Dr Andrew Greenland: 0:00

Welcome to Voices in Health and Wellness. This is the podcast where we dive into the innovative approaches transforming care and the outcomes across the health spectrum. Today's guest is Dr. Stephen Barrett, a podiatrist, surgeon, educator, and the host of the Pod of Inquiry, a podcast for deep thinkers in medicine. He's also the chairman of the Association for Extremo Neurosurgeons and founder of the US Neuropathy Centers, where his work focuses on resolving chronic nerve pain and dysfunction. So with that, I'd like to welcome you to the show, Stephen, and thank you very much for joining us today.

Dr Stephen Barrett: 0:30

Well, thank you very much, Dr. Greenland. It is an honor always to come on somebody's platform who has very like-minded interests, such as yourself. So thank you for doing your podcast as well.

Dr Andrew Greenland: 0:42

Well, thank you. Maybe we could start with um take it from the top. Can you just tell us a little bit about your journey, how you've ended up doing what you currently do?

Dr Stephen Barrett: 0:51

Yeah, no, it's an interesting journey. I wished I could say that it was all planned out, and that that would be certainly the antithesis of what it really is. But I started out in you know re traditional reconstructive foot and ankle surgery and loved that. And uh then I crossed paths with a gentleman named Lee Dellon, who is a pro uh retired professor of plastic and neurosurgery at Johns Hopkins around 1999-2000 in that neighborhood there. And then um that got me interested in peripheral nerve and especially peripheral nerve surgery. And since about 2000, 2001, um, that's pretty much all I've specialized in. Uh so it just was one of those things that, you know, had we not crossed paths, I probably would have never ended up in the arena that I am today. But I I I consider that a very fortunate uh uh path crossing, so to speak.

Dr Andrew Greenland: 1:47

Thank you. It was good to hear about the journey. And can you just tell us a little bit about your practice, what you see, what you do, what does it look like?

Dr Stephen Barrett: 1:54

Well, right now I am winding down the practice. I uh have turned everything over to my partner who actually was uh one of my nerve fellows about 10 years ago. I can't believe it was that long. And uh I still am consulting to the practice as far as doing a lot of diagnostic work and working on some protocols, educational things, that type of thing. Um during my you know, time before I started slowing down a year or so ago, um, I spent a lot of time with diabetic peripheral neuropathy, which we're gonna talk about today. But we took care of everything from you know traumatic nerve injuries, uh, nerve transpositions, nerve repairs, those types of things. And when I first started looking at peripheral nerve surgery as a as a subspecialty, I thought, well, this won't be, there probably won't be that many people with you know problems that they need to come and see me, but uh I was totally wrong there. Um unfortunately, there are so many peripheral nerve injuries that people have sustained, whether it's trauma, um, iatrogenic situations post-surgeries, uh, and then of course the metabolic neuropathies themselves. So that's kind of I think a thumbnail sketch of what we do.

Dr Andrew Greenland: 3:13

Thank you. And maybe we can start with the big picture. I mean, why is diabetic neuropathy traditionally being seen as irreversible from your perspective?

