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:

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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