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08/31/2015 Barry Mullen, DPM
Sclerosing Alcohol Injections (Peter J. Bregman, DPM)
After reading several anecdotal responses to Dr. Bregman's post, it occurred to me that THE ONE compelling question to ask is to what extent should we, as clinicians, should utilize the anecdotal successful experience claims of our colleagues and forefathers relative to our own medical decision making process? In my humble opinion, this is an extremely important question our younger, less experienced colleagues should ask, though it transcends our entire profession. You are all receiving incredible training, yet lack the years of repeated patient exposure to know what truly does and doesn't work in clinical practice. As such, while I recommend remaining open minded, I also implore each of my colleagues to use significant grains of salt with respect to medical opinions posted on this site.
Dr. Block is wonderful because of the openness of his forum, but that is potentially dangerous too. So, I implore you all to consider what the evidence-based medical research demonstrates for a given treatment that you are considering and allow that to serve as your strongest ally in your medical decision process! You don't know who, or how reputable your sources are, for anyone can opine just about anything, and often do!
From my perspective, I am extremely careful in my choice of words in the event my comments have any influence on my peers, a concept we all should embrace. That said, is there a place in medicine for anecdotal based treatment? Of course there is, especially when presented from some of our profession's leaders, ESPECIALLY when evidence based medicine exists supporting that treatment. Case in point (I'm not anointing myself as a 'leader'), my anecdotal successful experience utilizing oral cimetidine to treat pedal warts is 84 per cent (JAPMA 2007- original manuscript- Orlow and Paller- Journal of Dermatology 1994) AND based upon EBM from Griswold's work with mice which demonstrated cimetidine's ability to enhance the host T cell immune response (Journal of Immunology 1984).
So, if warts need a blood supply to survive, and one effectively increases the concentration of T cells per unit of volume of blood in the host, and the T cell immune response can affect warts...draw your own conclusions. The key to success is patience and using the appropriate dose AND duration to achieve positive results. If you think your treatment failed after just 4 weeks of giving 200 mg of cimetidine bid, then you simply didn't read either article and don't understand, nor appreciate the physiology. OK- back on track.
Regarding Dr. Bregman's EBM reference of Dr. Mazoch's work with rat sciatic nerves, this study provides compelling evidence that at 4 per cent concentrations, dehydrated alcohol does NOT sclerose nerve tissue. What I'd like to learn is at what concentration this is achieved, and what additional detrimental effect(s) that has on surrounding soft tissue and lymphatics? I've tried this treatment with limited success and have not approached anywhere near the 89 per cent success rate Dr. Dockery reported in his 1999 JFAS manuscript. Could it be my technique? Possibly, but doubtful since alcohol does diffuse through tissue planes to exert its effect over greater distances than most other injectables. I, like Dr. Dockery, utilize the clinical tinsel sign response to know the tip of my needle is in very close proximity to the inter metatarsal nerve. Perhaps ultrasound guidance might improve success rates, though some studies refute this and to my knowledge, wasn't employed in Dr. Dockery's study. Personally, I've fallen out of favor, but would re- consider if future studies at higher concentrations demonstrate sclerosing ability without significant increases in local tissue damage. If alcohol doesn't sclerose nerve tissue at 4 per cent concentration, then exactly how does the purported prolotherapy effect work in the treatment of Morton's neuroma?
With respect to Dr. John's comments regarding the size of the neuroma being his common link to injection failure, my question is, why should that matter?! If one actually did achieve a true chemical neurolysis PROXIMAL to the site of entrapment via sclerosis, then by definition, painful nerve transmission to and from the actual neuroma site to the spinal cord is eliminated....period! As such, for me, with all due respect, that calls into question your overall anecdotal experience. You either created an effective chemical blockade, or you didn't . Size doesn't matter. Where it might matter is with failed decompression. We don't walk on wrists, so I understand the high success rate carpal tunnel surgery enjoys. In feet, true neuromas do form, so I can also appreciate how and why some decompression attempts fail, ultimately requiring neurectomy.
