Talk:Magnetic resonance neurography

External Links

• Neurography Video

Authorship

I was asked to take a look at this because it's possible that one of the inventors of the technique may be involved in writing the article <edit: this is not a problem in and of itself, but it is good to be aware of the guideline on writing about subjects you're involved in>. I read it and made a few minor tweaks. Overall I thought it was very good, and well referenced. You can tell it's written by a professional. I marked one spot I thought needed a reference, and one I thought needed explanation in layperson's terms. Ideas for improvement include adding explanations in layperson's terms and using more scientific review articles, which are preferred over primary literature in Wikipedia. If the technique has disadvantages compared to standard MRI, they should be included per the very fundamental neutrality policy. Thanks for the great work on the article so far, I look forward to seeing more from these contributors. Don't hesitate to contact me on my talk page if you need any help or want to discuss anything. delldot talk 19:05, 10 July 2008 (UTC)

• I will leave a note on wikiproject medicine. Cheers, Casliber (talk · contribs) 15:01, 11 July 2008 (UTC)

• From reading this article, I have no idea how widely or where it is practised. A google search lists the Neurography Institute as the exclusive provider (on google description but not the page), which gives me concerns about notability. Now this article needs to mention this material in a neutral fashion. also needs some criticism - is it widely taken up? If not , why not? Cheers, Casliber (talk · contribs) 15:19, 11 July 2008 (UTC)

Dr. Filler is openly the creator of this article. Fact checking would be helpful.

Dr. Filler is open that he first created and made many edits to this article and recieves financial benefits from this technology. His openess about his creation of the original article (and many of its edits) and conflicts of interest is fair, but fact checking would be helpful. The article was created by the user AFiller, and this same user did many of the edits. If you click AFiller user name it links to Dr. Filler's user information. In this information Dr. Filler openly states the following:

"Conflict of interest note: In addition to being an inventor and author as noted above, I am a major shareholder in and CEO of NeuroGrafix, a company I founded that holds a license to US patent 5,560,360 (which is owned by the State of Washington) the patent covering MR Neurography and various forms of diffusion anisotropy imaging such as DTI (diffusion tensor imaging). I am a working neurosurgeon and earn income from providing medical care including surgery and also from doing professional readings (interpretations) of images including MR Neurography and DTI images."

Biased inappropriate comments on insurance coverage

Does "Laced with Silver" speak with a forked tongue? The writer has no evidence at all about how much various insurance payors and plans reimburse for Neurography. What is the basis for the statement that "some patients have received at least partial insurance coverage" for this "experimental procedure." The fact is that most insurance companies do pay well for the procedure after appeal. Most insurance payments involve deductibles, percentages of usual and customary, or copays. Do you mean to suggest that most procedures are reimbursed in full but that only MR Neurography gets "partial" reimbursement. Do you have references to support this? Should that be discussed on a Wikipedia page about health insurance reimbursement or is it a technical encyclopedia matter about MR Neurography that has no available literature reference. This goes far beyond the informational standard for Wikipedia. It is fair and reasonable to say - as the article does - that many insurance carriers classify it as experimental. The writer of these comments does not appear to have a NPOV but rather is a person with an ax to grind. They cannot cite one non-peer reviewed debate paper as against 6,000 peer reviewed articles just because the title of the article sounds provocative. Dr. Tiel's article was part of our debate series about the existence of piriformis syndrome. Dr. Tiel did not do any research on MR Neurography and does not claim that he ever did. The insertion of a quote from an insurance company non-payment statement is misleading because the insurance company has a pure profit motive for denying payment and they cannot be considered as an unbiased source for direct quotation in Wikipedia--Afiller (talk) 07:54, 25 March 2011 (UTC)

When I looked at this article in 2008, I said it is not a problem in and of itself for someone involved with the product to be editing the article. What is a problem, though, is if someone editing this article is so dedicated to one viewpoint that they're not willing to let others edit. That's a violation of WP:OWN. It's not ok to get into a revert war on any article, let alone one you have a financial interest in. If you're not going to be able to let people with different points of view edit the article, it will be necessary for you to take a step back from the page.

