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PubMed2004

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach.

STUDY DESIGN: Definitive and unequivocal evidence to support the practice of early or late surgery is still lacking in clinical studies. Accordingly, meta-analysis is one of the few methods that offer a rational, statistical approach to management decision. A review of the clinical literature on spinal cord injury with emphasis on the role of early surgical decompression and a meta-analysis of results was performed. OBJECTIVES: To determine whether neurological outcome is improved in traumatic spinal cord-injured patients who had surgery within 24 h as compared with those who had late surgery or conservative treatment. METHODS: A Medline search covering the period 1966-2000, supplemented with manual search, was used to locate studies containing information on indication, rationale and timing of surgical decompression after spinal cord injuries. The analysis included a total of 1687 eligible patients. RESULTS: Statistically, early decompression resulted in better outcome compared with both conservative (P<0.001) and late management (P<0.001). Nevertheless, analysis of homogeneity showed that only data regarding patients with incomplete neurological deficits who had early surgery were reliable. CONCLUSIONS: Although statistically the percentage of patients with incomplete neurological deficits improving after early decompression appear 89.7% (95% confidence interval: 83.9, 95.5%), to be better than with the other modes of treatment when taking into consideration the material available for analysis and the various other factors including clinical limitations; early surgical decompression can only be considered as practice option for all groups of patients.

Clinical Trials as Topic↗
PubMed2002

Occurrence of hepatopulmonary syndrome in Budd-Chiari syndrome and the role of venous decompression.

BACKGROUND & AIMS: Hepatopulmonary syndrome (HPS) has been predominantly detected in cirrhotic patients and rarely in patients with noncirrhotic portal hypertension. The aim of this study was to determine the occurrence of HPS in patients with Budd-Chiari syndrome (only anecdotal reports available) and evaluate the role of venous decompression in its reversal. METHODS: Twenty-nine consecutive cases of Budd-Chiari syndrome without primary cardiopulmonary disease were investigated by air contrast echocardiography and arterial blood gas analysis. Venous decompression (e.g., by balloon cavoplasty) was attempted when feasible. RESULTS: Eight cases (27.6%) of HPS and 9 cases (31.0%) with positive contrast echocardiography but unimpaired oxygenation were detected. Duration of disease was longer (P = 0.026) among those with positive contrast echocardiography. Cavoplasty reversed 4 of 5 cases of HPS and 2 of 2 cases with positive contrast echocardiography alone. Venous decompression by drainage of amebic liver abscess (which was compressing hepatic venous outflow) also reversed 1 case of HPS. HPS was relieved by venous decompression in 5 of 6 cases. CONCLUSIONS: HPS developed in a substantial fraction of our patients with Budd-Chiari syndrome, with positive contrast echocardiography occurring mainly in the benign, slowly progressing variety. Venous decompression showed promise in reversing such cases.

Adult↗
PubMed2003

[Development of ocular motility following modified 3-wall decompression of the orbita in endocrine orbitopathy for functional and rehabilitative indication].

INTRODUCTION: Permanent visual damage due to an increase in volume of the orbital contents may be the result of the failure of conservative therapeutic concepts in the treatment of endocrine orbitopathy. Considerable progress has been achieved in developing successful orbital decompression techniques with regard to functional and cosmetic outcome. Decompression techniques with resection of the bony orbital walls are adequate tools in restoring visual acuity and reducing exophthalmus. A considerable degree of deterioration of motility disorders has been described in the literature depending on the techniques being used. PURPOSE: The purpose of this study was to investigate whether a modified technique of 3-wall orbital decompression with preservation of a medial part of the periorbital tissue to support the medial rectus muscle, is able to reduce the postoperative risk of diplopia. MATERIAL AND METHODS: A modified technique of orbital 3-wall decompression with resection of the medial orbital wall, the medial orbital floor and the floor of the frontal sinus has been used in patients with compressive optic neuropathy (n = 20) and for cosmetic reasons (n = 7) in cases of uni- or bilateral proptosis. Analysis of the results was performed concerning visual outcome, exophthalmus reduction and development of horizontal and vertical motility changes. RESULTS: In all cases of optic neuropathy improvement of visual function at an average of 4.63 +/- 4.5 lines could be achieved. Exophthalmus reduction was 3.2 +/- 2.4 mm in the functional group and 3.9 +/- 1.7 mm in the rehabilitative group. In this group motility of the medial rectus muscle remained unaffected except in one eye. In the functional group motility deterioration was observed in 62 %. CONCLUSION: The modified 3-wall decompression technique with preservation of a medial periorbital tissue strip is an adequate alternative technique in the therapy of optic neuropathy and exophthalmus reduction in endocrine orbitopathy with a low risk of postoperative motility disorders.

