Monofiliments Not an Accurate Test of Neuropathy (Lee Rogers, DPM)

10/22/2008      Peter J. Bregman, DPM, James J DiResta, DPM,MPH


RE: Monofiliments Not an Accurate Test of Neuropathy (Lee Rogers, DPM) From: Peter J. Bregman, DPM, James J DiResta, DPM,MPH With all due respect to my colleagues, I am not promoting the PSSD machine and while I do perform nerve decompressions for people with painful neuropathy both diabetic and non- diabetic I am not advocating the machine for anyone. Dr. Rogers is correct regarding LOPS and seems to be looking to be argumentative towards me regarding the mono-filaments. I assumed that all reading my post would understand that I was referring to loss of protective sensation (neuropathy ) rather than neuropathy itself. If I did not make it clear then it is now.

The studies he referenced are, in my mind, not based on my experience and are presented by people who choose not to believe the 8 or so published articles on nerve decompression surgery that have been published and are consistent. They are not the double-blind randomized prospective studies that people are looking for but they are good enough for me and I have stacks of letters from patients and please even view my website for video testimonials from my patients who have had the surgery.

Dr. Rogers chose to attack the surgery with the usual rhetoric of the “non-believers”. In my experience the non-believers are not surgeons, so their toolbox is limited. They also have a lot of money to lose if patients can be treated with surgery and do not need expensive emg/ncv testing and can get off the neuropathy medications. I cannot tell you how many times I have had a “Negative EMG” and performed decompression surgery despite this so called negative test and the patients do well 85-90% of the time.

The PSSD machine is sensitive and an early detector of neuropathy. Yes, it is expensive I cannot argue with that. As for the learning curve to be able to use it properly I guess you just have to accept the training that comes with it for which you get certified to do. Dr. Dellon by the way has recently responded to recent position statements by the Neurologists and the ADA. I am attaching two articles written by Dr. Dellon which elucidate in a clear manner the arguments here. Also, it should be know that as we (Association of Extremity Surgeons) are preparing to do the prospective randomized study on the decompression surgeries. I have little doubt it will end the debate over this unless you just want to deny the results no matter what they say.

I would ask Dr. DiResta not to infer that I think the PSSD is the Gold Standard for Neuropathy detection. I simply said and quite clearly that Monofilaments are not. I would like to know how it finds false positives if done properly? I do not appreciate the clear inference that I or one of my colleagues would perform surgery on someone who was not a candidate for the surgery just because they had a positive PSSD test. They need to have the physical compression of the nerves to benefit. Please refer to the attached papers from Dr. Dellon. As for the cost of the PSSD to the health care system Dr. DiResta you don’t see the big picture.

First of all, it is significantly cheaper than EMG/NCV studies which are not accurate for lower extremity testing for tarsal tunnel and compression neuropathies. Also, if you can put away your biased opinion on the PSSD machine which is FDA-approved and covered by Medicare in most states you might understand the bigger picture. Billions of dollars are spent on treating ulcers and the resultant amputations etc. If we can stop ulcers from occurring in the first place then we save the system Billions of dollars and give patients a better quality of life. See the Neuropathy Registry on www.Dellon.com and you will see that patients whom underwent decompression do not get ulcers just a very small percentage. This is fact.

In closing, I did not want to get into this discussion but I felt compelled to respond. I can say that I have used the PSSD machine and Monofilaments and treated patients with Neurontin and other modalities and performed surgical decompressions done the Dellon way. Have you also had this experience? I feel like I can speak about both with equal experience. Please show me all of the studies on how aspirin works on curing headaches? We know it works but there are no double blind randomized studies on this so should we not take aspirin for headaches?

As far as the surgery being in dispute this is only by people who don’t do it. Please let anyone who was trained by Dr. Dellon who had performed more that 20 of these procedures come forward and tell us how it does not work. How many people are still using Anodyne treatment despite the articles showing it does not work? I will continue to use my experience in practice and continue to perform these surgeries on the appropriate candidates and make a difference in their lives as evidenced by the fact that they have said on camera they are better. I have received numerous letters from them thanking me for changing their lives and they come back to have the other side done. If these procedures did not work why would this be? How many of you inject “neuromas” with absolute alcohol injections? Show me the double-blind studies on that? I am sure I will get even more responses now and I think I shall wait until our study is finished before continuing this debate.

Peter Bregman, DPM, Tewksbury , MA, footguru@comcast.net