01/27/2017    David E. Samuel, DPM

Nerve Biopsy on a Diabetic? (John M. Hurchik, DPM)

Several years ago, better vitamin therapy was
introduced by a few companies that started
showing better efficacy for diminishing
neuropathic pain. You purchase the vitamins,
and resell them to your patients. You make a little
on the vitamins and many times, patients feel
better and are happy.

Good clinical studies on it and biopsy, I'm
sure, played a roll in determining what the
vitamins ultimately did to warrant a trial with
them. We have used these vitamins and some have
seemed to give some moderate improvement and
some have also not been helpful. It just depends
on the individual patient how it does for them.

They then developed a biopsy to show pre- and
post-vitamin therapy, how many new nerve fibers
were seen that was heavily marketed to the
practices. This was a revenue generator for
both the lab and the office performing the
biopsy, but really of limited value for the
patient. The bottom line is that if the
vitamins were working, the patient would feel
better, and who cares how many new nerve fibers
are present. If they didn't feel better, again
whether more fibers are seen means very little
if they don't feel any better.

If you are treating a patient in the office
that has some mild erythema to their hallux
from an ingrown nail, and you opt to use some
keflex, post nail removal and the pain and
redness diminish, would you order lab work to
show the white count went down? I bet if the
insurance companies paid the office anything
for that WBC test from a simple in-office
finger stick, a whole bunch would be done vs.
doing one once in a while for a patient with a
larger wound that tells you they didn't feel
well.

We all need to be more prudent with tests we
order as well as modalities available. Just
because you can doesn't mean you should. A
small punch biopsy is easy and relatively
simple until it gets infected or your diabetic
patient with moderate edema now gets a large
wound or cellulitis from a 'simple' punch. We
have all seen the nightmare scratch that leads
to major necrosis or bruise from the car door
that becomes a crater in someone's leg or
ankle.

If issues arise from necessary studies that
lead to better overall care for the patient,
then those things happen and for me easier to
accept. But I am not sure why I need to know
microscopically there is improvement if the
patient tells me they feel better from the
treatment, and even a small biopsy can pose any
risk. Would you biopsy your mom if she told you
she loves how the vitamins made her feel or
just give her more vitamins?

Insurance companies will certainly catch on at
some point and this and so many other things we
do will just make it more difficult for all of
us to get needed treatments paid for when they
are now reviewing cases to prove "unnecessary
use" of some necessary things, as everything
gets more scrutinized. Does anyone remember
when insurance companies paid us pretty well
for orthotics? That became a license to
prescribe them for tinea pedis and bye bye
orthotic coverage.

Do you need an ultrasound to inject a plantar
fascia or put a 25g 1.5 inch needle in an
ankle? If you do, I'm thinking workshop on
injections vs billing for an ultrasound.
Clearly we can show many examples of these
types of, what I personally believe is over
utilization, that makes it harder and harder to
get reimbursement for all of us.

I'm just saying be prudent with studies and
making conscious efforts to save some money
ordering less as well as putting patients
through less and maybe in a small way improve
better use of healthcare dollars.

David E. Samuel, DPM, Springfield, PA

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01/28/2017    Bradley Bakotic, DPM, DO

Nerve Biopsy on a Diabetic? (John M. Hurchik, DPM)

I'm a bit confused by the post related to ENFD
by John Hurchik, DPM and some of the subsequent
responses, particularly that offered by Eliot
Udell, DPM, who seemed to imply that clinical
doctors, and their labs, are doing ENFD testing
strictly for "massive" financial gain, rather
than optimal patient care.

First let me say that I have been informed that
Dr. Hurchik did intend for his note to take the
negative tone that it seemed to. Secondly,
those that believe that a punch biopsy pays a
"massive" amount of money, probably have never
done a punch biopsy. The "massive"
reimbursement for a punch biopsy is about
$85.00. It might buy you dinner at a two star
restaurant, if you don't order a glass of wine.
On the lab side, it is the most labor
intensive, and lowest margin test that we run.
In addition, although the test is performed at
Harvard, Johns Hopkins, Stanford, and Cleveland
Clinic, many payors refuse to reimburse for it
at all, erroneously calling it experimental.
ENFD is the best test for diagnosing,
verifying, or quantifying small fiber
neuropathy. That is why we offer it.

I do not know of all the cases that Dr. Hurchik
is referring to; however, I can say that with
respect to the most recent case, the patient
did NOT present with typical small fiber
neuropathy symptomatology, thereby prompting a
confirmatory ENFD biopsy. Parenthetically, with
all do respect to Dr. Udell, I must clarify
that ENFD testing is not a nerve biopsy, it is
a 3mm punch of skin.

It is absolutely true that ENFD is not for
everyone, but it certainly has its indications.
Many conditions, from large fiber
polyneuropathy, to multiple sclerosis, to
entrapment, can present with symptoms identical
to those of small fiber neuropathy. Assuming
that every patient presenting with stocking
and/or glove discomfort has small fiber
neuropathy is oversimplification. This is
particularly true if the affected patient's
symptoms are unconventional.

Finally, Dr. Hurchik's experience, though
disconcerting, is not typical. Overall, 3mm
punches from the leg are very well tolerated,
even in the diabetic population. In fact, a
study on the subject of ENFD complications in
Europe several years ago was abandoned, because
no complication came to fruition! This of
course, does not mean that complications cannot
occur. Additional post-biopsy care certainly
should be taken when dealing with diabetic
person's, or those with poor circulation.
Throwing a suture, and extending the period for
which the wound is kept dry, will both help to
diminish the postoperative infection rate.

Bradley Bakotic, DPM, DO, Alpharetta, GA