Dr Stephen Barrett: 3:21

Oh, that's such a fascinating and great question, and it's something that irritates me during the middle of the night when I wake up uh frequently. Um, you know, it's been taught and is still being taught today that that uh there's nothing that you can do for uh folks that are suffering from diabetic peripheral neuropathy except maybe give them some neuron or pregablin and you know, or maybe a tricyclic antidepressant and and say, you know, this is what you got, be off and and live with it. And we know that that's just horribly untrue. And one of the one of the uh foci of uh the extremity, the association of extremity nerve surgeons is to get the word out that you know Dr. Dellon discovered that most of the symptoms of diabetic peripheral nerve or most of the symptoms of diabetic peripheral neuropathy are really due to um uh compressive injuries to the nerves in different areas. And if you look at carpal tunnel, for example, in the U.S., about 2% of the general population is affected with carpal tunnel syndrome. In the diabetic population, it's anywhere from 14 to 28 percent. And I've even seen a couple of articles showing a higher incidence than that. So you have to ask yourself what's going on with this condition? And it turns out that it is a um a situation where glucose overloads the nerve, so to speak, and then that causes an interruption of one of the uh polyol pathways and leads to a lot of sorbitol. And for some reason, even though sorbitol and glucose have a very similar molecular weight, sorbitol is a very osmotic, uh it loves water and it sucks water into the nerve. So diabetic peripheral, excuse me, diabetic peripheral nerves are about 50% bigger in cross-section than non-diabetic nerves. So where nerves go through tight tunnels like the carpal tunnel in the hand that I just mentioned, they get squeezed. So it's a focal nerve compression. Now that's a good thing from the standpoint that there is something that we can do for that uh with a nerve decompression procedure. We can get into that a little bit more. But if you have, like in the in the upper extremity, you've got the ulnar nerve uh going through its its tight uh tunnel at the you know uh ulna, and then you've got the median nerve, obviously in the in the in the carpal tunnel itself. But in in the lower extremity, it's a very similar analogous situation where you have basically the common fibular or common perineal nerve and the tibial nerve, and they're they're distal branches then go through this. So if you get a nerve compression at multiple sites, it can give you this um presentation, which they're still teaching the stocking and glove distribution. And that's a nonsense. That's that's just old dogma, and it's been talked about so long that it's it's true. But in the lower extremity, there's one nerve called the sural nerve, which you're very well aware of, and that nerve doesn't have a known anatomical um tunnel or a known site of entrapment. So you can have people that are so so insensate that you can really, I mean, you're performing a transmetatarsal amputation for for someone without any local anesthesia, and they can't feel anything while you're transecting the first, second, third, and fourth metatarsals. You get over to the fifth, and all of a sudden they say, Oh, wait, wait, stop. I can feel that. It's like, well, wait a second. If this, if diabetic peripheral neuropathy was a systemic disease that just burned all of the nerves, so to speak, at the same time in an equal fashion, then why would one nerve distribution like the CERL still stay uh sensate versus all of the others that are insensate? And that's kind of what Lee Dellon discovered in the mid-80s. And his story is fascinating for several reasons. One, um, he's probably the most incredible clinical observationist that I've ever had the fortune to meet. He sees things that everybody else sees, but he actually takes the time to acknowledge him and figure out, well, why is this? And then takes it down to the cadaver lab and then figures it out. And that's exactly what happened. So when he was um, this was about the mid-80s. So when he was uh work finished his hand fellowship, uh he's a plastic surgeon by training and then did a hand fellowship, and then he would get a lot of patients that would be sent to him by neurology uh with carpal tunnel syndrome, who also happened to be uh unfortunately affected with by diabetic peripheral neuropathy. And so he would be doing these uh carpal tunnel surgeries, and the patients would come back and they say, you know, my pain's gone, but the weird thing is, is I have sensation now in these two fingers and half of this one, and he's saying, Well, wait a second, they're teaching us in medical school, and by the way, they still teach it today, but they're they're teaching us that once you have this lack or loss of sensation, there's nothing that can be done to reverse that. So the next question was, Well, what could I do to maybe get sensation in the little finger and you know part of the the fourth or the ring finger? And that would be the answer to that would be decompress the you know cubital tunnel. Um, and and he did that, and that would restore sensation there. And then they said, Well, this is great. I've got sensation completely in my hand, but the top of my thumb is still no. So then he found a branch of the radiosensory nerve that um would would become entrapped and they would get sensation in all of their hands back. Now that's a big deal because um, I mean, think about that, not only the the pain, but the ability to have sensation, which we use almost subconsciously all of the time. So the next question to him was then, well, you you've restored sensation in my hand. What about my foot? Because my foot's numb more numb than my hand ever was. Well, it's like, well, I'm not a uh a foot and ankle guy, but we've got a great cadaver lab here at Johns Hopkins, so let's go down and take a look at it. And he had identified the analogous tunnels then in the in the lower extremity, and then they would have their their decompressions, and all of a sudden, you know, more than 70% of the cases, uh their uh protective sensation was restored, which is huge. We can talk about why that's so important in in a minute, but um, and then also eliminate the pain and increase motor strength. So that's kind of the trifecta, and then nobody really even talked about balance too much, and then people started looking at balance and figured out that you know, insensate people have very poor proprioception, and if you can restore the sensation, all of a sudden their proprioception gets better, so that leads to less falls, and you know, and so they can be more active and live a more normal life, which, as you know, the more active people are, the better their quality of life and the longer their longevity is going to be.

