Dr. Stephen L. Barrett, Executive Producer

00:00 – Introduction

Welcome to Pod of Inquiry with holiday greetings. The documentary is titled “Some Nerve: Hope for Patients with Diabetic Peripheral Neuropathy” – intended as a resource to share with those affected by this condition.

01:31 – Patient Case Presentation

Introduction of a juvenile-onset diabetic patient with poor circulation and diabetic neuropathy, presenting with diabetic ulcers, lymphedema, and evidence of gangrene.

02:42 – Meeting Dr. Arnold Lee Dellon

More than 20 years ago, Dr. Stephen Barrett crossed paths with Dr. Arnold Lee Dellon, a pioneer in developing the modern field of peripheral nerve injury and professor of plastic surgery and neurosurgery at Johns Hopkins.

03:31 – Initial Skepticism

Dr. Barrett describes his initial skepticism when learning that symptoms of diabetic peripheral neuropathy could be reversed by nerve decompression surgery, but his perspective changed after witnessing results.

03:58 – Patient Impact Testimonials

Patients describe severe impacts including:

• Inability to walk due to pain
• Loss of ability to perform their jobs of 30 years
• Restoration of day-to-day functioning after treatment

05:00 – Dr. Barrett’s Conversion Experience

Dr. Barrett recalls staying up at night after witnessing surgeries, initially challenging Dr. Dellon’s approach, but being convinced after deeper questioning about his understanding of the condition.

05:34 – Practice Revolution

Introduction to how meeting Dr. Dellon revolutionized podiatric practices, completely transforming approaches to neuropathy treatment.

05:51 – 14 Years of Experience

Approximately 14 years since initial introduction to nerve decompression techniques, practitioners describe amazing positive effects despite initial skepticism.

06:52 – Understanding Diabetic Neuropathy

Discussion of diabetic peripheral neuropathy terminology and variations in naming.

07:05 – Biochemical Basis

Explanation of how high glucose levels biochemically affect nerves through the polyol pathway and sorbitol accumulation, leading to nerve swelling.

07:56 – “Silent Sufferers”

Introduction of the concept that many neuropathy patients suffer silently.

08:00 – Common Symptoms

Neuropathy commonly presents with burning, tingling, and pain – the “emotional symptoms” that motivate patients to seek help.

08:53 – Prevalence Statistics

• Approximately 30-31 million people with diabetes in the United States
• About half have some form of neuropathy
• 85% of amputations are preceded by ulceration or open wounds

10:00 – Wound Complications

Explanation that about half the time, diabetic wounds become infected during their natural course.

10:28 – Global Impact

There is an amputation every 20 seconds somewhere around the world – potentially preventable events.

11:07 – Surgical Benefits

With nerve decompression surgery, annual recurrence rate of foot ulceration can be reduced from 17% to 3-5%.

11:37 – Cost Analysis

• Average diabetic foot ulcer costs and requires approximately 6 weeks to heal
• If complications develop, costs rise to $40,000-$80,000 per occurrence
• Represents extremely expensive burden for healthcare system and patients

12:32 – Failed Medical Management

Patient testimonials about trying various medications with limited success:

• Amitriptyline
• Cymbalta
• Lyrica
• Stem cell injections (twice)
• Laser therapy for blood flow All providing only minor relief

13:22 – Compression vs. Axonal Disease

Discussion of how to distinguish between nerve compression and disease where the nerve axon itself is involved.

15:00 – Anatomical Considerations

Explanation of how nerves travel through specific pathways in the body, particularly at or around joints where compression can occur.

16:55 – Systemic vs. Local Causes

Acknowledgment that there are many systemic and proximal causes of peripheral neuropathy beyond simple nerve compression.

17:22 – Stocking Distribution Myth

Discussion of unpublished data showing that the classical “stocking distribution” of diabetic neuropathy doesn’t actually exist as traditionally described.

17:45 – Diabetic Nerve Vulnerability

In diabetes, when compression occurs, the already “sick” nerve gets progressively worse fairly quickly.

18:04 – Skeptics’ Position

Even skeptics acknowledge that individual nerve entrapments can occur, with neurologists and endocrinologists agreeing that proper treatment involves nerve release.

18:20 – Multiple Entrapment Concept

The key insight: patients can develop a “suite of entrapments” – up to four entrapments in the lower leg – producing the picture classically attributed to pure metabolic neuropathy.

18:52 – Professional Divide

Description of the divide between practitioners who perform the surgery and see results (wonderfully enthusiastic) versus those who have never examined a diabetic nerve directly.

20:25 – Unknown Entrapment Sites

Discussion of nerves without known entrapment sites in the context of metabolic processes causing nerve swelling.

