1.25m SCS Implant Settlement

[drmamba]

Patient receives $1.25M in spinal cord stimulator case

A 61-year-old man who suffered complications after having a spinal cord stimulator implanted will get $1.25 million in a settlement, New Jersey Law Journal repo

www.beckersspine.com

Would this case change how early you or your practice checks in on a patient after an implant or advanced intervention?

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[bedrock]

Patient receives $1.25M in spinal cord stimulator case

A 61-year-old man who suffered complications after having a spinal cord stimulator implanted will get $1.25 million in a settlement, New Jersey Law Journal repo

www.beckersspine.com

Would this case change how early you or your practice checks in on a patient after an implant or advanced intervention?

It would make me get an MRI before doing a spinal cord stimulator. Really no excuse not to and it sounds like the doc skipped that clear step.

 

[Gnarvin]

I have been on the fence about getting thoracic MRIs before SCS trials for a while. Out in practice, at least where I am, it seems that the majority of pain physicians do not get a thoracic MRI first. I think it makes sense to get a T spine MRI prior to trial and this case certainly tips me in favor of starting to get them.

For those of you that get a T spine MRI prior to SCS trials, what ICD10 are you using to submit to insurance to justify the T spine MRI?

 

[buddababa]

I have been on the fence about getting thoracic MRIs before SCS trials for a while. Out in practice, at least where I am, it seems that the majority of pain physicians do not get a thoracic MRI first. I think it makes sense to get a T spine MRI prior to trial and this case certainly tips me in favor of starting to get them.

For those of you that get a T spine MRI prior to SCS trials, what ICD10 are you using to submit to insurance to justify the T spine MRI?

surgical planning diagnosis

 

[bedrock]

I have been on the fence about getting thoracic MRIs before SCS trials for a while. Out in practice, at least where I am, it seems that the majority of pain physicians do not get a thoracic MRI first. I think it makes sense to get a T spine MRI prior to trial and this case certainly tips me in favor of starting to get them.

For those of you that get a T spine MRI prior to SCS trials, what ICD10 are you using to submit to insurance to justify the T spine MRI?

I used thoracic stenosis. I say why thoracic spine mri critical for safety in my note. Never been denied.

 

[PinchandBurn]

So this is a sad case.

I have defended a physician tht this exact thing happened to.

The NACC guidelines changed in 2016.

I can tell you in fellowships across the country no one got MRIs of T Spine up until 2014ish.

That stated. Most people would nowadays get it. This case happened in 2017. So it's tough to blame the doc. Literally the NACC guidelines came a year before and at that time unless a patient had thoracic radic symptoms no reason to get the mri. That's how we defended (and won) for a similar case.

Hindsight is always 20/20.

 

[cameroncarter]

I routine get a thoracic MRI and a coag panel. I just found out today that my partner does neither.

 

[GoBeers]

5 days after implant? I wonder how the trial had gone first?

 

[BobBarker]

I typically do not get a thoracic mri.

 

[buddababa]

I typically do not get a thoracic mri.

but will you now?

 

[bedrock]

I typically do not get a thoracic mri.

Why not. Costs you nothing to order the mri. Could cost you a lot, not to

 

[BobBarker]

I don’t think it is standard of care in my community. Just another hoop for patients to jump through.

 

[bedrock]

I don’t think it is standard of care in my community. Just another hoop for patients to jump through.

Not asking that much of them. Anyone getting an SCS trial will hit their deductible that year.

 

[gdub25]

This case could've been an epidural hematoma, it just says they had a CT scan that showed compression and had laminectomies. If that were the case, the thoracic MRI before surgery would not have helped.

No one in our market gets a thoracic MRI that I have seen and we don't in fellowship. I would argue against it, unnecessary waste of money and instead do the trial with the patient awake. No way you're advancing a stim wire gently up someone's spine and hit resistance or stenosis and push hard enough to paralyze them in an awake patient. If you're putting them to sleep for these cases, then yeah, get the MRI.

The major argument I would have against getting the thoracic MRI is that we have no clear guidance on how much narrowing is too much. It's just a judgment call and we would all have different opinions on different scans probably. If you can gently slide a wire up in an awake patient with no resistance and no discomfort then it's a pretty good argument that we are safe.

 

[bedrock]

This case could've been an epidural hematoma, it just says they had a CT scan that showed compression and had laminectomies. If that were the case, the thoracic MRI before surgery would not have helped.

