SCS trial for spinal stenosis w/o having had decompression?

[pharmer]

I wanted to see what your guys thoughts were on this. I had 63 y/o male about 300#s come in today upon referral from our local VA for spinal cord stimulator. MRI with severe central stenosis at L2/3 with disc extrusion up to L1/2 (AP diamter is 0.5cm), severe stenosis at L3/4, L4/5 with severe stenosis and compression of the cauda equina, mod central stenosis at L5/S1. He had had prior ACDF at C4/5 but no decompression or other lumbar surgery. He says that he will not have another surgery as his neck surgery made things worse (was done 2 years ago and claims he did not have back problems before this). He has symptoms of neurogenic claudication and can ambulate about 10-15 yards before leg pain becomes very intense and relieved upon sitting down or even better laying down. He does not have cauda equina syndrome despite findings of compression on the MRI, no other red flags, reflexes were 3+ in patella and achilles, strength intact 5/5 but painful for him to perform. I am very reluctant to consider doing a trial when decompression seems indicated (he has had prior epidurals without relief at the VA). He claims he saw a back surgeon and was told he was not a candidate for surgery or he was to high risk. I do not have documentation of this and am attempting to get ahold of this from his PCP, not sure why he is too high risk. He is taking 30mg MSSR BID and 15mg MSIR 6 times daily. I up titrated gabapentin on him to 800mg TID from 400mg TID which he started a few weeks ago per his PCP today on initial consult while I attempt to get records. Would you guys consider doing a stimulator trial on him??? To me it seems like decompression is clearly indicated if epidurals do not help and placement of a SCS will likely only prolong the inevitable which would be decompression. Thoughts appreciated.

---

Members don't see this ad.

 

[CB1Antagonist]

Please send this poor man to a surgeon for multi level lumbar lam. SCS sounds like a bad idea in this case.

 

[bedrock]

I wanted to see what your guys thoughts were on this. I had 63 y/o male about 300#s come in today upon referral from our local VA for spinal cord stimulator. MRI with severe central stenosis at L2/3 with disc extrusion up to L1/2 (AP diamter is 0.5cm), severe stenosis at L3/4, L4/5 with severe stenosis and compression of the cauda equina, mod central stenosis at L5/S1. He had had prior ACDF at C4/5 but no decompression or other lumbar surgery. He says that he will not have another surgery as his neck surgery made things worse (was done 2 years ago and claims he did not have back problems before this). He has symptoms of neurogenic claudication and can ambulate about 10-15 yards before leg pain becomes very intense and relieved upon sitting down or even better laying down. He does not have cauda equina syndrome despite findings of compression on the MRI, no other red flags, reflexes were 3+ in patella and achilles, strength intact 5/5 but painful for him to perform. I am very reluctant to consider doing a trial when decompression seems indicated (he has had prior epidurals without relief at the VA). He claims he saw a back surgeon and was told he was not a candidate for surgery or he was to high risk. I do not have documentation of this and am attempting to get ahold of this from his PCP, not sure why he is too high risk. He is taking 30mg MSSR BID and 15mg MSIR 6 times daily. I up titrated gabapentin on him to 800mg TID from 400mg TID which he started a few weeks ago per his PCP today on initial consult while I attempt to get records. Would you guys consider doing a stimulator trial on him??? To me it seems like decompression is clearly indicated if epidurals do not help and placement of a SCS will likely only prolong the inevitable which would be decompression. Thoughts appreciated.

SCS trial is not indicated.

First thing to do is remind the patient that he is not a doctor. Silly statements like "I'm not having lumbar surgery, because my neck surgery didn't help", need to be corrected. Apparently his PCP didn't have the balls to say this. You need to tell them what is happening to his nerves each time he walks 10 feet.
He needs to be educated regarding the seriousness of his condition and that there is only one appropriate treatment option--Surgical decompression.