LacedWithSilver emailed me because they were concerned that the page looked like an ad for the technique. I am the one who encouraged them to edit (partly because I don't have time these days to be editing the article). So I see no reason to assume they have an axe to grind. I think that would be an unfair assumption. It's also important that we welcome new users and not bite them. So if you think there's a problem with a particular source (and that may well be the case), I think you should bring that here for discussion, rather than immediately reverting a new user's edits. With a new user you have a disagreement with, it would be best to outline exactly what you're looking for in terms of references, and explain why you don't feel that the references provided make the cut. I don't see any reason this can't be worked out amicably. delldot ∇. 17:06, 29 March 2011 (UTC)

Delldot, I agree fundamentally, but these edits are not about the science but rather about the insurance reimbursement. Where they cover the science they are wrong. For instance, T2 neurography is about selectively eliminating the non-neural signal so that a weak endoneurial fluid signal can be detected. This signal provides a distinct image of the nerve. There are hundreds of publications. This editor suggests that it is all "post-processing" which is completely incorrect - that would mean it is an ordinary image that is manipulated in some way in a computer after it is collected to generate an MR Neurogram - bizarre unsupported idea. Does this person have any one out of the 6,000 papers in this are that can be referenced to support this position, if so why not provide a citation? . Stating that it is only "potentially" useful is biased, since there are numerous large scale formal outcome trials from Johns Hopkins, UCSF, UCLA, Cedars Sinai, Mayo Clinic (although involving some patent infringement) etc showing clinical utility and it is taught in the neurosurgery and neruoradiology textbooks as a mandatory technique. The editor writes that it is potentially useful, and used for experiments. That is just completely inaccurate. Why should grossly inaccurate and unreferenced information be inserted into a painstakingly accurate and well referenced article. The Wikipedia editors are everywhere complaining about poorly referenced or poorly researched articles. It is very discouraging to specialists who take the time to write a formal detailed article if the article can then be chopped and altered by someone who obviously has no technical knowledge. This is a person trying to make a point that many health insurance carriers still classifies the technique as experimental so will reimburse it only on appeal. That was clearly stated in the article as written before the edits. We went through all this two years ago. If the LWS brought specific well referenced technical information to the article then that would be a good thing. If you plunge into a formal technical well referenced technical article by changing major components (e.g. saying it is post-processing rather than being a biophysically based data acquisition technique) with incorrect unreferenced unverifiable comments - it is vandalism. I take your point that if I care about the accuracy of the content then I have to be banned because it is not encouraging enough for those who value participation above accuracy. It would also be reasonable if LWS had accurate or even debated aspects of Neurography to add or dispute. I'm well aware there are different opinions on substantive matters related to this an other techniques. But this is not a biography of Britney Spears, it is a technical medical article. I appreciate the interest on the part of LWS, but if LWS means to change the definition of the technique and dispense with 20 years of science behind it, then if LWS has no reference to support this change, LWS will find that like everywhere else in Wikipedia, other editors will restore correct information. Honestly Delldot, you start out by threatening to ban me. That is not appropriate either. Afiller (talk) 04:57, 30 March 2011 (UTC)

References to support the non-experimental status of MR Neurography among physicians