Dr Andrew Greenland: 10:44

Thank you. Um really um clear explanation of the mechanism. I have to admit, I don't think I've heard it in those terms before, so it's really helpful to understand why this happens. So let's think about a patient journey. So, patient coming to you with I don't know, a particular neuropathy. What would the um treatment process or the workup for them look like? And maybe tell us a little bit about the treatments themselves, just so we can get an understanding of that kind of timeline.

Dr Stephen Barrett: 11:09

Well, if you look in the neurology books, there's probably 150 different types of peripheral neuropathies, and they're classified by the guy who discovered them, or you know, some other mechanism, that type of thing. You know, what what what did we give to this patient to cause them to get the neuropathy? A good example of that would be chemotherapy-induced peripheral neuropathy. And the um the thing that that I learned over my 25 plus years of doing peripheral nerve is that we need to identify whether or not there is a superimposed nerve compression because we can have a metabolic disease, or we can have somebody like uh believe it or not, with uh Hansen's disease or leprosy, which affects the entire nerve. But there's another process, and like I mentioned with diabetic peripheral neuropathy, the diabetic nerve is 50% bigger, so it's a lot easier to drive the small little car through the tunnel than the big semi-truck. And that's kind of what's happening with this. So there are some um situations in in in chemotherapy-induced peripheral neuropathy where there is a coexistent edematis or swelling uh condition of the nerve. And those are people that we can help with a nerve decompression. Um diabetic peripheral neuropathy is first of all, it accounts for more than 50% of all of the peripheral neuropathy cases that are presenting to physicians throughout the world. But the the great thing, and I'm not trying to say that it's great to have diabetic peripheral neuropathy, but the great thing is that it's something we can address because if we can take and release that constriction or that tight tunnel, the nerve can suddenly start to function um in a more normal manner. You're not doing anything to treat the systemic condition other than just you're opening up a tight area that's pinching a nerve. But that really allows the nerve then to regenerate. So, to go back to your question about how we work these patients up, the first thing is probably the most important thing, and that's just simply that the HPI or the history of present illness. They will, if you listen to them long enough, they will give you some very insightful um things that help you make the diagnosis, whether you can help them or not with a nerve decompression surgery. The second thing that we do that we found incredibly powerful is um diagnostic lidocaine injections. And uh one of the things that that that I'm working on very hard right now is called the phoenix sign. And in 2017, we had a lady that had very severe diabetic peripheral neuropathy and actually presented with a drop foot. And she hadn't been able to move her foot dorsal flex it for about five years at that time. She wasn't coming to us to try to get her motor strength back, she she was coming to us to see if we could decompress this nerve or do something to get her out of pain because that was her presenting complaint was pain. And so, what we like to do is we like to put a sub-anesthetic dose of a local anesthetic without epinephrine, because what we want is we want a focal vasodilation. So we want to be able to increase the blood flow in an area where we suspect a peripheral nerve entrapment. And my my nerve fellow at that time came in. He I told him to to give her a block, see if that relieved her pain. He comes running in. I just got the perfect cup of coffee established, and I'm sitting at my desk. It's like, you got to come and see this. I just got my coffee ready. And he goes, No, no, you gotta come and see it. So I went in and he said, Move your foot. And she and I had done the pre uh the examination pre-infiltration, and she had no motor strength, she couldn't dorsal flex her foot, and then all of a sudden, now she had full five out of five motor strength for her anterior compartment, which was shocking. So we kind of like, what the hell's going on here? This is so bizarre. So uh I I asked her back the following week, and she was very willing to come back. We re we replicated the block, and this is a block where we're only using about three-tenths of a cc of 1% lidocaine, very, very small subanesthetic dose. And then in about four minutes, um, we checked to see if they have any increase in motor strength. If they do, then it's a positive phoenix sign, like the phoenix rising from the ashes. It's very predictive. We published an article in 2021 in the uh uh Journal of Orthopedics, and uh we were able to not only diagnose, but we were way also able to use this as a metric for prognosis. And if they have a positive phoenix sign, we only had 26 patients in that study, but uh all 26 had um restoration of dorsal flexion, they regained their motor strength back that they didn't have, so that is probably the single most important diagnostic thing that we can do. And now recently we discovered that you can do this without ultrasound guidance just simply by injecting D5W. So dextrose 5% in water will do the same thing. Now, what's real interesting is we had a study uh that was published in 2024 in uh BMC Musculoskeletal, uh, which is a very credible journal, where we compared the uh effects of the lidocaine with papaverin, a known vasodilator, and we we found the same effect. So we were pretty solidified in our our belief that this was a vasodilatory phenomenon, more blood flow to an area that's pinched that has neural ischemia, you get it there, nerve temporarily functions, and this this effect lasts from about four minutes to 10 minutes after the injection. Then it goes away, they're back to their their current state or previous state. And um, so that is is very powerful in diagnosis. But then uh in 2024, I had a patient of mine that came in and and she had had a a really weird uh history of Lyme disease, mold exposure, ended up with a drop foot. She demonstrated the phoenix sign before we decompressed her, she got full function back, and this was like five or six years ago. She came back in 2024 and said, Hey, I I I must have scarred down or something, you know, because I don't have the motion. And I I looked at her and I said, Yeah, you probably did have some scarring because why would you be good for a long period of time and then then get worse? So I thought, well, I don't want to take her to surgery right away because you know that's you know, we always try to do everything we can to not have to take them to surgery. I said, Well, what if we do a hydrodissection with dextrose 5% in water? There's no harm to it. Ultrasound guidance, we know where we're at. Very, very, very small chance of nerve injury from the uh infiltration itself. And within two minutes, she said, Oh, I've got all my dorsal flexion back. Well, that was very upsetting because we all tend to fall in love with our hypotheses, right? We, you know, we knew, oh, this is a vasodilation. And it turned out that it wasn't just that. Yeah, the vasodilation does what? It provides more energy to a nerve that is focally compressed. Well, D5W does a very similar thing. It provides more energy and glucose to the nerve that is undergoing focal nerve compression. And if you look at the the physiology of what's happening in these focal nerve entrapments, there's also a disruption of glucose and its ability to, it's first of all, there's lower amounts of it. Second, all the receptors and everything change on the peripheral nerve itself. It's it's quite magical what happens to a nerve when you you put some pressure on it for a long period of time. So we had to kind of redefine our um hypothesis as it's more of a bioenergetic um situation. So if you're providing some kind of energy to the nerve in an area where that nerve doesn't have a good blood flow, whether it be by giving the substrate of glucose or whether it's by something that is causing a vasodilation like papaverin or lidocaine. So that's kind of what you know. I know that's a long winded answer uh to your question, but it's so critical. And the beautiful thing about this discovery was number number one, aside from the fact that it it taught us that you never fall completely in love with your hypotheses as a scientist. But the second thing is that it now can be done without ultrasound guidance. So you can just any practitioner in the world that has access to um some D5W, which is super inexpensive, you know, as an ER physician, I mean, I think they call it glucose and water over there, don't they? Rather than dextrose.