Regarding the surgical consult. He was likely told he isn't a surgical patient by a private practice surgeon. That doesn't mean he isn't a surgical candidate. That private practice (or VA) surgeon may have been feeling lazy or didn't want to take on a stupid patient who says things like "I won't have lumbar surgery because my neck still hurts".

Refer the patient to an academic spine surgeon at a university hospital. The patient will get the surgery his nerves are crying out for, while his brain watches Jerry Springer reruns.

 

[oreosandsake]

for my clarification...

in the patient with neurogenic claudication clearly from SS who is not a candidate for surgery (cards wont clear them, etc etc) will you trial a SCS?

I have seen a few papers on this, and there are people advocating for it to be an "intermediate" step for SS ("surgery sparing") even if the patient can get medical clearance for surgery.

 

[clubdeac]

Duh.... perc disc decompression at L2-3 and MILD at L3-4, L4-5 and L5-S1... don't know how you missed the obvious??

 

[lobelsteve]

SPORT Study. This is a surgical problem and you cannot help him. Informed consent should say paralysis and loss of control of bowel/bladder. From not having decompression.

Scs as useful as appendectomy. Just not indicated

 

[Ducttape]

seems like this guy needs a second opinion on surgery. and seems like there might be additional risk with the L2-3 disc extruding upwards.

otoh, i would reiterate oreosake's question. for the sake of argument, patients with multilevel spinal stenosis, neurogenic claudication, fails meds, fails epidural/TF, fails PT, fails Bmed, has seen, say, 5 surgeons, none of whom would operate on him because of 1. comorbidities 2. other extraneous reasons

at what point is SCS "off the table" for the rest of you?

or give him >120 MED?

 

[Louisville04]

Regarding the surgical consult. He was likely told he isn't a surgical patient by a private practice surgeon. That doesn't mean he isn't a surgical candidate. That private practice (or VA) surgeon may have been feeling lazy or didn't want to take on a stupid patient who says things like "I won't have lumbar surgery because my neck still hurts".

Refer the patient to an academic spine surgeon at a university hospital. The patient will get the surgery his nerves are crying out for, while his brain watches Jerry Springer reruns.

Would the academic/university hospital see him if he doesn't have insurance? Most VA patients don't have other insurance.

 

[Aether2000]

SCS doesn't work in these situations.

 

[lobelsteve]

SCS doesn't work in these situations.

Do you mean doesn't work for the patient or doe$n't work for the doctor?

 

[pharmer]

Thanks all. I am eager to get the records from his back surgeon that said he was not a candidate and see why as the patient is big w/o other comorbidities outside of DM2, HTN, OSA. I am definetly going to send him to one of our spine surgeons if not a univeristy hospital for evalution for back surgery as I really do feel that is the best thing for him. I have a soft spot for our veterans and wanted to help but I think ultimately surgery is the best route.

 

[clubdeac]

Thanks all. I am eager to get the records from his back surgeon that said he was not a candidate and see why as the patient is big w/o other comorbidities outside of DM2, HTN, OSA. I am definetly going to send him to one of our spine surgeons if not a univeristy hospital for evalution for back surgery as I really do feel that is the best thing for him. I have a soft spot for our veterans and wanted to help but I think ultimately surgery is the best route.

If the patient was referred from the VA, it's not surprising he was told he was not a surgical candidate. When I worked there the surgeons were very reluctant to operate. Even the slightest issue would preclude surgery. It was nice for me as I then got to work on a lot of unsurgerized backs and hone my SCS, MILD, perc disk and other skills.

 

[emd123]

Speaking in general, not about this specific patient....


If a guy is truly having neurogenic claudication, ie, motor weakness, spinal cord stimulation is not going to doing anything to keep the nerves from being squeezed when he stands to walk. In that case, stim will not keep him out of a wheelchair. Would it help his pain as he progresses to wheelchair bound status? Hmm... don't know. Seems pretty "off label" to me.