20:57 – Long-term Follow-up Case

Patient case from 2003 with triple decompression, noting that superficial fibular nerve was not addressed at the time, with minor ongoing issues afterward.

21:15 – Superficial Fibular Nerve

Continuing symptoms were attributed to ongoing entrapment of the superficial fibular nerve – these compressed nerves are targeted for decompression by making more room for them.

22:19 – Blood Flow Restoration

Discussion of lower limb nerve decompression and how blood flow can be restored very quickly during surgery.

22:35 – Vascular Anatomy in Tunnels

In anatomical tunnels, nerves travel alongside arteries and veins. Decompression affects the entire neurovascular bundle.

22:58 – Decompression Mechanism

If a nerve goes through a narrow tunnel causing swelling, decompression of that tunnel relieves pressure on the nerve.

23:37 – Specific Anatomical Sites

Common entrapment sites include:

• Tight medial/lateral plantar tunnels
• Tight calcaneal tunnel
• Extra fibrous band underneath peroneus longus
• These anatomical variations combined with diabetic nerve susceptibility produce symptoms

24:03 – Intraoperative Monitoring

Description of monitoring nerve function during decompression surgery, recording nerve signals while releasing the nerve.

24:20 – Immediate Nerve Response

Observation of a huge increase in amplitude of muscle activity immediately after decompression – muscle activity “jumped through the roof” right away.

25:00 – Skeptical Reaction

Initial disbelief about immediate nerve improvement, questioning whether it could be placebo effect.

25:27 – Paradigm Shift Moment

Practitioner’s realization: “I thought I understood peripheral nerves. I really don’t.” This led to researching possible mechanisms of action.

26:03 – Dual-Level Impairment

Explanation that nerves are being impaired at two levels:

1. High blood sugars and metabolic toxins
2. Physical compression at anatomical tunnels

28:23 – Repeat Case Discussion

Another mention of the 2003 triple decompression case and superficial fibular nerve issues.

28:50 – Treatment Philosophy

Focus on compressed nerves as the target, relieving them by making more room.

29:46 – Vascular Benefits

Blood flow restoration occurs very quickly during lower limb nerve decompression – within seconds.

30:24 – Neurovascular Bundle Concept

Tunnels contain nerve, artery, and vein together – decompressing benefits all structures.

31:29 – Monitoring Study

Detailed description of intraoperative monitoring study examining nerve function changes during surgery.

31:46 – Dramatic Immediate Results

Repeated observation of immediate, dramatic increase in muscle activity amplitude following nerve release.

32:50 – Scientific Confusion

Honest admission of initial inability to understand the mechanism despite observing the results.

33:22 – Mechanism Development

Process of developing theoretical mechanism to explain observed clinical results.

33:37 – Two-Level Injury Model

Nerves are impaired at two levels: metabolic toxicity affecting the most distant parts of nerves, combined with physical compression.

34:29 – Patient Background

Patient with biochemical engineering degree and nearly 30 years in complex problem solving, developing diabetes in 2012.

34:51 – Post-Operative Assessment

Patient evaluation showing:

• Much less pain
• Improved movement
• Better color in affected limb
• Preparing for second side surgery

35:06 – Patient Motivation

Patient looking forward to getting out of pain and being able to do more activities.

35:23 – Literature Support

Discussion that data in medical literature is showing promise for this approach.

35:37 – Parallels to Carpal Tunnel

The results are remarkable and tie into other medical evidence – just as releasing a compressed median nerve in carpal tunnel can save a hand, releasing compressed nerves in the leg can save a foot.

36:33 – Call for Paradigm Shift

“We need an entrapment hunt. We don’t need any more evidence. We’ve got plenty of evidence. We know it works. End of discussion.”

37:07 – Patient Outcome Comparison

Patient describing results as “far better” than previous plantar fasciitis treatment – couldn’t even put heel on floor before surgery.

38:57 – Scientific Validation

Nerve PhDs working on these studies are “flabbergasted” at the kind of improvement that can be demonstrated – describing great success.

40:00 – Functional Independence

Patient able to walk independently and drive for 1-2 hours – basis of ongoing study.

40:24 – Intraoperative Monitoring Tool

Discussion of learning about intraoperative nerve monitoring from head and neck surgery, using it to demonstrate real-time effects of decompression.

40:39 – Demonstration Value

Using monitoring to show “what we’re doing is really doing something” – providing objective evidence during surgery.

41:16 – Long-term Experience

Started performing this surgery in 1982; by 1989, had operated on about 50 patients with 80% showing improvement – representing five independent basic science mechanisms.

42:02 – Medical Conservatism

Acknowledgment that medicine is appropriately conservative – took long time to accept aspirin for heart attack prevention and ulcer treatment approaches.

42:22 – Need for Conservative Approach

Medicine should be conservative because drugs and surgical procedures significantly affect people’s lives and health.