Although it may be a subject of complaint that I (afiller) wrote chapters for Schmidek and Sweet - the major operative neurosurgery textbook and am the section editor for Youman's Neurological surgery our principal textbook - just as my comments in this article are being questioned the academic and professional standards are well met. In the new editions - coming out this year - of both textbooks, there is a chapter on MR Neurography. In the previous edition of Youman's (which I had nothing to do with) there was also a chapter on MR Neurography. There are now MR Neurography chapters in many other recent Radiology textbooks. Every other year I am invited to teach a course on MR Neurography interpretation at the annual meeting of the American Society for Peripheral Nerve. I have also been invited to give similar hour long teaching sessions - which I have done at the annual meeting of the American Association of Neurological Surgery and the annual meeting of the Congress of Neurological Surgery - the two major professional societies in this field. I did a similar invited lecture and the annual meeting of the American Society for Spine Radiology. In addition Dr. Ken Maravilla has taught a course on MR Neurography interpretation every year for the past twelve years at the annual meeting of the Radiological Society of North America - the premier society in this field. Dr. Robert Spinner taught a course on MR Neurography at the annual meeting of the International Society for Magnetic Resonance in Medicine (the leading MRI professional society). I don't think medical societies provide some sort of listing of what techniques in imaging or surgery are listed as "experimental." You can look through the program of these major meetings on line. I can certainly come back with a fully referenced paragraph - however, one gets attacked on Wikipedia in an article like this if you are not referencing peer reviewed publications. In Medicine, we rely on the quality of peer reviewed medical literature to decide what is useful or not. Insurance companies are in the business of denying payment to improve profits. It is fair to say that an insurance company considers a procedure experimental, but it is not fair to say that physicians or medical societies hold that position on a formal basis. Medicare considers MR Neurography to be a useful technique and does not classify it as experimental. A reimbursement request for MR Neurography sent to Medicare will get paid if it is offered by a Medicare enrolled provider. Any provider doing MR Neurography who simply bills it as a soft tissue MRI will find that it is reimbursed, but there is always a possibility that the insurance carrier will complain later that it was a class of MRI they do not approve. The Neurography Institute, Johns Hopkins, UCLA, UCSF, Mayo and University of Washington (when offered despite possible patent infringement) will typically describe these as MR Neurography imaging studies in order to be upfront from the start. So if all the major societies in Neurosurgery and Radiology are doing regular annual professional technical courses in this subject and the textbooks all cover it, I think that it can be said that it is not viewed as a potential or experimental technique by most specialist physicians

Here is a reference from Siemens (see page 26): http://www.medical.siemens.com/siemens/en_GLOBAL/rg_marcom_FBAs/files/apps/magazine/magnetom_flash/RSNA_2010/ The doctors from Hopkins conclude their article by saying: In summary, the 3D-PSIF sequence with high spatial resolution and high contrast provides reliable and objective identification of peripheral nerve anatomy and may be incorporated as part of the high-resolution MR study of peripheral nerves, whenever accurate nerve localization and/or pre-surgical evaluation are required.

Here is a link for the ISMRM meeting: http://www.ismrm.org/06/clinicalmri3(%2706).htm

Here is a recent overview from NYU that flatly states that MR Neurography is the clinical method of choice in the abstract: http://radiographics.rsna.org/content/30/4/983.abstract

Here is a link for the 2008 RSNA meeting: http://rsna2008.rsna.org/event_display.cfm?em_id=7002489

It is a keynote (major presentation) talk at the RSNA meeting in front of thousands of radiologists and they say: CTS MR was really the birthplace of neurography which is becoming a standard part of most skeletal imaging practices.

The position of the insurance companies on this is more or less fraud in my opinion since they call it experimental and don't pay even though all the major medical centers, society annual meetings, and textbooks consider it standard based on 20 years of extensive research.

Overall, the designation by insurance companies depends on competitive rather than scientific grounds. If they are losing valuable customers because of not covering this technique, then it suddenly is no longer experimental. As long as they all call it experimental, then they have no competitive pressure. Patients tend to complain to providers and not to complain - as they should - to the payors making the same incorrect assumption that you made as to why it is deemed experimental. It has nothing to do with the evidence for the technique. It is about insurance company profitability. I think they had a concern in the past that it was not widely available geographically. Then, if it was medically necessary, they would have been obligated to fly patients to locations where it was provided. I have been told this directly by a Blue Cross medical director. There are some techniques that they have serious questions about - MR Neurography is not one of them. They know it is a standard, well proven, reliable technique and they are far less likely to approve payment for a piriformis surgery if there is no Neurography imaging. This is because the major recent papers about piriformis syndrome, for instance, rely on MR Neurography in the published evaluation and outcome protocols. Afiller (talk) 06:02, 30 March 2011 (UTC)

Class A Study Methodology to support Neurography

LWS - you can't say there is no discussion of Class A study methodology if you simply didn't look. Have you actually read the referenced articles or do you consider that part of preparing to write to be unnecessary? Class A study methodology is developed by scientists not by insurance companies. Dr. Longstreth and Dr. Jarvik have been involved with the American College of Physicians in its attempts to help improve the quality of medical literature over many years and both have been involved in a series of studies of carpal tunnel and cubital tunnel patients with the best available methodology. Here are quotes from:

Filler AG, Haynes J, Jordan SE, et al. (February 2005). "Sciatica of nondisc origin and piriformis syndrome: Diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment". J Neurosurg Spine 2 (2): 99–115. doi:10.3171/spi.2005.2.2.0099. PMID 15739520."

