We read Wei et al’s article1 on nerve block in diabetic foot ulcer patients with interest. The study examined nerve stimulation thresholds and block duration. As hand and foot surgeons, we greatly appreciate the clinical relevance of this research, particularly in light of the high incidence of diabetes-related complications among our patients. However, we would like to raise some concerns and offer constructive suggestions to improve the comprehensiveness and impact of the study.

Firstly, we commend the authors for their effort in conducting a prospective cohort study that compares nerve block characteristics between patients with and without diabetes. Their findings of increased stimulation thresholds and prolonged nerve block durations in diabetics offer insights into diabetic neuropathy. However, the analysis could be enhanced by considering additional factors such as glycemic control, diabetes duration, and neuropathy severity (assessed via standardized scales). These factors, known to impact neuropathic pain outcomes in type 1 diabetes, are supported by evidence from studies like Braffett et al2 which reported a high incidence of neuropathic pain in type 1 diabetes patients. Incorporating these factors could lead to a more nuanced understanding and improved clinical strategies for managing neuropathic pain in diabetics.

Secondly, we are concerned about the potential risk of neurotoxicity associated with the prolonged nerve blocks observed in diabetic patients. The study mentions that nerve injury was observed in 4 patients (4.8%) within the diabetes mellitus group, which is a notable finding. However, the specific nature and severity of these injuries are not clearly described. We recommend that the authors provide more detailed information on the type, severity, and clinical course of these nerve injuries. Additionally, further discussion on the potential mechanisms underlying the prolonged nerve block durations and increased risk of neurotoxicity in diabetic patients would strengthen the conclusions of the study.3

In terms of constructive suggestions, we recommend that the authors consider including additional outcome measures in future studies. For instance, assessing patient-reported outcomes such as pain levels, functional recovery, and quality of life could provide a more holistic view of the impact of nerve blocks on diabetic foot ulcer patients. Additionally, long-term follow-up studies would be valuable to understand the persistent effects of nerve blocks on nerve function recovery and the development of chronic neuropathic pain.4 Furthermore, we suggest that the authors explore the use of alternative anesthetics or adjuvant methods that may have a reduced risk of neurotoxicity while maintaining adequate anesthesia and analgesia.5

In conclusion, we appreciate the contributions of Wei et al to the understanding of nerve block characteristics in patients with diabetic foot ulcers. We hope that our comments and suggestions will be taken into consideration by the authors and the editorial board to enhance the quality and impact of future research in this important area.

The authors declare no conflicts of interest in this communication.

1. Wei Q, Rong H, Zhang G, Xie Y, Dai W. Nerve block extends nerve function recovery in patients with diabetic foot ulcers. J Pain Res. 2024;17:3949–3957. PMID: 39600397; PMCID: PMC11590638. doi:10.2147/JPR.S491539

2. Braffett BH, El Ghormli L, Albers JW, et al.; DCCT/EDIC Research Group. Neuropathic pain with and without diabetic peripheral neuropathy in type 1 diabetes. Diabetes Care. 2024;47(9):1559–1567. PMID: 38300889; PMCID: PMC11362121. doi:10.2337/dc23-1749

3. Lirk P, Flatz M, Haller I, et al. In Zucker diabetic fatty rats, subclinical diabetic neuropathy increases in vivo lidocaine block duration but not in vitro neurotoxicity. Reg Anesth Pain Med. 2012;37(6):601–606. PMID: 23011115; PMCID: PMC3480545. doi:10.1097/AAP.0b013e3182664afb

4. Sveen KA, Karimé B, Jørum E, et al. Small- and large-fiber neuropathy after 40 years of type 1 diabetes: associations with glycemic control and advanced protein glycation: the Oslo Study. Diabetes Care. 2013;36(11):3712–3717. PMID: 24026557; PMCID: PMC3816884. doi:10.2337/dc13-0788

5. Uemura T, Watanabe H, Yanai T, Kawano H, Yoshida A, Okutsu I. A minimally invasive full endoscopic approach to tibial nerve neurolysis in diabetic foot neuropathy: an alternative to open procedures. Plast Reconstr Surg. 2021;148(3):592–596. PMID: 34432688. doi:10.1097/PRS.0000000000008299