a complete understanding of how this condition may affect their presentation, surgical recommendations, and recovery from surgery. In conditions that the neuropathy is the main factor in their evaluation by us, we often discuss modalities of treatment to help their condition. With the latest US Food and Drug Administration (FDA) indication for spinal cord stimulation as a treatment option for painful diabetic peripheral neuropathy², we may also take this into consideration in their treatment recommendations.
 
In your experience, what are some of the most impactful ways physicians can address this condition? 

Explaining diabetic peripheral neuropathy and the frequency of coexistence in diabetes is critical so patients can understand. A physician must be transparent with their knowledge for patients to understand how they may help prevent this dreadful complication. If a patient already suffers from painful diabetic neuropathy, they must be aware of how to slow its progression and aware of options to lessen their suffering. I believe a solid communication line of knowledge between a patient and their provider is the most impactful way we can address these common conditions.
 
How do you feel podiatry’s work can intersect with neurosurgery in a team approach to managing this condition? When might cross-referrals be helpful, in your observation?
 
A collaborative patient care team will only amplify a successful outcome in healthcare. Painful diabetic neuropathy and spinal pathologies can overlap at times, and evaluation of a patient with these symptoms by a neurologist or neurosurgeon may be prudent. If spine pathology is suspected, a cross-referral may be warranted to help with the work up of spinal etiologies. In addition, with the newest literature supporting high frequency spinal cord stimulation to improve outcomes in patients that fail medical management of painful diabetic neuropathy,^3,4 a neurosurgical referral is welcomed.

Final Notes

Painful diabetic neuropathy can result in the loss of protective sensation. As podiatrists are well aware, this puts patients at an increased likelihood of foot ulceration and lower extremity amputation. Studies show that strategies such as high-frequency SCS can provide improvement in this protective sensation and theoretically reduce their risk of ulceration and amputation.^3,4
 
Dr. Grunch is a neurosurgeon specializing in spine and is board-certified by the American Board of Neurological Surgery. She practices with the Longstreet Clinic in Georgia. Instagram, Facebook, TikTok, and YouTube: @LadySpineDoc
 
References
1.     Hicks CW, Selvin E. Epidemiology of peripheral neuropathy and lower extremity disease in diabetes. Curr Diab Rep. 2019 Aug 27;19(10):86.
2.     Yeung AM, Huang J, Nguyen KT, Xu NY, Hughes LT, Agrawal BK, Ejskjaer N, Klonoff DC. Spinal cord stimulation for painful diabetic neuropathy. J Diabetes Sci Technol. 2024 Jan;18(1):168-192.
3.     Yu J, Wong S, Lin Z, Shan Z, Fan C, Xia Z, Cheung M, Zhu X, Liu JA, Cheung CW. High-frequency spinal stimulation suppresses microglial kaiso-p2x7 receptor axis-induced inflammation to alleviate neuropathic pain in rats. Ann Neurol. 2024 Mar 7. doi: 10.1002/ana.26898. Epub ahead of print. PMID: 38450773.
4.     Boulton AJM, Jensen TS, Luecke T, Petersen EA, Pop-Busui R, Taylor RS, Tesfaye S, Vileikyte L, Ziegler D. Where does spinal cord stimulation fit into the international guidelines for refractory painful diabetic neuropathy? A consensus statement. Diabetes Res Clin Pract. 2023 Dec;206 Suppl 1:110763. doi: 10.1016/j.diabres.2023.110763. PMID: 38245326.