"Class A Imaging Efficacy Study.We designed the study to meet the criteria of a Class A quality imaging efficacy study for diagnostic accuracy according to guidelines established by the American College of Physicians.40,41 High quality studies of imaging efficacy are different from those based on treatments because they assess the ability to predict the outcomes of treatment and can be completed before treatment is commenced. For this reason, appropriate group matching rather than randomization is the critical aspect of study quality. When a gold-standard diagnostic method exists, both the gold standard and the new diagnostic technique can be applied to the same individuals to establish the best predicted outcomes, rather than relying on effectively identical groups, assigned at random, with each patient receiving one of the two treatments. In this case, however, thereis no existing accepted predictive method of diagnosing piriformis syndrome (that is, no gold standard), and the only definitive diagnosis known is based on outcome after surgery. Therefore, the appropriate question concerns the efficacy of a test or pair of tests in predicting this diagnostic outcome compared with the findings for that pair of tests in matched individuals in whom this diagnosis definitely does not exist. The relevant portion of the guideline statement is as follows: “For diagnostic accuracy and effect, methodological quality was rated as A if the study had more than 35 patients with and more than 35 patients without the pathological abnormality in question, drawn from a clinically relevant sample whose clinical symptoms were completely described, whose diagnoses were defined by an appropriate reference standard, and whose magnetic resonance images were technically of high quality and were evaluated independently of the reference diagnosis.”40 The results reported in this study, together with this position on methodology from the American College of Physicians, constitute an absolute and definitive indication for the use of MR neurography in patients with sciatica in whom an obvious spinal origin for this condition is absent.

40. Kent DL, Haynor DR, Longstreth WT Jr, Larson EB: American College of Physicians, Position paper: Magnetic resonance imaging of the brain and spine: a revised statement. Ann Intern Med 120:872–875, 1994 41. Kent DL, Haynor DR, Longstreth WT Jr, Larson EB: The clinical efficacy of magnetic resonance imaging in neuroimaging. Ann Intern Med 120:856–871, 1994"

See Jarvk, JG; Haynor DR, Longsreth WT: Assessing the Usefulness of Diagnostic Tests American Journal of Neuroradiology 17:255

And here is a quote from

Jarvik JG, Comstock BA, Heagerty PJ, et al. (March 2008). "Magnetic resonance imaging compared with electrodiagnostic studies in patients with suspected carpal tunnel syndrome: Predicting symptoms, function, and surgical benefit at 1 year". J. Neurosurg. 108 (3): 541–50. doi:10.3171/JNS/2008/108/3/0541. PMID 18312102.:

"The major strength of our study design was that we guarded against the biases that commonly occur with the evaluation of diagnostic technologies. By recruiting only patients referred for nerve conduction studies, we assured that our cohort consisted of the clinically relevant spectrum of patients. Because the interpretations of both the MR images and EDSs occurred before the assessment of outcomes, we avoided test-review and diagnosis-review bias."

If you - LWS - have any literature attacking the study methodology or disputing the Class A status - please cite it.Afiller (talk) 03:01, 4 April 2011 (UTC)