If he truly has exhausted all surgical options, which it doesn't sound like he has, I suppose you'd be looking at a palliative spinal cord stimulator, with no goal of improved function, only pain relief.

Doesn't sound like a very good candidate to me. Also, just because a patient makes a poor decision regarding his care, doesn't mean a poor treatment option is suddenly a better one.

I like slam dunks.

 

[SSdoc33]

i dont know. 5 level lumbar laminectomy and foraminotomy? then a year later when that doesnt work, a 5 level fusion? on a guy 300 lbs? i can see why the surgeons at the VA didnt want to touch him. he probably needs the surgery, but not having it may not be worst thing in the world.

 

[Pacman27]

SCS sounds only palliative at best. Of course if he has to have paddles placed, that is a surgery.

Is he a candidate for the MILD procedure

 

[SSdoc33]

Is he a candidate for the MILD procedure

prob cant get paid for it and the disc extrusion makes me think not. plus, it is several levels.

 

[Taus]

I've had several elderly very medically comorbid patients recently with multi level mod- severe central and foraminal stenosis at least 3 levels all of whom reasonable surgeons said no OR. Most have had a significant neuro claudication component plus radicular symptoms at rest n worse w extend/stand/supine. None w signif weakness or bowel/bladder issues (aside from the bph....).

Have had variable success w caudal esi w catheter and reasonable trials of various neuropathics. Most now on low dose opiod again w limited success.

I understand that pure neurogenic claudication is not a good indication for SCS....but for those w intolerable and function limiting pain-- how much of a component of polyradic from the foraminal stenosis must be present clinically to consider SCS in these types of patients?? Other options pretty limited in these folks....

 

[emd123]

Spinal Cord Stimulation for the Treatment of Chronic Pain in Patients with Lumbar Spinal Stenosis



Objective:  Chronic back and leg pain associated with lumbar spinal stenosis (LSS) is common in the elderly. Surgical decompression is usually performed when conservative treatments fail. We present an evaluation of the long-term outcome of patients suffering from symptomatic LSS treated with spinal cord stimulation (SCS).

Materials and Methods:  Data were collected prospectively in three independent registries in three European centers. Pooled data were analyzed retrospectively. Changes in pain intensity, functional status, and analgesic medication were compared at baseline and at the last available follow-up. Demographic data as well as details regarding the implantation procedure and any adverse events were systematically recorded.

Results:&#8194; Data were recorded in 69 patients with a mean follow-up period of 27 months. All patients showed clinically and statistically significant improvement in pain relief, the visual analog scale decreasing from 7.4 ± 2.3 to 2.8 ± 2.4 (p < 0.05). The use of analgesic medication decreased and the functional status improved.

Conclusion:&#8194; Spinal cord stimulation seems to be effective in the treatment of patients suffering from chronic pain associated with LSS. Being less invasive and reversible, SCS should be considered before surgical decompression, particularly in patients with increased risks associated with back surgery.



http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1403.2010.00289.x/abstract

 

[oreosandsake]

Spinal Cord Stimulation for the Treatment of Chronic Pain in Patients with Lumbar Spinal Stenosis


Conclusion:&#8194; Spinal cord stimulation seems to be effective in the treatment of patients suffering from chronic pain associated with LSS. Being less invasive and reversible, SCS should be considered before surgical decompression, particularly in patients with increased risks associated with back surgery.



http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1403.2010.00289.x/abstract

I've seen this study before.

I guess my question was how many people support this concept. is SCS an intermediate step before surgery?

there is a paper coming out soon pushing this idea...

 

[lobelsteve]

Spinal Cord Stimulation for the Treatment of Chronic Pain in Patients with Lumbar Spinal Stenosis



Objective:&#8194; Chronic back and leg pain associated with lumbar spinal stenosis (LSS) is common in the elderly. Surgical decompression is usually performed when conservative treatments fail. We present an evaluation of the long-term outcome of patients suffering from symptomatic LSS treated with spinal cord stimulation (SCS).

