Advanced Pumps and Stims Workshop ISIS

[Aether2000]

It is time again for the ISIS Pumps and Stims Advanced workshop, to be held Park City Utah Feb 26-28th 2010. More information will be available soon but this is not simply a review course. It is an advanced bioskills workshop and lectures on the foremost modalities and modifications used in the field of pain medicine. Check the ISIS website www.spinalinjection.com for more info in a couple of days. (by the way, there will be skiing and the housing will be on the slopes...no ski buses required).
Some of the lectures include:
1. Advanced lead anchor concepts and techniques – Trans interspinous lig, trans spinous
process, strain relief loops and where to place them, knotting the lead, separate anchors (2) on
a lead, what suture to use (non-absorbable ethibond etc), tension on the lead and when
extension will be necessary eg obese or long distance to SCS generator
2. SCS Generator placement, pocket development – Depths of gen placement, removal of
SC fat in the pocket pro and con, when to suture to deep fasia, pro and cons of SCS generator
placements based on patient anatomy/preference of patient, which side they have to hold the
programmer and whether that arm has arthritis prohibiting reaching the generator
3. SCS Trials: Types, length, what is acceptable psych – Also what is unacceptable, pro and
con of perm lead implant at trial using extension, table trial only
4. SCS Complications of lead implants – Migration Sub Cutaneous and into the cord during
trial or implant, difficulty occasionally in approximating the trial lead location during perm lead
implant, case disaster analysis
5. SCS Complications of generator implantation and programming – Avoiding infections
(irrigation, antibiotic coverage, tight control of diabetes before/during/after procedure
for one week, use of non-braided suture, avoidance of excess electrocautery use), seroma
treatment, pro and con of I and D with irrigation vs explant of infected subcutaneous
area vs SCS pocket, literature on washing of pocket and reimplant of infected stim,
programming errors
6. Generator types, characteristics and comparison of battery, stim parameters
7. Discussion of paddle lead vs round lead implants – Cost differential, revision considerations,
stimulation discomfort of lig flavum stimulation
8. PNS and Angina Utilization – Optimal lead placement and lit supporting techniques
9. IT Trial Types: What constitutes an adequate trial in the 4 trial types – Single shot vs
Continuous epidural vs IT; home IT trials; respiratory depression unlikelihood given high oral
doses of opiates; to wean or not to wean prior to IT pump trial, anticoagulant considerations
10. IT Pump complications – Pump pocket, programming, med complications, pump
malfunction eg. MRI rotor freeze, CT complications, gear 5 complications, bolus valve
malfunctions
11. IT Catheter complications – Kinking, disconnect, pithing during refill, twisting due to
pump rotation, shearing at the anchor due to weight gain, granuloma (will be covered more in
the didactic)
12. IT Pump types – 4 pump types, survey of the 2 products on the market and those
coming soon
13. Advanced medication concepts – Microdose morphine, mixing and matching meds

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[foxtrot]

I have never been to an ISIS conference but this sounds pretty good. How do you find out who the instructors are?

 

[Aether2000]

All have years of experience and most implant multiple systems. Their names will be online on the brochure coming out soon.

 

[Aether2000]

Here are the course educational objectives:
Develop skill sets that will provide tools for anchoring of leads and catheters
under difficult clinical situations

Understand the occurrence and treatment of complications of intrathecal
pumps and spinal cord stimulators, some of which have not been reported in
the literature but have been reported to the FDA

Recognize the expanding role of neuromodulation in the treatment of
different types of pain but with deference to evidence based support of the
use of these modalities

Maximize the potential of neuromodulation devices by becoming an expert
in programming and medication management of these devices
Become an advocate for your patients by avoiding errors that lead to
complications

Develop the skills necessary to compare the different systems available
and make the system, technique, and modality selection based on specific
patient needs

 

[nvrsumr]

Algosdoc, I have an SCS implant question that maybe you could answer? What are your thoughts on bipolar vs monopolar electrocautery? I use bipolar but find monopolar works best for what Im generally trying to accomplish in the OR. Is there any information on adverse events in SCS implantation when using monopolar? Ie. frying the cord.... Thanks.