Insurance company bias

LWS it is puzzling that the work of hundreds of researchers over two decades is so upsetting to you. You should declare any bias - if you work for an insurance company and are trying to defend their unsupportable designation of this methodology as experimental you should declare your bias. Deldot has asked that you and I use the discussion section rather than have an edit war, but I don't see you responding. Calling the previous work "sloppy" is a pejorative that has no place in the edits. Correction of typos and grammatical errors is alway very helpful and much appreciated. Issues of bias are fair game, since after all, you have asked that this article be reassessed after a prior detailed review in 2008. For some reason, you don't like the article even though you will see it is supported by detailed references arising from tens of thousands of hours of works by academic scientists and physicians around the world who are committed to trying to improve the quality of diagnosis and treatment for patients with nerve entrapment disorders. If there is a fundamental objection you have to tissue selective nerve imaging, then - as long as you are remaining anonymous - why not use the discussion page to explain why you are for instance, against the use of optimized methods from UW, UCSF, Johns Hopkins, NIH, and UCLA for the improved medical treatment of nerve pain patients (perhaps you are concerned about patent infringement on their part). Perhaps you are one of those who thinks they are all better off suffering without diagnosis and treatment.Afiller (talk) 03:57, 4 April 2011 (UTC)

Use of "potentially" medical useful

From the point of view of physicians being trained anywhere in the world, the medical literature and the textbooks leave no doubt that this is medically useful. You seem to be hung up on an insurance reimbursement position which is unrelated to medical utility. In the United States, for instance, it is now malpractice if a surgeon makes an error that was avoidable if prior nerve imaging could have been done but wasn't done. When you have an untried and untested method that some group or physician has just proposed, for which there is no evidence one way or the other, then you have a new method that is potentially useful.

There is no suggestion anywhere that having detailed anatomical nerve images that show pathology is bad for patient care. There are numerous formal high quality studies that show that there is a statistically significant improvement in treatment outcome when these types of imaging studies are used. Numerous studies of this type are already cited in the Wikipedia article. We could put in six time as many references as are already in the article. That goes beyond what is usually done for a Wikipedia article. But I certainly can convert this to 200 references. However, none of that will probably convince LWS that medical literature is the source of information to be relied on as opposed to pseudospeak from insurance companies.

If LWS can provide - in the discussion - some references that would show that a medical procedure supported by hundreds of papers over 20 years with no negative results and which is presented as factual requirement for diagnosis in the major professional textbooks would only be considered "potentially" useful, then I would like to see that so I can provide specific refutation. LWS has yet to provide one single reference to support any one of his/her changes.Afiller (talk) 04:26, 4 April 2011 (UTC)

Please follow talk page guidelines

AFiller -

Please follow talk page guidelines. Being friendly is helpful. This is not a forum for anger and accusations, it is for discussion and explanation. Class A methodology refers to the actual methodology - not to a reference that references it as the references you list do. It is not clear in the body of the page whether this is study design methodology, imagining methodology - just WHAT it is is unclear. If you cannot directly reference the methodology, then describe it in plain terms, please. Only in the discussion to you use the terms "Class A Imaging Efficacy Study" which is somewhat more descriptive than just "Class A methodology," " Class A Study," or "Class A Outcome study."

By reading the references you give and following the links to try and find a description of the actual study methodology, I can only come up with the methodology as described in the following abstract:

The Efficacy of Diagnostic Imaging Dennis G. Fryback, PhD John R. Thornbury, MD Abstract

The authors discuss the assessment of the contribution of diagnostic imaging to the patient management process. A hierarchical model of efficacy is presented as an organizing structure for appraisal of the literature on efficacy of imaging. Demonstration of efficacy at each lower level in this hierarchy is logically necessary, but not sufficient, to assure efficacy at higher levels. Level 1 concerns technical quality of the images; Level 2 addresses diagnostic ac curacy, sensitivity, and specificity associated with interpretation of the images. Next, Level 3 focuses on whether the information produces change in the referring physician's diagnostic thinking. Such a change is a logical prerequisite for Level 4 efficacy, which concerns effect on the patient management plan. Level 5 efficacy studies measure (or compute) effect of the information on patient outcomes. Finally, at Level 6, analyses examine societal costs and benefits of a diagnostic imaging technology. The pioneering contributions of Dr. Lee B. Lusted in the study of diagnostic imaging efficacy are highlighted.

This refers to numerical Levels of diagnositc imaging assessment, not alphabetic. Yes, I do read the references, and I don't find description of documentation of "Class A" methodology, which is elswhere refered to as "Class A outcome" methodology. It is still not clear. so a clear citation to the methodology is still needed.

And please, follow the talk guidelines.