Dr Andrew Greenland: 20:19

We actually call it dextrase. Yeah.

Dr Stephen Barrett: 20:20

Yeah. Okay. So anyhow, long story short, uh, you can put three, you can just infiltrate three cc's of D5W subcutaneously right at the fibular neck. Wait for four minutes and ask them if they can move their foot more, particularly their big toe, and invariably they're going to have much more motor strength or completely normal motor strength from that. Well, now that's huge because not only do you diagnose it, and a lot of times it's very difficult for even the most astute practitioners to figure this out because, like, how much is maybe coming from the low back? Because almost everybody that's over 40 has low back in the United States. They have something going on. So your question is, is this more of a centrally mediated situation, or is it uh more of a peripheral focal nerve uh compression? Which this does differentiate that. Now, interestingly enough, I've actually demonstrated this on a couple of stroke patients. And you're gonna pull your hair out and go, no, the stroke is definitely a CNS lesion. It's like, absolutely it is, but what happens when people have a stroke? Well, sometimes they fall down, right? And they'll twist their ankle, and all of a sudden they'll injure their common perineal nerve, but it gets lumped into the category of this is just a sequela of the event that happened in the brain. And there's a there's no rule in medicine that people can't have two things at one time. And in peripheral nerve, we see this all the time. You can have carpal tunnel and diabetic peripheral neuropathy, or you can have you know, foot drop and you can have common perineal nerve entrapment and low back, you know, L5S1 entrapment, or or whatever it may turn out to be. So that's one of the most powerful things from a diagnostic standpoint that we do.

