Managing Spine Patients With Diabetes: A Patient-Centric Approach
Highlight from the 30th Annual Meeting of the North American Spine Society (NASS) in Chicago
Presented by Carrie A. Diulus, MD
More than 90 million adults—up to 50% of the U.S. population to date—have diabetes or prediabetes, and many of these patients don’t know it. Unfortunately, these numbers are growing and affect a disproportionate percentage of spine patients, noted Carrie A. Diulus, MD, in a presentation at the 30th Annual Meeting of the North American Spine Society (NASS), in Chicago, Illinois. Dr. Diulus discussed the unique challenges that diabetes poses for spine providers, including challenges with differential diagnosis, as well as medical, operative, and perioperative management.
Given the high prevalence of diabetes, spine surgeons should be on the alert for patients with diabetes symptoms who are not yet diagnosed, said Dr. Diulus, who is an orthopaedic spine surgeon at Crystal Clinic Orthopaedic Center in Akron, Ohio. “We start to see complications related to diabetes, both microvascular and macrovascular, often before the patient is even diagnosed,” Dr. Diulus said, adding that almost half of the patients with diabetes/pre-diabetes in her practice were initially diagnosed with the disease by her.
Thinking Outside of the Box
“The standard neuropathies that we see with diabetic patients are typically symmetric; they are length-dependent and mixed sensory-motor neuropathies,” Dr. Diulus said. In addition, there are a variety of more subtle neuropathies that may be found in patients with diabetes, including diabetic lumbosacral radiculoplexus neuropathy, diabetic amyotrophy, diabetic myelopathy, proximal diabetic neuropathy, diabetic motor neuropathy, and diabetic cervical radiculoplexus neuropathy. “So when the picture doesn’t fit, and you have a patient with diabetes or may have glucose intolerance, these are the things that you need to keep tucked into the back of your mind,” Dr. Diulus noted.
In addition, patients with diabetes are at increased risk for frozen shoulder and iliotibial band syndrome, problems with vascularity in their feet, retinopathy, and gastroparesis. The latter issue is pertinent given that gastroparesis can impact the way that patients absorb medications, Dr. Diulus said.
Case in Point: Diabetic Amyotrophy
Dr. Diulus illustrated the need to consider diabetes diagnoses when treating spine conditions by describing a case in which an 82-year-old woman with diabetes was scheduled for a 3-level decompression with instrumentation and fusion. The patient had undergone a fall thought to be caused by a ministroke, and presented with pain and weakness in her right leg as well as uncontrolled diabetes. Further examination showed profound weakness in her right quadriceps, but normal strength in all other muscles. Electromyography showed that the patient actually had a classic presentation of diabetic amyotrophy in addition to more classic sensory neuropathy in a stocking distribution bilaterally in her lower to mid-calves, Dr. Diulus explained.
“Diabetic amyotrophy is thought to be related to ischemic injury from nonsystemic microvasculitis,” Dr. Diulus explained. Diabetic amyotrophy typically presents as acute asymmetric focal onset of pain and weakness in the proximal leg; however, it also can be painless or start distally, and it can progress to impact the contralateral limb. In addition, many patients experience recent unexplained weight loss.
“Biopsies have shown that diabetic amyotrophy causes multifocal fiber loss, perineural thickening, and neovascularization. It is more common in type 2 diabetics, most of whom are recently diagnosed and reasonably well controlled. Diabetic amyotrophy often can be the presenting feature of diabetes, so when the picture doesn’t fit clinically, think outside the box,” Dr. Diulus said. “MRI imaging may show increased T2 signal with gadolinium enhancement around the roots, the plexus, or the peripheral nerves. Nerve conduction tests tend to show markedly reduced amplitude of compound muscle action potentials and sensory nerve action potentials, and conduction velocities only show a mild conduction velocity slowing. Electromyography typically shows fibrillation potentials, decreased motor unit recruitment, and long-duration high-amplitude motor unit potentials,” Dr. Diulus explained.
Moving Toward a Patient-Centered Model of Care
Dr. Diulus encouraged spine specialists to move away from the traditional disease-based model of care and to start treating patients using a more patient-centered model of care.