Silver

LacedWithSilver 03:34, 5 April 2011 (UTC) — Preceding unsigned comment added by LacedWithSilver (talk • contribs) What does insurance and study design methodology have to do with this discussion?

There is no "liking" this page, anymore than there is "happiness" with your textbook contributions.

Thank you for your civil discourse.

Silver

LacedWithSilver 03:00, 5 April 2011 (UTC) — Preceding unsigned comment added by LacedWithSilver (talk • contribs)

LWS - you are clearly aware of the role of insurance since you first inserted an extensive quote from an insurance website to support your assertion that neurography is "experimental" and only "potentially useful." In fact, the medical utility is established by the scientific publications in peer reviewed journals, and documented by how physicians present it to other physicians and how they use it in their practices. It is fair to discuss how insurance companies classify it for reimbursement, but as you now appear to agree, that is a separate issue that should only be discussed under insurance. Hopefully, you and I agree on that now. There is a question of "liking" the page since you stated that it read to you like an advertisement, but others - including senior Wikipedia editors who reviewed it in 2008 - felt that it was a fair, balanced and well referenced article. I suspect you personally needed a neurography study and were frustrated by insurance reimbursement or that you are working for Siemens or an insurance company and have some motive for picking this one subject out of the millions of Wikipedia articles to plunge in, redefine the method (incorrectly) as post-processing only, and declare it - equally incorrectly - as experimental and unproven. In academia, everyone has to sign their work for obvious reasons. Here you take the fact that I am not anonymous as if it is a bad thing. Rather it is the standard in academia so that we may anticipate a persons biases whether or not they declare them (as I have done). I have made the point that everyone in academia and medicine has an interest in the subject matter that they publish on. We understand that this does not mean that all work in academia and medicine is therefore invalid due to bias. You can see very easily that neurography produces detailed images of nerves. That is a fact. Yes I developed this and am reporting on that and on the scientific assessment of the utility. The fact that I am a proponent doesn't change the fact that the method images nerves and it doesn't change the fact that there is a large amount of excellent science that proves its validity and utility. Afiller (talk) 06:29, 5 April 2011 (UTC)

Methodology

I agree that a more formal explanation of methodology would be helpful. However, I think this needs a full page in Wikipedia. In medicine, physicians are always confronted by numerous reports and publications advocating various treatments and approaches. Very broadly - in neurosurgery - we have self reported retrospective series - which are considered class C (unreliable), studies with some controls on bias (Class B), and those that meet modern scientific standards which would be Class A. We are taught how to evaluate a study for Class A methodology. In some cases, such as the development of a new type of medication, the standard is a prospective randomized double blind trial with a study size that meets the statistical criteria dictated by the size of the effect. In imaging the situation is different. For medications and treatments, you can't give two different treatments to the same person since the two may interact or have additive effects. To compensate for this, we use randomized matching to simulate two identical populations. In medical imaging, you can do two different imaging tests on the same individual and see which is most predictive of the effect or outcome of interest, so randomized matching is not the essential component. For imaging, we have one set of methods to use when there is a "gold standard" method. For instance, if you have a good method (that everyone agrees is excellent) that determines whether or not there is a coronary artery blockage (coronary artery injection angiography) and you want to evaluate the usefulness of two new methods (CT based coronary angiography and MRI coronary angiography) then you can compare the effectiveness for identifying plaques against the gold standard. MRI might be 80% as reliable, but far safer (no chance of death caused by procedure vs a 5% risk of death for the more reliable injection angiogram) etc. In nerve imaging, there was no "gold standard" that is, no method that could even remotely accomplish the task. This is not a unique situation. Therefore, the American College of Physicians attempted to develop a rigorous approach to evaluating the utility and efficacy of an imaging method for which there was no existing "gold standard." For the study published in 2005, my group followed this "Class A" methodology specified by the American College of Physicians. The consequence is that we used a study methodology that used the most rigorous known methodology to assess the test of MR Neurography. Subsequently, an insurance company can report that there are no high quality studies, but the fact is that there is no way to improve upon the methodology of the 2005 study (ref 21 in the article currently). We could substitute the statement - "used the best accepted published methodology recommended by the American College of Physicians for study design" instead of saying "Class A". So as I said, this would be a great subject for a Wikipedia article if there is not one already written - I think the most relevant on a first pass is the Evidence-based medicine article but it uses a scheme that does not consider the special issues of radiological imaging evaluation methodology or the "no existing gold standard" issue - I could update that article with the information in the articles cited on this page and then we could link out to it to provide the reader with a more complete discussion. This issue applies to the question of how we interpret any study in medicine in regard to the extent that we may rely upon the validity of the result in deciding whether or not this is a medically useful test. Since we followed the best known methodology and showed that this was a valid and useful test, it seems inappropriate to simply dismiss the research and say there is no validity. If the best known methods in science and medicine say it's valid and useful, how can an insurance company with a profit motive or an anonymous Wikipedia editor whose biases are unknown to us, dismiss the science and declare the method untested?Afiller (talk) 06:14, 5 April 2011 (UTC)

