DRG stimulators

[deleted875186]

Who is placing these routinely? Are they worth the hassle? Have done a few but the success rate doesn’t seem to be any better than SCS and definitely more hassle.

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[lobelsteve]

Foot CRPS. Should be better than other options, and I am a Nevro proponent (no KOL).

But the world of SCS has gone crazy. It will end badly due to overuse and poor use. CRPS bloomed in Atlanta in 2000 and every pain clinic patient had it for a while, if just to get L8680'd.

 

[deleted875186]

Foot CRPS. Should be better than other options, and I am a Nevro proponent (no KOL).

But the world of SCS has gone crazy. It will end badly due to overuse and poor use. CRPS bloomed in Atlanta in 2000 and every pain clinic patient had it for a while, if just to get L8680'd.

Are you doing any DRG for abdominal, pelvic, or persistent post surgical pain in the abdomen/chest. Have Yoj seen any success, I’ve tried some pelvic and abdominal pain without any success.

 

[Ferrismonk]

Getting trained on this next month. I'm also curious about your experiences.

 

[Agast]

Are you doing any DRG for abdominal, pelvic, or persistent post surgical pain in the abdomen/chest. Have Yoj seen any success, I’ve tried some pelvic and abdominal pain without any success.

What ICD 10 codes did you use to cover abdominal pain?

I got 50% improvement with an interstitial cystitis patient. Made the case for CRPS pain. Probably only worked because they had a small local plan.

 

[lobelsteve]

Getting trained on this next month. I'm also curious about your experiences.

Me too. June. In Atl.

 

[deleted472101]

Just like everything it is a good therapy for the right patient.

Also just like everything you get faster as you do more.

 

[drrosenrosen]

I've done about 4 implants. All L5-S1 for foot/ankle CRPS. All good results. One thing to be aware of for those going to the training. Although DRG doesn't have it's own CPT, they will still push that it's only indicated for CRPS, and will encourage mental and ethical contortions to convince you that post-TKA(L3) or post-herniorrhaphy(L1) pain is "causalgia". At least, they were doing that 2 years ago.

I'd be open to trying it for either of those indications, but I would probably try to push it through under another approved indication for 63650. For knees they'd have to have failed genic RF, and for ilioinguinal neuralgia I'd probably try peripheral stim first.

I do have a guy with chronic testicular pain who failed genitofemoral nerve block but got complete relief with L1 SNRB, who will probably get a DRG trial. I'll post results if I end up doing that.

 

[Ronin1]

Having done more than 20 I would say it is a major hassle compared to regular SCS. Works well for specific applications I.e post hernia pain, foot/ankle crps etc. don’t reach for the rep pushed diagnosis, these are likely to fail.

 

[deleted875186]

Having done more than 20 I would say it is a major hassle compared to regular SCS. Works well for specific applications I.e post hernia pain, foot/ankle crps etc. don’t reach for the rep pushed diagnosis, these are likely to fail.

They are a huge pain to place, much more time than a SCS, and so far I haven’t seen any better results. I’m back and forth about CRPS in the arm or foot, because most of these patients do well with an SCS and it’s so much easier.

 

[drusso]

Who is placing these routinely? Are they worth the hassle? Have done a few but the success rate doesn’t seem to be any better than SCS and definitely more hassle.

It's all fun and games until the lead migrates. CRPS of the foot and ilioinguinal neuralgia make sense. I don't mind calling those things causalgia. But pelvic pain in the post-hysterectomy, post-endometriosis, post-interstitial cystitis (really chronic pelvic inflammatory disease but let's not say the quiet part out loud) is a whole other ballgame.

Your mileage may vary.

If a manufacturer could figure out a transforaminal approach like we do TFESI's, this technology would take off.

 

[Monterosso]

Pelvic pain and DRG stimulation is an interesting scenario. In our practice, we have seen some patients benefit from it. I agree with the above posts about the "hassle" of placing it, in addition to lead migration risks.

The other interesting point with pelvic symptoms is that sacral neuromodulation is quite established in urology (InterStim from Medtronic, often through the S3 foramen) for pelvic type symptoms such as overactive bladder as well as bowel symptoms. The InterStim uses tined leads instead of "S-loops."

As an aside, it's surprising to me how little talk there is between urologists and pain physicians regarding sacral neuromodulation though we both use it. Just the other week, I met a urologist who places InterStim regularly express they knew very little about how pain physicians did similarly. As another example, how often have you seen a urologist at NANS?

 

[TIVAndy]

I've done about 4 implants. All L5-S1 for foot/ankle CRPS. All good results. One thing to be aware of for those going to the training. Although DRG doesn't have it's own CPT, they will still push that it's only indicated for CRPS, and will encourage mental and ethical contortions to convince you that post-TKA(L3) or post-herniorrhaphy(L1) pain is "causalgia". At least, they were doing that 2 years ago.

I'd be open to trying it for either of those indications, but I would probably try to push it through under another approved indication for 63650. For knees they'd have to have failed genic RF, and for ilioinguinal neuralgia I'd probably try peripheral stim first.

I do have a guy with chronic testicular pain who failed genitofemoral nerve block but got complete relief with L1 SNRB, who will probably get a DRG trial. I'll post results if I end up doing that.

i've done few DRG implants - agree with foot/ankle/crps. when you have a focal pain, DRG tends to be superior/have good coverage.
that being said when i can do with SCS, i will always opt for regular SCS.
as for post TKA/post herniorhaphy, some pts are indeed CRPS - causalgia from damage to either infrapatellar saphenous / ilioinguinal/hypogastric nerves.
in those cases where i have done DRG implant (L3 and L1 respectively) , i've had a few homeruns - 100% relief post implant and only follows up yearly/prn

bottom line is - works well for focal pain but still pain in the axx to place.