Adipose Tissue↗
PubMed2005

Verification of nerve root decompression during minimally-invasive lumbar microdiskectomy: a practical application of surgeon-driven evoked EMG.

Lumbar microendoscopic diskectomy (MED) has gained widespread acceptance as an alternative to conventional open microdiskectomy due to several potential advantages, including reductions in postoperative pain and recovery time. However, constraints in visualization and working space present technical difficulties in the verification of nerve root decompression and the identification of sequestered disc fragments. This study was undertaken to investigate whether a surgeon-driven, evoked EMG paradigm could be used for intraoperative verification of nerve root decompression within the technical and mechanical confines of lumbar MED. Twenty-two patients underwent intraoperative EMG stimulation threshold recordings during lumbar microendoscopic diskectomy. In this series, the EMG threshold recorded directly from the nerve root immediately prior to diskectomy was 8.6 +/- 4.4 mA. Following decompression, the threshold was 4.2 +/- 2.1 mA. The difference in pre- and post-decompression EMG stimulation threshold, 4.4 +/- 4.0 mA, was statistically significant (p < 0.001). In two of the 22 cases (9.1 %), the EMG threshold was initially unchanged following diskectomy, and further exploration revealed sequestered disc fragments. After removal of these fragments, an appropriate decrease in the EMG threshold was observed. The results from this study suggest that surgeon-driven, evoked EMG threshold testing may provide a simple, effective adjunct to lumbar microendoscopic diskectomy for intraoperative verification of nerve root decompression.

Adult↗
PubMedDate not supplied

[MRI-controlled outcome after core decompression of the femur head in aseptic osteonecrosis and transient bone marrow edema].

PURPOSE: We evaluated the signal changes of avascular necrosis and transient bone marrow oedema before and after core decompression of the femoral head to deduce prognostic factors for this operative procedure. METHOD: 38 to 40 cases with core decompression (35 patients, medium age 44 years) were analysed with a mean follow-up time of 26 months. Preoperatively patients were staged by the ARCO classification. MR-images were judged in accordance to the criteria of Mitchell and Steinberg. The clinical outcome was analysed according to the hip index of Merle D'Aubigne. RESULTS: All hips with transient bone marrow oedema showed normal signal patterns at an average of 3 months after core decompression. In stage I and II, all patients with a preoperative necrosis area less than 30% of the femoral head showed a reduction of the necrotic zone and good clinical results. An unchanged or progressive appearance was observed in necrotic lesions with more than 30% head involvement. Because of failure a renewed operation had to be done in all patients with stage III and IV. CONCLUSION: In the case of transient bone marrow oedema, a restitutio ad integrum can be achieved with core decompression. In stage I and II of avascular necrosis, the successful outcome depends on the lesion size of the femoral head. Necrotic lesions less than 30% seem to have the best prognosis. In stage III and IV, core decompression cannot be recommended.

Adult↗
PubMed2003

"Balanced" orbital decompression for severe Graves' orbitopathy: technique with treatment algorithm.

BACKGROUND: Graves' orbitopathy can produce proptosis, compressive optic neuropathy, and extraocular motility abnormalities; symptoms result from an increase in orbital volume due to expansion of intraorbital fat, with or without extraocular muscle involvement. STUDY DESIGN: We conducted a chart review of patients who underwent orbital decompression to treat Graves' orbitopathy. Twenty-two orbits (13 patients) underwent orbital bone decompression, of which 17 orbits (9 patients) underwent the combined medial and lateral "balanced" decompression. RESULTS: All patients had significant improvement with an average decrease in proptosis of 5.9 mm in the balanced decompression group. Restoration of normal optic nerve function was achieved in all patients with compressive optic neuropathy. Diplopia was noted in 4 patients (30.7%) preoperatively. Two patients had new postoperative diplopia (15.35%). CONCLUSION: In our experience, "balanced" decompression results in a reduction of proptosis and improved optic nerve function and has a low incidence of complications.