42:53 – Patient Education Challenge

Physicians educate patients thoroughly, but once patients leave practice, they’re unlikely to find other doctors familiar with this approach or offering more relief than achieved.

43:38 – Acceptance Timeline

Fear that widespread acceptance will require training the next generation of physicians – but if patients with neuropathy and diabetes “pound the table,” change could happen sooner.

45:00 – Gradual Understanding

Process of learning and thinking through new concepts – “store this in my brain and just think about it.”

45:51 – Addressing Counter-Arguments

Every argument can be countered with simple facts – there’s power in truth about what nerve decompression can address.

46:49 – EMG Testing Focus

Neurologists and physiatrists doing EMG/nerve conduction studies tend to focus on upper extremities rather than lower extremities.

47:39 – Pharmaceutical Economics

The profit model in medicine is in chronic medication, not in resolving chronic disease – this creates disincentive for procedures that actually resolve problems.

48:23 – Misinformation Problem

Strong statement that opposing information is “wrong, it’s misinformation” – the evidence is out there that nerve decompression works.

48:48 – Professional Relationships

Story of plastic surgeon and chief visiting neurologist who had previously opposed the work.

49:10 – Ultrasound Evidence

Discussion of ultrasound showing visible changes, referencing Scott Nickerson’s objective papers and studies.

50:00 – Professional Opposition

Encounter with someone “leading the bandwagon against this work” – asking why they opposed it.

50:18 – Friendship vs. Science

Interesting situation where former friends took opposing viewpoints on the science, maintaining cordiality but with evident polarization in the neurology community.

51:46 – Research Methodology Debate

Discussion of extrapolating from logical clinical index cases into patient treatments – taking the best of clinical experience, case series, and actual clinical research.

52:17 – Regulatory vs. Clinical Evidence

Tension between regulatory approval process and incorporating best clinical experience and research into practice.

52:41 – Patient Need

The diabetic population suffering with painful problems needs to know something is available – this has been established.

52:57 – Educational Goals

Goal to have residents trained in this approach at all university schools, including newly opened programs.

53:18 – Life-Changing Impact

Described as “life changing” – has changed more lives than even work in the leprosy field according to practitioners.

54:16 – Grassroots Approach

“We’re not going to beat the medical profession into shape, so we need to appeal to the people and have a grassroots demand for it.”

54:30 – Beyond Pain Management

Patient describes reaching the end of conventional treatments – doctors offered only pain management.

54:47 – Complete Reversal

From February to November: “100% reversal” of symptoms.

54:56 – Return to Normal Life

Patient just returned from Disney World after surgery in July – able to take grandchildren and enjoy the parks “like a normal person.”

55:05 – Documentary Purpose

People with diabetes and neuropathy deserve knowledge that this option exists.

56:07 – Closing Message

The greatest gift of all is the relief of suffering.

Key Themes:

1. Paradigm Shift: From viewing diabetic neuropathy as purely metabolic to recognizing the critical role of nerve compression at multiple anatomical sites
2. Dual Pathology Model: Nerves are impaired at two levels – metabolic damage from high blood sugar AND physical compression at anatomical tunnels
3. Immediate Objective Results: Intraoperative nerve monitoring shows dramatic immediate increases in nerve function amplitude upon decompression
4. Multiple Entrapment Sites: Key locations include medial/lateral plantar tunnels, calcaneal tunnel, and fibrous bands – creating a “suite of entrapments”
5. Preventive Potential: Nerve decompression can reduce annual ulcer recurrence from 17% to 3-5%, potentially preventing amputations
6. Economic Impact:
   • Standard ulcer treatment: ~6 weeks, significant cost
   • Complicated cases: $40,000-$80,000 per occurrence
   • One amputation occurs every 20 seconds globally
7. Failed Medical Management: Conventional treatments (Cymbalta, Lyrica, amitriptyline, stem cells, laser therapy) provide only minor relief
8. Professional Resistance:
   • Deep divide between practitioners who see results and traditional specialists
   • Pharmaceutical model favors chronic medication over curative procedures
   • Acceptance hindered by conservative medical culture and economic incentives
9. Patient Outcomes:
   • 80% improvement rate in early studies (1982-1989)
   • Patients describe “100% reversal” of symptoms
   • Return to normal functional activities and independence
10. Grassroots Strategy: Recognition that change will come from patient demand rather than convincing medical establishment
11. Evidence Base:
    • Ultrasound imaging shows visible changes
    • Objective nerve monitoring data
    • Parallels to proven carpal tunnel release surgery
    • Multiple independent basic science mechanisms
12. Historical Pattern: Similar to slow acceptance of aspirin for heart attacks and H. pylori for ulcers – medicine is appropriately conservative but sometimes slow to change

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