Dr Andrew Greenland: 22:05

Thank you. And what kind of outcomes are you seeing in your clinic? And how do these compare to published results?

Dr Stephen Barrett: 22:11

Well, I'm gonna tell you the published results and and um our our our stats are very much in line with that. Now, the the cool thing about this is there's close to about 100 papers published in worldwide about this peripheral nerve decompression for patients with diabetic personal neuropathy. Generally speaking, it's greater than 90% a reduction in pain or elimination of pain. And that's a very big thing because most patients will come to you because of pain over loss of sensation. We can have a discussion a little bit about that, but um, and then as far as restoration of protective sensation, it's greater than 70%. So that's pretty good. The complications are very small because there's a beautiful thing that happens. Well, one is you have to make sure that your patient has enough vascularity to subject them to surgery. Last thing you want to do is put an incision on somebody that they can't heal, right? So that's part of the general workup. But what happens with nerve decompression surgery is you actually get an increase in blood flow almost immediately. And there's a couple of reasons for that. One is you know, the nerve, artery, and vein are all together in the type tunnel, and you take the tunnel and open it up, all of a sudden you've you've increased the arterial um flow. Uh, and then you know, you if you reestablish um better nerve function, then that's going to help the autonomics and that helps your your circulation as well. And we've got great studies on that. Um, but generally speaking, in the literature, you can expect about 70% of the time they will get a restoration of sensation and about 90% reduction of their pain. Now, if you look in the literature, this is what's so important, and really this is what's the most infuriating thing uh for us here in the US uh within the the Association of Extremity Nerve Surgeons is that if you have a patient that has a diabetic foot ulcer, they can expect about a 40% annual recurrence rate. That's the literature, that's what the literature says. Um if you re-establish their protective sensation and do these nerve decompression procedures, that annual recurrence drops to below 5%. Now that's a really big thing. Not only is it a super big thing for the economy of healthcare, because uh billions of dollars are spent here in the U.S. in wound care clinics every year. That doesn't that doesn't even indicate the hardship that the patient's going through, getting to the wound care clinic every week, their family, all of the things that they have to do. So that is a really big thing, is if you can prevent a recurrence uh of the ulceration, you've done a great thing, not only for the patient themselves, but for the economy of the healthcare system.

Dr Andrew Greenland: 25:11

So are there any patients that don't do particularly well that you would sort of um ideally try to screen out just because the approach is not going to suit them any particular conditions or features of the patients?

Dr Stephen Barrett: 25:24

Yeah, well, I think the the number one thing is if they if they don't have adequate vasculature to even begin proximally, you just don't even want to. Unfortunately, as bad as you want to help them, you you you know you're just gonna make them worse doing that. Um, so that would be the number one contraindication. Um the longer that they've had it, obviously that means the nerve has more internal damage. And you know, so if if there's no living uh tissue in the peripheral nerve, for lack of a better way to put it, we can do all the greatest decompressions in the world, and obviously they're not going to have a restoration of sensation, or or sometimes they'll have a reduction of pain, but they may not get a restoration of sensation. And I think that's why our our success rates over 90% in reduction of pain versus only 70% of getting protective sensation back.

Dr Andrew Greenland: 26:25

Got it. So with results like that, why isn't this procedure become standard care yet?