Adult↗
PubMed2002

Pterional orbital decompression in diseases with acute increase of intraorbital pressure.

BACKGROUND: Orbital cellulitis as well as traumatic or spontaneous intraorbital hemorrhages can lead to an acute rise of intraorbital pressure, threatening the function of orbital vascular, muscular and neural structures. The treatment of this rare entity with extended pterional orbital decompression is described in comparison with other methods of orbital decompression. PATIENTS AND METHODS: Between 1991 and 2000 the authors treated 16 patients with sight-threatening acute elevations of intraorbital pressure due to orbital cellulitis (3 patients) and spontaneous (3 patients), postoperative (1 patient) or traumatic diffuse or localized intraorbital hemorrhage (9 patients) with extended pterional orbital decompression. Pre- and postoperative parameters, like visual acuity, exophthalmos, restrictions of extraocular motility and pupillary disturbances, were retrospectively analyzed. RESULTS: In all patients, a distinct improvement of preoperative symptoms, like complete reduction of proptosis in all cases, improvement of visual acuity in 12 patients, improvement of eye motility disturbances in 14 patients and of afferent pupillary disturbances in 6 patients, was achieved by decompressing the orbital contents within a mean of 30.5 hours after onset of symptoms. Severe, operation-related complications were not seen. CONCLUSION: Extended pterional orbital decompression represents an effective treatment alternative and supplement in cases of severe, ocular function-threatening cases of acute elevated orbital pressure, due, for example, to orbital cellulitis or diffuse or localized spontaneous and traumatic intraorbital hemorrhage, where immediate reduction of pressure on orbital neural, muscular and vascular structures is intended.

Adolescent↗
PubMed2002

Evaluation of cerebral gas retention and oedema formation in decompressed rats by using a simple gravimetric method.

OBJECTIVE: The objective of the study is twofold: first, to develop a specific gravity method for distinguishing between bubbles and oedema following decompression, and, second, to evaluate the extent to which the change in specific gravity is due to retained gas in cerebral tissue. METHODS: A brombenzene/kerosene gradient column was used to measure changes in brain specific gravity at 100 and 300 kPa, respectively. This study was performed on 23 rats. Non-exposed rats constituted the control group A (n=6). The exposed animals were divided into two groups according to the number of bubbles they developed upon decompression; group B (bubble grade 0-2, n=9) and group C (bubble grade 3-5, n=8). RESULTS: Cerebral gas retention was determined by increasing the pressure on the gradient column from 100 to 300kPa. Median specific gravity of the brain at 300kPa bar was significantly higher compared to 100 kPa for the decompressed groups B (p= 0.018) and C (p=0.012), thus implying gas retention. The cerebral gas volume was significantly higher for rats with a high bubble score compared to rats with a low bubble score (p=0.043). However, the major contribution to the change in specific gravity was due to oedema formation. CONCLUSION: The brombenzene/kerosene gradient column was found to be a sensitive method for distinguishing between gas retention and oedema formation in decompressed animals. There was a higher gas retention in rats with a high bubble score compared to rats with a low bubble score. The major contribution to the change in specific gravity in decompressed animals is due to oedema formation.

Animals↗
PubMed2002

Nasogastric decompression is not necessary in operations for gastric cancer: prospective randomised trial.

OBJECTIVE: To assess the need for routine nasogastric decompression after extensive resections in patients with gastric cancer. DESIGN: Prospective randomised study. SETTING: University hospital, Korea. SUBJECTS: Over a 1-year period (July 1999-July 200), 136 patients with gastric cancer who underwent radical gastrectomy with D2 or more lymph node dissection. INTERVENTIONS: Randomised to have nasogastric decompression (n = 69) or not (n = 67). MAIN OUTCOME MEASURES: Postoperative course, morbidity, and mortality. RESULTS: Time to passage of first flatus, time to taking liquid diet, length of operation, and postoperative hospital stay were all significantly shorter in the no decompression group. Two patients in each group required subsequent nasogastric decompression. There were no significant differences between the two groups concerning the presence of postoperative fever, nausea, vomiting, anastomotic leaks, or pulmonary or wound complications. No patients died. CONCLUSIONS: Routine nasogastric decompression is not necessary in elective operations for gastric cancer.