 

[Aether2000]

I have seen nothing in the literature that addresses this issue. Theoretically with a shielded set of lead wires encased in plastic insulation, there should be little chance of cooking the cord. On the other hand, those of us that have seen monopolar activation of said shielded lead wires when using an electrocautery close to the wires are much more circumspect. We are suspicious that the up to 9,000 V electrocautery is either arcing or setting up induction currents in the lead wires with transmission of these currents to the cord causing a rather pronounced subsequent motor response. Bipolar would be much safer near the lead, given the observed occasional pronounced motor response. However bipolar is more expensive, cumbersome to use for larger bleeders, and is not useful for fulguration or cutting.

 

[Disciple]

Algos,

Attendance at the ISIS lumbar and cervical courses are a pre-requisite to attending this one, correct?

 

[nvrsumr]

Algos, Thanks.

 

[foxtrot]

Algos,

Attendance at the ISIS lumbar and cervical courses are a pre-requisite to attending this one, correct?

Oh man, is this true? That is kind of weak, particularly if you have already done a fellowship. Guess I am not going.

 

[Aether2000]

Hold on...I am checking on the entrance requirements for this course. It is designed for those already implanting stimulators....

 

[GMEN]

you know if there is any type of finical assistance for poor fellows who would like to attend?

 

[Aether2000]

2 years ago ISIS held the Stims meeting at Whistler in BC and had the lowest meeting cost ever seen in a bioskills workshop. It is our desire, based on sponsorship by corporate sponsors, to have a low tuition cost for this conference also. Some of the corporate sponsors might also be willing to support their physicians doing implants by funding part of their trip/tuition/etc. as long as they are in line with avamed guidelines.
We will have plenty of "free time from about 11am til 5 on Sat and Sun, and the Friday conference lectures begin at 3pm, so you will have "free time" before that. It just so happens there will probably be a lot of snow during that time period and there are a lot of mountains around, so you can use your imagination on what might be done with your 'free time". 🙂

 

[Aether2000]

Criteria for ISIS Advanced Pumps/Stims Bioskills Workshop:

1. Having taken an ISIS Lumbar Course and either
2 Currently implanting pumps or stims or
3. In a fellowship learning pumps and stims

Additional requirement: base residency in PMR, anesthesiology, neurosurgery, radiology, ortho surgery. Other background residencies are considered by exception.

 

[foxtrot]

So if I one has already done a pain fellowship and am out doing pain (pumps and stims), one can go? It sounds like a great conference.

 

[Aether2000]

As long as one has completed an ISIS Lumbar course, then those meeting the other criteria above can attend... It IS a great conference! ISIS has had numerous repeated requests to replicate the stims conference from 2 years ago at Whistler and we are proud to offer this cutting edge conference to help improve your SCS and IT Pump skills. Unlike review courses, this is not a basic skills course. Unlike industry sponsored individual company courses, this one permits direct comparison between the products of the different companies head to head. Oh, and did I mention skiing is available for those who enjoy such things? Who says all conferences have to be in boring places.....

 

[Mister Mxyzptlk]

Suggested courses:

What to do when the patient says "I feel it" every time the blood pressure cuff inflates during a stim trial.

How to keep a straight face when someone with a BMI of 40 looks at a pump model and says "Won't that stick out?"

Explaining to ER docs that if someone with a pump falls and hits their head, the subsequent altered mental status is probably not due to pump malfunction and no, you are not coming out at 3 a.m. to "check the pump".

Round table discussion: What is that beeping noise coming from the patient?

 

[lobelsteve]

Suggested courses:


Round table discussion: What is that beeping noise coming from the patient?

Better yet, getting called to a funeral to shut off the beeping noise.

Or trying for 30 minutes to get the stupid Medtronic programmer to read a pump to find out it's a Codman.