No one in our market gets a thoracic MRI that I have seen and we don't in fellowship. I would argue against it, unnecessary waste of money and instead do the trial with the patient awake. No way you're advancing a stim wire gently up someone's spine and hit resistance or stenosis and push hard enough to paralyze them in an awake patient. If you're putting them to sleep for these cases, then yeah, get the MRI.

The major argument I would have against getting the thoracic MRI is that we have no clear guidance on how much narrowing is too much. It's just a judgment call and we would all have different opinions on different scans probably. If you can gently slide a wire up in an awake patient with no resistance and no discomfort then it's a pretty good argument that we are safe.

I’ve done over 500 scs. Always got a t spine mri. 2 revealed things that could have been major issues.

1- large AVM, could have bled=epidural hematoma, 2- moderate severe unexpected stenosis.

Again , no good reason not to get the mri. MRI No risk to 99.5% of patients. No cost to patient already getting an SCS that year.
if you found things very rarely, that could avoid SCI, it’s worth it.

Literally billions of dollars is wasted every year in america because one kid can’t accept that mom/dads useful life is over….and so they spend many unnecessary extra weeks or months in the ICU

I’m not worried about the expense of a few T spine MRIs that could identity a potential catastrophe.

 

[Ducttape]

the question comes as to whether to get a thoracic MRI prior to a trial.

they can be denied. one particular insurer denies thoracic MRI scan prior to trial even with diagnosis of "presurgical screening", and the reason for denial was that the MRI was not indicated for the trial.

how do i know? N of 5 (out of 5), i read posts previously saying this phrase always works, and it didnt.



oh and in terms of cost - there is a cost to the patient. its called a deductible. usually about $200.

 

[gdub25]

I’ve done over 500 scs. Always got a t spine mri. 2 revealed things that could have been major issues.

1- large AVM, could have bled=epidural hematoma, 2- moderate severe unexpected stenosis.

Again , no good reason not to get the mri. MRI No risk to 99.5% of patients. No cost to patient already getting an SCS that year.
if you found things very rarely, that could avoid SCI, it’s worth it.

Literally billions of dollars is wasted every year in america because one kid can’t accept that mom/dads useful life is over….and so they spend many unnecessary extra weeks or months in the ICU

I’m not worried about the expense of a few T spine MRIs that could identity a potential catastrophe.

In the group that I work in over 2000 SCS cases have been done over the years and not a single patient ever had a thoracic MRI and we've never had a spinal cord injury. I'm not saying that to argue my point but more so to say that all of our experiences are varied. Maybe we've never had a patient with any stenosis or AVM and just got lucky. Also, regarding the AVM, how can we know if that could have or would have caused a hematoma or not, there's no risk stratification that we can lean on so it's just an judgement call. There are a lot of practices that don't get MRIs and maybe there have been a lot of leads placed around things like that that never caused any issue and we just don't know.

It would be good if we had some studies and guidelines to follow and I do agree that getting an MRI wouldn't be considered wrong and I don't think anyone would really fault you for doing it. I equally don't think that we should say everyone should get one no matter what, there's pros and cons both ways.

I think we could all agree that the absolute safest thing would be thoracic MRI for everyone and do the trials with no sedation, yeah?

 

[gaspasser127]

As mentioned in a previous post - how much stenosis is too much stenosis on a thoracic MRI?

I don’t routinely get thoracic MRIs. On the lumbar MRI often you can see T12-L1 and if there is no stenosis there or at L1-2, I believe the likelihood of finding significant thoracic stenosis with no symptoms is highly unlikely.

I think it makes sense to get a thoracic MRI prior to paddle though

 

[swamprat]

I do not get thoracic MRIs. I do the trials awake in office. No way there is clinically significant stenosis if the lead floats up like usual. There is always a risk of epidural hematoma and/or nerve/spinal cord injury when you are placing metal in the spine. I suspect that the MRI of this patient had they gotten it prior probably would have been fine - the patient just had badluck/bad outcome. I don't get how this was even brought to litigation it is a known rare complication and it is discussed prior to the procedure. This should get appealed and overturned IMO.

 

[Centurion38]

He's a neurosurgeon. This had to be a paddle. I've seen several epidural hematomas with paddles. Paddle has to be treated with respect, finessed in there. Takes a rare neurosurgeon with experience to be facile with this.

Tough case, but probably would not have happened with perc leads.

 

[MitchLevi]

He's a neurosurgeon. This had to be a paddle. I've seen several epidural hematomas with paddles. Paddle has to be treated with respect, finessed in there. Takes a rare neurosurgeon with experience to be facile with this.