Adenocarcinoma↗
PubMed2004

Primary-gaze diplopia in patients with thyroid-related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome.

Our goal was to investigate the incidence of postoperative primary gaze diplopia in patients with thyroid-related orbitopathy (TRO) undergoing deep lateral wall orbital decompression surgery with intraconal fat debulking in the Jules Stein Eye Institute over a period of 4(1/4) years. Overall 201 orbital decompression surgeries were performed in 116 patients (23 males, 93 females). All surgeries were performed by two of the authors (R.A.G. and J.D.M.) and in the noninflammatory phase of the disease. Exophthalmos decreased by an average of 3.4 +/- 2.7 mm from 23.8 +/- 3.2 mm (17-31) to 20.4 +/- 2.5 mm (14-29), p < 0.001, 95% confidence interval (CI) (3.0:3.8). 31% of patients had preoperative primary gaze diplopia and 28.4% had postoperative primary gaze diplopia. Thirty (83%) of the 36 patients with preoperative diplopia had also postoperative diplopia; 6 (16.7%) of the 36 patients had improvement in diplopia following deep lateral wall decompression. Of the 80 (69%) of patients without preoperative double vision 3 developed postoperative double vision in primary gaze (2.6% of all patients). These 3 patients were older (56 versus 46 years, p = 0.047), had more limitation in ocular movements (p = 0.017) and achieved more decrease in proptosis with surgery (6 versus 3.1 mm, p = 0.024). No complications were associated with orbital decompression. In conclusion deep lateral wall orbital decompression surgery with intraconal fat debulking is associated with a low rate (2.6%) of new-onset primary gaze diplopia. Some patients (5.2%) with preoperative diplopia actually had improvement in diplopia postoperatively. This surgery is effective in reduction of congestion and exophthalmos, and is not associated with detrimental effects on visual acuity.

Adipose Tissue↗
PubMedDate not supplied

Cardiopulmonary bypass through peripheral cannulation with percutaneous decompression of the left heart in a model of severe myocardial failure.

Prolonged closed chest cardiopulmonary bypass for severe total biventricular myocardial dysfunction requires invasive decompression of the left heart. The authors have developed an elongated helical coil that is permanently attached to the distal 8-10 cm of a flow directed Swan-Ganz catheter. When properly positioned, the helical coil kept the pulmonary artery (PA) and the tricuspid valves open, and allowed closed chest retrograde decompression of the left heart. The authors have evaluated the merits of closed chest cardiopulmonary bypass with decompression of the left heart in this manner in four sheep subjected to 30 min of warm global myocardial ischemia, along with induced ventricular fibrillation. All sheep developed severe global myocardial failure, with no left ventricular (LV) ejection. The authors have shown that pulmonary blood flow during cardiopulmonary bypass was reversed from the left heart, across the lungs, and into the right heart. The wedge pressure never exceeded 12 mmHg at any time, attesting to good decompression during periods of total ventricular failure, during partial recovery with some LV ejection, and after good recovery of LV function, followed by weaning from bypass after 44, 67, and 78 h of such support. One sheep could not be weaned from bypass, even after 5 days of CPBP. Lung function in all sheep remained unimpaired throughout, and there was no wound bleeding. The authors conclude that in this model of total myocardial failure, and while on closed chest CPBP, at all times and with all degrees of myocardial dysfunction, excellent LV decompression with the helical coil catheter was attained.

Animals↗
PubMed1998

Osteonecrosis of the humeral head treated by core decompression.

Core decompression is one treatment used for symptomatic osteonecrosis of the humeral head. The purpose of this report was to examine the long term outcome of this procedure. Sixty-three shoulders in 43 patients who underwent a core decompression for humeral head osteonecrosis were followed up from 2 to 20 years (mean, 10 years). None of these patients had responded to nonoperative treatment before core decompression. Results of core decompression according to preoperative Ficat and Arlet stage revealed Stage I disease had 15 of 16 (94%) successful outcomes and Stage II had 15 of 17 (88%) successful outcomes. Stage III had 16 of 23 (70%) successful results and Stage IV had one of seven (14%) successful result. Core decompression of the shoulder is a safe procedure with few recognized complications and can be performed on an outpatient basis. The procedure has been successful for Stages I, II, and III osteonecrosis in terms of early relief of pain and increased function.

