Thinking About the Future of Treating Neuropathic Pain

At the AAWP Scientific Conference, Elizabeth Hewitt, DPM shared her thoughts on a protocol for neuropathic pain. Podiatry Today had a chance to touch down with Dr. Hewitt regarding the high points of the lecture.

She pointed out that the primary challenge clinicians face when it comes to treating neuropathic pain is that there is no clear protocol in place. This makes it especially difficult to qualify efficacy of any treatment pathway chosen.

She reviewed the pathophysiology, evaluation, and treatment options for painful peripheral neuropathy. Then, she presented her practice’s protocol for addressing this concern for patients with diabetes.

First, said Dr. Hewitt, the patient must present with a concern of diabetic nerve pain. She then institutes 3 months of vitamin therapy, then 3 months of pharmacologic therapy and shared multiple options for each that DPMs can consider. She advocated for epidermal nerve density fiber (ENDF) testing for further evaluation and encouraged a patient HbA1c under 8.0. If all of these are not successful, then she said she pursues a Dellon triple nerve release, with ENDF testing at 6 and 12 months postop. She reviewed surgical techniques and pearls for decompression of key sites.

Postoperatively, Dr. Hewitt stressed that patient education is important, as pain may arise as the nerve regenerates, and regeneration is very slow, up to 6-12 months. She also supplements with vitamins during the postop period.

Dr. Hewitt conveyed that providers should not neglect neuropathic pain.

“This is a difficult topic and can be a terrific service line for your practice and a tremendous value for your patients,” she added. “I caution physicians to be disciplined in their therapies so you can look back and quantitatively evaluate your outcomes.”