Dr Stephen Barrett: 26:32

Well, I wished I knew the answer to that. I can give you some some speculation on my part. Um one is I think established medical paradigms um have been so entrenched that people are afraid to actually challenge the paradigm a little bit, you know, and so it takes a while for you know that to you know um settle out for new mindsets to to come along. I will tell you that um it's in our practice, more than 85 percent return to have their second leg done. All right, that's a pretty compelling, uh pretty compelling uh statistic. When I first started doing these in 2000, I went to my uh small little hospital and uh I I was pretty well established there. I talked to the medical director and and uh I said, hey, we want to start doing these. And he's like, Well, because seems kind of wacky to me, but um you've always been very good uh you know and honest with us, and and your patients do well, so uh let's give it a whirl. At six months, he came in, he and he was the anesthesiologist there, so he would see all the you know all the patients before and and then and about six months after I started doing this at the hospital, he said, Hey, I gotta talk to you about something. I'm in trouble here. He goes, he goes, All these people are coming back for their other leg, and I'm seeing how they do have normal sensation. Their hair's regrown on their leg, their skin's no longer that parchment cigarette thin looking cigarette paper, thin looking skin, and everything. He's like, this means more to me than you know any journal article that could ever be published. So why? I mean, that's such a great question, and and that's really one of the things that is kind of my uh my mission right now is to get this uh knowledge out there, and you know, the more people see it, then they they believe it. I mean, I I had so many neurologists that were very skeptical, and then their patients would go back and say, hey, look at this, you know, this look at this foot, look at compare it to the one that hasn't been done yet. And all of a sudden they're calling up going, well, maybe there is something to it. You know what I mean? So I don't know. It's a it's a tough thing. It's I wished I I mean, we create we we made a documentary that that people can access um about this very topic. Why are we not doing better in communication and and getting this message out? And it's something that we're still working on to this day.

Dr Andrew Greenland: 29:11

That's really helpful, really helpful insight. So you talked about established medical paradigms. Where do you think the biggest resistance is? Is it endocrinologists, is it other podiatrists, is it surgeons, or just inertia in the system in general? Or I missed out on your own.

Dr Stephen Barrett: 29:24

Um I think, well, you know, we've had a lot of pushback from the American Diabetic Association. And, you know, I'm I'm gonna say something probably get me in trouble a little bit here, but I don't really have much, I don't think too much about them. I mean, they're if you look at the American Diabetic Association, one of their biggest sponsors is the Idaho Potato Association. Well, that's a pretty crappy carbohydrate, to be, you know. So they're captive, they're captive to their financial issues. A lot of a lot of people are very captive uh to big pharma. This is the way, gabapentin, pre-gablin, those are that's what I'm doing. That you know, so I I don't know, you know, I think that um I've had pushback much more 25 years ago than than we do now. Um, because when people see, regardless if you're a neurologist or endocrinologist or family practice doc or whatever, when you see somebody that comes back and has a dramatic result. I mean, and I've even I've even performed this surgery on some endocrinologists themselves who had diabetic peripheral neuropathy, and they're like shaking their heads going, well, why didn't we know about this? You know, it's like it's out there, but I'm sure the same thing in emergency medicine for you guys, right? That you know that there's stuff that you know can do great things, but yeah you just can't access it because it it's not in the paradigm.

Dr Andrew Greenland: 30:53

What would you say the biggest misconceptions are among providers that you hear the most often in your world?

Dr Stephen Barrett: 30:59

Well, I think the biggest misconception is the um the true situation of what the pathophysiology really is. And like I mentioned, once they can understand, and and I've found the more you can educate a person, the more their ability to grasp different concepts, it it exponentially goes up. So if I can set down just like we're doing, and I can explain to you, like, listen, yeah, there's the there's definitely the metabolic component to it. I would love to get their blood sugars as as perfect as possible and do all of the things that internal medicine would do. But there's something else that's going on with this nerve, and that is that it's swollen and it's pitched. In the upper extremity, believe it or not, neurologists don't have any problem at all. And this is really one of the great conundrums. You ask a neurologist, what would you do if you if your patient with diabetic peripheral neuropathy would come in with carpal tunnel syndrome? And invariably, I would send it right over to a hand surgeon and get that carpal tunnel decompressed. Well, hell yeah, you would, because it's a nerve compression. But it's the same thing lower extremity that is upper extremity, but somehow the brain just shuts off when people start going south and thinking about the foot and the ankle. You know, it's it's pretty incredible.

Dr Andrew Greenland: 32:23

So you're obviously running a business because you are running a clinic business. Um, what's going particularly well? Obviously, I know that the work you do and the outcomes and the patient satisfaction is great, but from a kind of a business angle, what is uh some of the things that you're most proud of?