Activities of Daily Living↗
PubMed2001

Gastrostomy as a decompression technique in children with chronic gastrointestinal obstruction.

BACKGROUND: Percutaneous or surgical insertion of gastrostomy tubes for feeding children has been well described. However, there is no report of percutaneous gastrostomy for chronic decompression in children with chronic gastrointestinal obstruction. The objective of this study was to evaluate this technique. METHODS: Eighteen gastrostomies were performed for gastrointestinal decompression in children. The patients ranged in age from 2 to 125 months (median: 15.5), and all had prolonged hospital stays for severe disease: severe gastroparesis and/or duodenal dysmotility (n = 8), duodenal stenosis (n = 2), chronic intestinal pseudo-obstruction (n = 4), enterocolitis (n = 2), and metastatic abdominal carcinomatosis (n = 2). The duration of symptoms before gastrostomy placement ranged from 0.5 to 44 months (median: 2), with major symptoms including epigastric pain, early satiety, nausea, vomiting, and bloating. RESULTS: The goals of gastric decompression and removal of the nasogastric tube were achieved in all patients, and all had significant relief of both nausea and emesis. Oral intake of liquids and soft foods was possible in 17 of 18 of the children. The tubes were kept in place for a median of 22.5 months (range, 2-73). There was neither long-term morbidity nor mortality associated with the presence of the tube. Seventeen patients returned home with gastric decompression and cyclic parenteral nutrition, two of them for terminal care. Six patients died. In all patients, gastrostomy was used throughout and did not contribute to the death of the patients. For seven children, tubes were removed because of resolution of small bowel or gastric outlet obstruction. CONCLUSIONS: Gastrostomy is an efficient and well-tolerated method of achieving long-term gastric decompression in children with abdominal obstruction not amenable to surgery and/ or resistant to medical treatment.

Child↗
PubMed2002

Pterional orbita decompression in orbital hemorrhage and trauma.

BACKGROUND: This article presents a series of patients with traumatic retrobulbar hematoma and orbital trauma, treated with extended pterional orbital decompression. METHODS: Fifteen patients, showing symptomatic retrobulbar hematoma or symptoms of orbital injury after various trauma mechanisms, were treated with deep lateral orbital decompression and removal of orbital blood/bone fragments via this approach. Preoperative and postoperative course, neuroradiologic findings, additional brain or facial injuries, and outcome of eye function are analyzed in detail. RESULTS: Mean delay between trauma and decompression was 70 hours (3 days), with a range from 2 hours to 15 days. Proptosis decreased in all patients and visual acuity improved or remained normal in nine patients and stayed defective in four. Impaired extraocular movements and pupillary changes recovered in 10 patients. Apart from one case of permanent deficit of the frontal branch of the facial nerve, no severe complications were seen. CONCLUSION: The presented pterional orbital decompression represents an effective alternative approach for patients with sight-threatening retrobulbar hematoma or orbital trauma, especially in cases that require direct access to damaged structures and maximal decompression of the orbit. Immediate detection and treatment of orbital hematomas is mandatory for acceptable outcome of eye function.

Adolescent↗
PubMed2001

Optic nerve decompression in the comatose and conscious patients after trauma.

OBJECTIVE: To investigate the efficacy of early optic nerve decompression in comatose and conscious patients with indirect traumatic optic neuropathy. STUDY DESIGN: Retrospective analysis of 65 optic nerve decompressions. METHODS: The total collective of optic nerve decompressions comprised 65 patients treated within the period between February 1987 and December 1998. Thirteen of these 65 patients (average age, 32 y) were comatose and required critical care treatment, so visual acuity could not be measured. The indication for surgical decompression in all patients was based on the ophthalmological examination and the finding on computed tomography (CT) scan of a lesion inside the optic nerve canal or the orbit apex, respectively. RESULTS: In the comatose patients the time interval between trauma and surgery was 16.1+/-12.1 hours (mean +/- standard deviation). During the subsequent postoperative examinations (on average, 12.3 mo postoperatively) five patients showed a normal visual acuity (20/20), two patients a visual acuity of 20/30 and 20/50, and one a visual acuity of 20/200. Three patients (three eyes) remained amaurotic. Two patients died of the general and severe consequences of injury. The beneficial visual acuity results achieved within the group of comatose patients were equivalent to those achieved within the group of patients who were conscious during the preoperative examination. The success rate, defined as an improvement of three lines with a final visual acuity of at least 20/1000, was 57.7% versus 61.5%. CONCLUSION: The results confirm our concept of early decompression of the optic nerve, based on close interdisciplinary cooperation and the ophthalmological findings.