 

[TIVAndy]

It's all fun and games until the lead migrates. CRPS of the foot and ilioinguinal neuralgia make sense. I don't mind calling those things causalgia. But pelvic pain in the post-hysterectomy, post-endometriosis, post-interstitial cystitis (really chronic pelvic inflammatory disease but let's not say the quiet part out loud) is a whole other ballgame.

Your mileage may vary.

If a manufacturer could figure out a transforaminal approach like we do TFESI's, this technology would take off.

i dont do this but stimwave claims DRG stimulation via transforaminal approach. i've considered it in a pt with laminectomy where you can't do an abbott DRG.

 

[Ferrismonk]

Me too. June. In Atl.

Sweet. I'm in Detroit unfortunately.

 

[Dawkter]

It's all fun and games until the lead migrates. CRPS of the foot and ilioinguinal neuralgia make sense. I don't mind calling those things causalgia. But pelvic pain in the post-hysterectomy, post-endometriosis, post-interstitial cystitis (really chronic pelvic inflammatory disease but let's not say the quiet part out loud) is a whole other ballgame.

Your mileage may vary.

If a manufacturer could figure out a transforaminal approach like we do TFESI's, this technology would take off.

Place a SPRINT pns lead at the DRG.

 

[Crybaby]

i dont do this but stimwave claims DRG stimulation via transforaminal approach. i've considered it in a pt with laminectomy where you can't do an abbott DRG.

I have seen some done with stimwave that seem to get good results, I have yet to try.

 

[deleted875186]

I have seen some done with stimwave that seem to get good results, I have yet to try.

Why would someone do a transformational approach? Seems unnecessarily risky. What would be the advantage over DRG?

 

[TIVAndy]

Why would someone do a transformational approach? Seems unnecessarily risky. What would be the advantage over DRG?

arguably easier access, also laminectomy pts

 

[Espn123]

I’ve done more than a few. For chronic post surgical Pain or crps of the groin, knee, and foot, it is a home run.
There are lots of technical nuances that improve w practice. I’d recommend using 90cm leads for implants and making multiple loops to reduce migration. (No mri w 90cm, but pick your poison)

 

[bedrock]

I’ve done more than a few. For chronic post surgical Pain or crps of the groin, knee, and foot, it is a home run.
There are lots of technical nuances that improve w practice. I’d recommend using 90cm leads for implants and making multiple loops to reduce migration. (No mri w 90cm, but pick your poison)

Have you done many for pelvic pain?

When you refer to groin, I assume you primarily mean for post hernia neuralgias?

Knee cases are fairly clear CRPS after TKA?
I see more than a few patients with knee pain s/p TKA that have a mechnical nature to their symptoms, the joints get warm, and it is very activity dependent. I'm not too enthused about trialing those vs the TKA patients with diffuse hyperalgesia, pain all the time, even at rest, and other causalgia symptoms who I do expect would respond to DRG.

 

[Espn123]

Have you done many for pelvic pain?

When you refer to groin, I assume you primarily mean for post hernia neuralgias?

Knee cases are fairly clear CRPS after TKA?
I see more than a few patients with knee pain s/p TKA that have a mechnical nature to their symptoms, the joints get warm, and it is very activity dependent. I'm not too enthused about trialing those vs the TKA patients with diffuse hyperalgesia, pain all the time, even at rest, and other causalgia symptoms who I do expect would respond to DRG.

I find those knee patients you refer to do fairly well if there is a neuropathic component - 99% of those I see are mixed

Groin yes I meant post hernia. I do T12-L1

pelvic pain I have done a handful for post-surgical etiologies, it works sometimes (usually the L1 lead has provided the most relief)

 

[deleted875186]

Have you done many for pelvic pain?

When you refer to groin, I assume you primarily mean for post hernia neuralgias?

Knee cases are fairly clear CRPS after TKA?
I see more than a few patients with knee pain s/p TKA that have a mechnical nature to their symptoms, the joints get warm, and it is very activity dependent. I'm not too enthused about trialing those vs the TKA patients with diffuse hyperalgesia, pain all the time, even at rest, and other causalgia symptoms who I do expect would respond to DRG.

The post TKA patients are often mixed neuropathic nociceptive it seems, no clear etiology. I haven’t tried DRG on any of them but perhaps should try.

 

[cameroncarter]

I have seen some done with stimwave that seem to get good results, I have yet to try.

Any reason TFESI approach can’t be used for DRG placement? Anyone try?

 

[Gnarvin]

Any reason TFESI approach can’t be used for DRG placement? Anyone try?

I did a couple transforaminal approach DRG stims in fellowship. I don’t like the approach due to concern for injury to the nerve root and/or DRG itself when steering that 14 gauge introducer to the foramen. Also, there is really no way to make strain relief loops with that approach so I would think there would be a higher risk of migration, though I didn’t see any during fellowship.

I would do the traditional Abbott approach/system every time if possible. However, if the patient has a laminectomy at the level you want to go for, the transforaminal approach is pretty much your only option unless you can find a neurosurgeon who will do an open implant, though I am not sure they would do that without a successful trial.

I also do not agree with Abbott pushing using “causalgia” for any post-operative pain just so that they can get DRG approved for it.