Dr Stephen Barrett: 32:38

Well, truthfully, it's a non-business thing. The the thing that I I mean, I I was very fortunate I developed uh the first endoscopic surgery in the foot back in the early 90s, and it's that that and another endoscopic procedure that I developed are in Campbell's Operative Orthopedics, which is considered one of the Bibles of orthopedic surgery. Um, but the thing that I'm most proud of is the phoenix sign, because the phoenix sign is gonna get care to people that never would have gotten it. Because when somebody comes into any neurologist in the world and they say, I've had this drop foot for five years or two years, they're gonna be told you need to go to the orthopedist, the prosthetist, or whatever, and get a brace for it because there's nothing we can do. And the answer is, well, we know that's not true, and we know that we can see these effects with something as simple as D5W, and that's going to get more people the care that they need than any than any amount that I could have ever ever operated upon in my career. So that that's the thing that's the most uh that I'm most proud of, and that's really I'm actually uh trying to complete a PhD at University of Barcelona on this very same thing. And uh so that that's what I'm most proud of, because I think that's gonna have the big biggest ripple effect.

Dr Andrew Greenland: 34:02

What about the the challenges or anything you've had to overcome in the work? Obviously, you've talked about some of the pushback and resistance and people not really understanding the process, but from a kind of a clinical or business angle, what what are some of the challenges of bottlenecks in the work?

Dr Stephen Barrett: 34:18

Well, today it's there's enough published literature that you can go into your hospital and you can lay it down, and and if you have the credentials, you can get you know uh credential to do the surgery. When like I said, when I first started doing this, nobody except probably Lee Dellon and a handful of other uh guys in the in the world were doing this procedure. Um, but now there's a there's probably a good 200 plus surgeons in the U.S. We have people very prestigious uh uh surgeons that like University of Vienna, um in the Netherlands, uh University uh is it Utrecht, you uh but that that are doing this. So the pushback now is it's nothing like like what I had when I first started doing it. And and I think that's the really frustrating thing, um, is that as much as we've come along, we're still only maybe like down the the whole track of where we want to be, maybe a tenth of where we need to be. But back when I was just starting this, it was less than like one hundredth of a percent, you know what I mean? So it's it's come a long way, but we still have a long way to go.

Dr Andrew Greenland: 35:36

What keeps you most motivated to share keep sharing this message, especially when it does challenge the status quo?

Dr Stephen Barrett: 35:43

Well, I I just think I mean it's one of those things where you know, certain, yes, we do surgery, we did surgery to to you know being reimbursed just like any other business in the world. But you have the same feeling that I have when that patient comes back, and when they come back and they they thank you for saving their life in in the ER. Uh it's pretty hard to quantify that feeling. It's a it's a spiritual karma-like feeling, and it's something that uh uh for me it's always been the the high octane fuel.

Dr Andrew Greenland: 36:23

And what what's next for you? What are you planning over the next year or so? Do you have any plans for the business, the clinic, your work, your research? What's coming up for you?

Dr Stephen Barrett: 36:31

Yeah, so uh what we are uh really looking forward to now is um we want to get another um robust clinical study done demonstrating uh the effects of D5W for elicitation of this phoenix science. So we're in the process, we're in the IRB standpoint now, you know, getting the trial approved. We have about 12 or 13 sites throughout the world, Australia, um, Spain, numerous places that will participate in this study. And um I think that's gonna be big. We're we're gonna shoot for a pretty high number of patients to be enrolled because we have that many clinics. But if we're able to do that, that's gonna really, I think, get the message out that and and the beauty of that, Dr. Greenland, is that this is not just for diabetic peripheral neuropathy. If somebody has a drop foot, like I mentioned from stroke, which is a rare exception, um, or they have a, you know, they developed a drop foot 16 weeks after a bad ankle sprain and nobody knows what to do. And then you have this ability to not only diagnose it as a focal entrapment, but you also have the ability to um have uh a prognosis because if they have the positive sign from the infiltration, then greater than 90%, they're going to have a successful surgery. So that that's kind of what I'm really working on now is trying to get that um done.

Dr Andrew Greenland: 38:00

Well, with that, Stephen, I'd like to thank you so much for joining me today. It's been such an incredibly powerful conversation. This is exactly the kind of insight we created this podcast to spotlight underutilized evidence backed approaches that can dramatically improve lives. Thank you so much.

Dr Stephen Barrett: 38:14

Thank you for having me on. I'll I'll be happy to send you a couple of links too if you want to put them in the show notes. But thanks so much. I appreciate you getting the message out.