With respect to Dr. Peacock's comments on his success using Sarapin, if I recall, you also have an MS designation, so kindly explain how that works since Manchikenti's double blind study in 500 patients demonstrated no difference in success rates between the control group and those who received Sarapin? Homeopathic products will likely make you a ton of cash, but do they really work, and if so, how? What's the physiology on the cellular level behind success, and where is the EBM to support that particular medical decision? In this case, the EBM tells us it doesn't work, so how does rationalize that medical decision? As such, respectfully, I question that anecdotal reporting.
Look...I'm open minded and will try anecdotal treatments supported by EBM (cimetidine), but I'm also quite skeptical and a closet idealist which forces me to place my patient care and medical decision making process before my wallet. As doctors, we are bound by our Hippocratic oath. As family financial providers incurring huge debt upon graduation from medical school, we also have significant fiscal responsibilities. That's a seeming contradiction. Achieving fiscal balance and procuring a win-win for our patients in a declining medical market is our biggest challenge, one I hope all my colleagues find and embrace.
Sorry for this long winded post, but appreciate the opportunity to express myself and sincerely hope it helps the newer practitioners now challenged with the dual task of providing quality patient care and achieving positive patient outcomes while earning a decent living. "If you treat your patients like you or a family member would want to be treated", THAT to me is the "EBM" for success and there isn't a day that goes by where I don't acknowledge those immortal words espoused by the late, great Dr. Emmanuel Sugarman!
Barry Mullen, DPM, Hackettstown, NJ
Other messages in this thread:
08/27/2015 Dock Dockery, DPM
Sclerosing Alcohol Injections (Peter J. Bregman, DPM)
In reference to the article on alcohol injections into the rat sciatic nerve, I have a few observations: 1. this study doesn't explain why literally hundreds of thousands of patients have had permanent relief from nerve symptoms that were injected with a 4% ethanol solution. 2. this study explained that the sciatic nerves were "exposed" prior to injections and were not injected into an intact animal. 3. this study only did one injection of each trial agent: 0.5 ml of 0.5% Marcaine alone, left sciatic nerve in 11 rates and 0.5 ml of 4% ethanol with 0.5% Marcaine, right sciatic nerve in 11 rats and also 0.5 ml of 20% ethanol with 0.5% Marcaine, left sciatic nerve in 11 additional rats and 0.5 ml of 30% ethanol with 0.5% Marcaine in the right sciatic nerves of those same 11 rats. What is a little confusing in this study is that the 22 rats were subdivided into 3 groups for intraneural, perineural and perimusclular injections. Then all 22 rats were sacrificed at 10 days to look at the nerves and muscles.
So, my questions are: 1. Why are so many patients improved and cured of nerve pains, nerve injuries, and nerve entrapments by a 4% dilute injection of ethanol?
I am sure from 30+ years of injecting 0.5% Marcaine alone that this isn't the reason. I am also sure, for the same reason, that adding steroid does not give the same results as 4% alcohol solution and adding steroid to injections greatly increases the risks of complications.
2. Why did the examiners feel obligated to expose the nerves before starting the project? I have never "surgically exposed" a human nerve before injecting it with 4% alcohol solution. I would have been a little happier if the authors had done a similar protocol of weekly injections, in an intact animal, around the sciatic nerves.
3. Were the solutions mixed properly to get the correct percentages of solution to 4%, 20% and 30% ethanol or were the solutions of 4%, 20% and 30% ethanol mixed with 0.5% Marcaine?
I wish there was an easy way to do a comparative human study with the 4% alcohol solution, but I think it would be extremely difficult to get a pre-injection histology report on the nerve, do the series of injections and then subject the patient to surgical dissection of the tissue for pathology evaluation.
I would like to hear from the hundreds of DPMs out there that routinely inject neuromas, painful scars and nerve entrapments with 4% alcohol solutions and get great long-term results. I certainly would not stop recommending this treatment or stop believing in it, since I know that it works. Even with increasingly reduced reimbursements and those that speak against the treatment, I will continue to use it.
Dock Dockery, DPM, Seattle, WA
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