I'm one of the two senior Wikipedia editors who you mentioned reviewed the article in 2008--the problem is that neither of us knows enough about this type of imaging to know whether this is neutral article. At the time I mentioned the neutrality policy because I had noticed that the article didn't list disadvantages of the technique. So if someone comes along and says they think the article's biased, I think we should at least take that seriously, and Assume good faith on their part. So rather than talking about whether or not someone's identity is known, let's focus purely on the sources, because at the end of the day what gets included is going to come down to what reliable, independent sources say. It makes sense to have a discussion of how widely and accepted by physicians the technique is, as Casliber pointed out in 2008. If there are a wealth of sources saying the technique is widely respected, let's include that information. If someone finds a reliable source that says "this technique is treated as experimental by insurance companies", I can't see any reason why that should not be included as well. I would think most people can draw their own conclusion about the profit motive there, or we can link to an article that discusses it. delldot ∇. 01:46, 6 April 2011 (UTC)

Deldot - these issues were not only raised in 2008, but - in response - the article was revised. CItations from several major independent research groups working in this field from around the world are cited, negative aspects and concerns were pointed out. I have pointed out that you can assert a profit motive to anyone or anything in academia, science or ordinary life - here we just don't know if LWS has a profit motive because of the anonymity. The reason for raising the bias question about LWS is that LWS did not bring any references to support raising the questions. It seems that LWS did not even read the 30 or so articles referenced as LWS made major factual errors - which of course are easily correctable - and that several of the LWS edits were directed to discussion of the insurance reimbursement. The article - since 2008- has explicitly stated that insurance companies treat this as experimental. LWS went on to suggest that since the insurance companies say this, that the reader should ignore the medical scientific literature. This was - on the face of it - a set of edits which revealed an agenda or preconceived point of view. I'm sorry but say what you will, LWS did have a preconceived agenda not supported by any scientific literature. This makes it fair to ask that any bias be revealed - even if your editor maintains anonymity. It may be helpful to clarify that is is not some specialized commercial product. In medical imaging, there was no reliable way to image nerves. Nerves are important for a very large number of medical conditions. This method uncontestably provides very details images of nerves in the human body on a reliable basis and the pathology it reveals has been shown repeatedly to be accurate. There is no alternate method except - for instance - doing surgery blindly without imaging first. This is why human subjects committees will not agree to have patients randomized into a group for blind surgery vs a group for imaging before surgery. The fact that it was not known how to do this required an act of invention to make it possible for physicians and patients to take advantage of this. My employer, the University of Washington decided to file a patent and it was granted. This was covered in the Lancet, the New York Times, ABC news etc. It was an important medical breakthrough in 1993. The fact that I am an inventor does not inherently contaminate this important medical advance that has benefited hundreds of thousands of patients around the world in the past two decaces.

Wikipedia seems to have this backwards. If you tried to publish an academic article anonymously it would be highly suspect. However, on WIkipedia you seem to suggest that BECAUSE someone insists on anyonymity they must be unbiased and because someone voluntarily identifies themselves then they MUST be biased. I would think the opposite. Ask yourself, why shouldn't I have just stayed anonymous and avoided all the repeated rounds of unsupported accusations. Afiller (talk) 15:45, 7 April 2011 (UTC)

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