Materials and Methods:&#8194; Data were collected prospectively in three independent registries in three European centers. Pooled data were analyzed retrospectively. Changes in pain intensity, functional status, and analgesic medication were compared at baseline and at the last available follow-up. Demographic data as well as details regarding the implantation procedure and any adverse events were systematically recorded.

Results:&#8194; Data were recorded in 69 patients with a mean follow-up period of 27 months. All patients showed clinically and statistically significant improvement in pain relief, the visual analog scale decreasing from 7.4 ± 2.3 to 2.8 ± 2.4 (p < 0.05). The use of analgesic medication decreased and the functional status improved.

Conclusion:&#8194; Spinal cord stimulation seems to be effective in the treatment of patients suffering from chronic pain associated with LSS. Being less invasive and reversible, SCS should be considered before surgical decompression, particularly in patients with increased risks associated with back surgery.



http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1403.2010.00289.x/abstract

You forgot the most important part of the study:

Conflict of Interest:&#8194;Dr. Costantini, Prof. Buchser, and Dr. Van Buyten are consultants to Medtronic for sharing medical expertise. No financial support has been received for conducting and managing this study.

 

[emd123]

You forgot the most important part of the study:

Conflict of Interest:&#8194;Dr. Costantini, Prof. Buchser, and Dr. Van Buyten are consultants to Medtronic for sharing medical expertise. No financial support has been received for conducting and managing this study.

I know. I didn't say I agreed with it. I just stumbled across it and thought I'd throw it into the discuss since it's relevant to the thread. It's a very small sample size, too.

 

[Ducttape]

You forgot the most important part of the study:

Conflict of Interest:&#8194;Dr. Costantini, Prof. Buchser, and Dr. Van Buyten are consultants to Medtronic for sharing medical expertise. No financial support has been received for conducting and managing this study.

Clearly a concern.


Is there any COI with the SPORT study neurosurgeons?

Otoh, those results from SPORT suggested little difference between pts getting surgical vs nonsurgical care 8-10 years out...

 

[Pain Applicant1]

That compression and extrusion is high, I would keep an eye out for conus medullaris

 

[rdb32]

The natural course of lumbar stenosis most frequently remains stable, with a small percentage improving over time, and a small percentage worsening over time. Although he'd probably do better with surgery, this is still an elective procedure and certainly not required. Telling him this will progress to paraplegia would be inaccurate.

 

[Preganglionic]

I was sent a patient from a reputable surgeon- 79 yo frail osteoporotic female with severe multilevel stenosis, DDD, and dextroscolosis- for SCS. She did not have cauda equina symptoms and surgery would be rather extensive.
I wasn't enthusiastic about it, but patient was motivated and understood all risks and benefits. In general, as long as they are educated about their options, patients are entitled to decide what treatment they receive. BTW- her trial went great!

 

[lobelsteve]

In general, as long as they are educated about their options, patients are entitled to decide what treatment they receive. BTW- her trial went great!

Illogical. Replace SCS with oxy.

We call your statement rationalization.

Let us know her functionality during the trial. What are the treatment goals? Sounds like my taxes just went up.

 

[bedrock]

On this case, I agree with steve in that functionality is critical. For this LOL, you need to measure what she does during the day with stim, vs without it.

However, I disagree that oxy is automatically better for her. Some many older patients can't tolerate a opioid dose sufficient to reduce their pain, without causing many serious side effects.

Should definitely do a few medication trials first, but if she fails them, then yes, I think SCS would be reasonable to try, with functional goals measured pre and during trial.

 

[lonelobo]

Illogical. Replace SCS with oxy.

We call your statement rationalization.

Let us know her functionality during the trial. What are the treatment goals? Sounds like my taxes just went up.

..and you know she hasnt't been tried on multiple meds how?