Adolescent↗
PubMed2003

Embolic inner ear decompression illness: correlation with a right-to-left shunt.

OBJECTIVES/HYPOTHESIS: Inner ear decompression illness is thought to be a rare phenomenon in recreational divers, isolated signs and symptoms of inner ear dysfunction usually being attributed to inner ear barotrauma. STUDY DESIGN: We present 11 cases of inner ear dysfunction in nine divers with inner ear decompression illness. RESULTS: All nine divers had significant right-to-left shunt as diagnosed by transcranial Doppler sonography. CONCLUSIONS: The authors thought that mechanism of causation in these cases may have been intravascular bubble emboli and that inner ear decompression illness may be more common among recreational divers than currently recognized. Failure to treat inner ear decompression illness with recompression therapy can result in permanent disability. Because the differential diagnosis between inner ear barotrauma and inner ear decompression illness can be impossible, the authors suggested that divers who present with inner ear symptoms following a dive should have recompression immediately after having undergone bilateral paracentesis.

Decompression Sickness↗
PubMed2001

An assessment of perfusion deficits in decompression illness using 99Tcm HMPAO SPET and statistical parametric mapping.

AIM: The aim of this study was to use statistical parametric mapping (SPM) to investigate differences in the regional cerebral blood flow (rCBF) of decompression illness (DCI) and non-diving control subjects. METHODS: Twenty DCI subjects were imaged using 99Tcm hexamethylproplylene amine oxime (HMPAO) single photon emission tomography (SPET) within days of their incident of DCI, and on a second occasion between 2 and 27 months after their DCI event. SPM was used to make a comparison between decompression illness studies and a second group of non-diving control studies for both early and late imaging of DCI. A paired comparison of early and late imaging was also performed testing for correlation between time of imaging and changes in the rCBF pattern. RESULTS: The comparison between control subjects and early imaging of decompression illness showed a large, significant (P = 0.002), irregularly shaped, multi-focal area of reduced uptake in the left occipito-parieto-temporal region of the brain. Comparisons between control and repeat decompression illness imaging studies showed two areas of reduced uptake. The first was similar to that found in the initial comparison although it was less significant (P = 0.035). The second region was similar but contra-lateral to the first region with significance P < 0.001. An attempt to correlate any changes in rCBF with the time that elapsed between each set of imaging found no areas of significant correlation. CONCLUSION: 99Tcm HMPAO SPET images of decompression illness display areas of reduced perfusion, which persist in the majority of cases.

Adult↗
PubMed2000

Results of decompression of peripheral nerves in diabetics: a prospective, blinded study.

Diabetic neuropathy traditionally is considered progressive and irreversible and will result in lower extremity ulceration and amputation in a segment of the diabetic population, despite the best efforts to control serum glucose levels. Restoration of sensation to the diabetic may prevent these complications of neuropathy. The present study was designed to evaluate whether decompression of a peripheral nerve at a known site of anatomic narrowing can restore sensibility to that nerve in the diabetic. Twenty diabetic patients ( 14 type I, 6 type II, with a mean duration of diabetes of 14.8 years) had surgical decompression of a median nerve at the wrist and an ulnar nerve at the elbow, or a decompression of the posterior tibial nerve at the ankle (total of 31 nerves). A therapist, in a manner blind to the operative site, evaluated two-point discrimination in the pulp of the appropriate digit. The postoperative sensibility was compared with that of the nontreated, contralateral extremity. At a mean of 23.3 months, 69 percent of the lower-extremity nerves and 88 percent of the upper-extremity nerves (79 percent overall) had improvement in sensibility. In comparison, 32 percent of the control (not decompressed) contralateral nerves had measurable progression of neuropathy. The hypothesis that decompression of a peripheral nerve in the diabetic will improve sensibility was confirmed at the p < 0.001 level.

Adult↗