Tough case, but probably would not have happened with perc leads.

Agree.

Percs and paddles are in no way similar.

 

[Agast]

He's a neurosurgeon. This had to be a paddle. I've seen several epidural hematomas with paddles. Paddle has to be treated with respect, finessed in there. Takes a rare neurosurgeon with experience to be facile with this.

Tough case, but probably would not have happened with perc leads.

Oh that makes a HUGE difference

Very odd for a spine surgeon to do a lami on a section of spine with no advanced imaging. On the rare occasion I refer for paddles, I always order the thoracic MRI. I consider it rude not to.

 

[paindoc007]

What neurosurgeon does not get tspine mri prior to paddle placement?? id venture it’s 0%.

 

[Ferrismonk]

We always get T-spine MRI prior to trials, but I think I'm the only one in our group that actually looks at the pictures.

We send all our implants to surgeons, so we tee them up as best as possible. Everyone gets relevant imaging (T and L spine if not available), psych clearance, surgical eval prior to trial, blood thinner clearance if needed, and psych clearance. When trial is done we can usually get the perm implanted within a month even if an outside surgeon is doing it.

 

[Agast]

Everyone gets relevant imaging (T and L spine if not available), psych clearance, surgical eval prior to trial, blood thinner clearance if needed, and psych clearance.

*Very* important to make sure they’re double-sane. I have a few patients who could have used that.

 

[Ferrismonk]

*Very* important to make sure they’re double-sane. I have a few patients who could have used that.

lol, 100%

 

[gaspasser127]

We always get T-spine MRI prior to trials, but I think I'm the only one in our group that actually looks at the pictures.

We send all our implants to surgeons, so we tee them up as best as possible. Everyone gets relevant imaging (T and L spine if not available), psych clearance, surgical eval prior to trial, blood thinner clearance if needed, and psych clearance. When trial is done we can usually get the perm implanted within a month even if an outside surgeon is doing it.

Do the surgeons always do paddle implants?

How are your outcomes?

 

[Gnarvin]

Very interesting timing. I just got a referral sent to me for SCS trial for lumbar post-lami. Surgeon must have already gotten an MRI T spine and MRI T spine shows T9/10 central canal stenosis with central canal narrowed to 8mm AP. I reviewed the images and there isn't CSF signal all the way around the cord at that level and there certainly isn't much or basically any visible epidural fat. Wondering what everyone's thoughts are.

 

[paindoc007]

Very interesting timing. I just got a referral sent to me for SCS trial for lumbar post-lami. Surgeon must have already gotten an MRI T spine and MRI T spine shows T9/10 central canal stenosis with central canal narrowed to 8mm AP. I reviewed the images and there isn't CSF signal all the way around the cord at that level and there certainly isn't much or basically any visible epidural fat. Wondering what everyone's thoughts are.

That’s a no go.

 

[lobelsteve]

Very interesting timing. I just got a referral sent to me for SCS trial for lumbar post-lami. Surgeon must have already gotten an MRI T spine and MRI T spine shows T9/10 central canal stenosis with central canal narrowed to 8mm AP. I reviewed the images and there isn't CSF signal all the way around the cord at that level and there certainly isn't much or basically any visible epidural fat. Wondering what everyone's thoughts are.

Pics needed to decide

 

[drmamba]

Needs to see imaging to determine. If there are any concerns, then retrograde vs send out for paddle.

 

[paindoc007]

Needs to see imaging to determine. If there are any concerns, then retrograde vs send out for paddle.

You do retrograde?

 

[Gnarvin]

Pics needed to decide

What specifically would you be looking for? I respect your knowledge and would like to know what you personally would be looking for. I was taught in fellowship to not put leads at/through a level if there isn’t CSF signal all the way around the cord at that level. Is there anything else that you would be looking for? I just ask because I want to learn.

 

[BobBarker]

@Gnarvin That is a good rule to stick to.

 

[lobelsteve]

What specifically would you be looking for? I respect your knowledge and would like to know what you personally would be looking for. I was taught in fellowship to not put leads at/through a level if there isn’t CSF signal all the way around the cord at that level. Is there anything else that you would be looking for? I just ask because I want to learn.

How much space between dura and flavum. How much csf around cord.

 

[drmamba]

You do retrograde?

Two trials - both referred for trial before implant. One was 2 leads and one was 1 lead. Would not recommend routinely but it is a viable option before someone gets a lami for paddles without knowing whether or not they'll likely respond. Lead targets were typical thoracic levels.