 

[lobelsteve]

I said nothing about her meds.


But what if we replaced the SCS trial with a trial of Oxycontin. The patient wants it and it should not be denied to her. Cause I think it sounds equally ridiculous.

 

[bedrock]

I said nothing about her meds.


But what if we replaced the SCS trial with a trial of Oxycontin. The patient wants it and it should not be denied to her. Cause I think it sounds equally ridiculous.

I guess u just recommend saying "suck it up" and goodbye.

There are no perfect options.

 

[Ducttape]

just to clarify...

your previous post earlier in the thread state unequivocally that you do not believe that SCS is valid at all for neurogenic claudication.

SPORT Study. This is a surgical problem and you cannot help him. Informed consent should say paralysis and loss of control of bowel/bladder. From not having decompression.

Scs as useful as appendectomy. Just not indicated

here you comment about functionality during the trial on a different patient, but with marked similarities.

Illogical. Replace SCS with oxy.

We call your statement rationalization.

Let us know her functionality during the trial. What are the treatment goals? Sounds like my taxes just went up.

would you consider a trial to determine if functionality is improved with SCS?


on the other hand, if surgery is not an option and you would never recommend SCS, then you are going to, as you eloquently termed it, "Replace SCS with oxy"....

 

[lobelsteve]

just to clarify...

your previous post earlier in the thread state unequivocally that you do not believe that SCS is valid at all for neurogenic claudication.




here you comment about functionality during the trial on a different patient, but with marked similarities.





would you consider a trial to determine if functionality is improved with SCS?


on the other hand, if surgery is not an option and you would never recommend SCS, then you are going to, as you eloquently termed it, "Replace SCS with oxy"....

I'd do the SCS if certain functional goals were ahead of the trial.

I did an implant in a 96 y/o male with stenosis and non-claudicatory constant leg pain. Goal of care was to allow him to return to one round of golf per week.

The oxy thing is only there as patient was dictating care. If patient said I want oxy and it works for me and the doc said ok, then that would be nonsense given the little history we have. But if the doc stands to make $5k on a procedure, it seems a lot easier to just try it out. L8682 bundling will happen and end SCS due to overuse.

 

[Ducttape]

I'd do the SCS if certain functional goals were ahead of the trial.

I did an implant in a 96 y/o male with stenosis and non-claudicatory constant leg pain. Goal of care was to allow him to return to one round of golf per week.

The oxy thing is only there as patient was dictating care. If patient said I want oxy and it works for me and the doc said ok, then that would be nonsense given the little history we have. But if the doc stands to make $5k on a procedure, it seems a lot easier to just try it out. L8682 bundling will happen and end SCS due to overuse.

so my doing an SCS trial on an elderly surgery-denied gentleman with primary neurogenic claudication symptoms (postlami syndrome too) when he walked more than 150 feet would have been appropriate in your book?


he went to perm, and now goes on 1 mile walks with his wife 5 times a week. havent had the guts to ask about his sex life, but they were holding hands last appointment..

 

[lobelsteve]

so my doing an SCS trial on an elderly surgery-denied gentleman with primary neurogenic claudication symptoms (postlami syndrome too) when he walked more than 150 feet would have been appropriate in your book?


he went to perm, and now goes on 1 mile walks with his wife 5 times a week. havent had the guts to ask about his sex life, but they were holding hands last appointment..

Why was surgery denied? If already post-lami then how tight was he?
If he had obtainable functional goals then it could be reasonable, but I'd have a tough time recommending this knowing the systems cost.

 

[Ducttape]

Why was surgery denied? If already post-lami then how tight was he?
If he had obtainable functional goals then it could be reasonable, but I'd have a tough time recommending this knowing the systems cost.

Cardiac disease, Multilevel dx that apparently would have lead to l1-s1 fusion.

Anyways, he is happy and roaming the mall every morning so he's probably improving the financial stability of the economy rather than saving it for her heirs...