 

[Aether2000]

Here is one I inherited today: anesthesiologist with no pain training in residency or subsequently except a weekend course did a dual lead trial for mechanical low back pain with absolutely no improvement in pain at all, and in fact made the pain worse. He trialed the patient only for 2 days then pulled the leads. Subsequently he implanted a permanent system telling the patient "the permanent system gives better coverage". The patient had the same pain on stimulation after the permanent implant and stopped using the unit almost immediately, but because the anesthesiologist implanted the stimulator so low over the distal SI joint, everytime the patient sat down, experienced a severe burning pain due to the SCS generator compression. The pseudodoc then moved the stimulator to the other buttock, at an equally inferior level, and now she has pain on that side too and cannot sit for more than a few minutes. The patient acquired another insurance which the pseudodoc does not accept. She was unceremoniously dumped without referral to another physician, and the pseudodoc thereby eliminated his surgical disaster from his practice, and also the very high dose opioid narcotics he was giving her.
Malpractice? Probably so. Unethical? Definitely. Certainly worth a discussion on examples of what not to do to patients.

 

[foxtrot]

Here is one I inherited today: anesthesiologist with no pain training in residency or subsequently except a weekend course did a dual lead trial for mechanical low back pain with absolutely no improvement in pain at all, and in fact made the pain worse. He trialed the patient only for 2 days then pulled the leads. Subsequently he implanted a permanent system telling the patient "the permanent system gives better coverage". The patient had the same pain on stimulation after the permanent implant and stopped using the unit almost immediately, but because the anesthesiologist implanted the stimulator so low over the distal SI joint, everytime the patient sat down, experienced a severe burning pain due to the SCS generator compression. The pseudodoc then moved the stimulator to the other buttock, at an equally inferior level, and now she has pain on that side too and cannot sit for more than a few minutes. The patient acquired another insurance which the pseudodoc does not accept. She was unceremoniously dumped without referral to another physician, and the pseudodoc thereby eliminated his surgical disaster from his practice, and also the very high dose opioid narcotics he was giving her.
Malpractice? Probably so. Unethical? Definitely. Certainly worth a discussion on examples of what not to do to patients.

This is what is wrong with pain medicine. When I hear these kinds of stories they just make me cringe. This does raise the question, should it be mandatory that those implanting devices in patients be fellowship trained and/or board certified? This doesn't stop all unethical behaviors but it sure might make a huge difference. Sorry, I didn't mean to hijack the thread, I just had a number of patients like this in fellowship and it is sad.

 

[lobelsteve]

This is what is wrong with pain medicine. When I hear these kinds of stories they just make me cringe. This does raise the question, should it be mandatory that those implanting devices in patients be fellowship trained and/or board certified? This doesn't stop all unethical behaviors but it sure might make a huge difference. Sorry, I didn't mean to hijack the thread, I just had a number of patients like this in fellowship and it is sad.

Or they can just eliminate the L codes and the problem solves itself.

 

[Aether2000]

Ah, but that raises the question regarding the validity of fellowships. Since ACGME pain fellowships now have essentially no standards at all as to who can be admitted (other than having a pulse), what is the point of fellowship? An allergist or geneticist, having completed an ACGME residency program, becomes disillusioned with the low reimbursement in their field and decides to get their one year pain fellowship. Whereas they would not be eligible for virtually any other ACGME fellowship, pain fellowships embrace anyone that has completed any residency with open arms. Does this make sense? Can one really argue an allergist (with one year training to become a pain doctor) has equivalent skills to a PMR or anesthesiologist completing a pain fellowship? The ACGME fellowships have become the equivalent of Obama's unlimited amnesty policy for illegal aliens....all comers are welcome, regardless of your qualifications. And with 40% of ABMS board certified (special qualifications in pain medicine) pain physicians having never done a fellowship training or virtually any subspecialty training at all, can one argue there is fungibility of certification?
The current system is broken with respect to fellowships and board certification.
But how can we make pain physicians behave responsibly instead of unethically? Perhaps pull their license to practice medicine?

 

[Ligament]

Criteria for ISIS Advanced Pumps/Stims Bioskills Workshop:

1. Having taken an ISIS Lumbar Course and either
2 Currently implanting pumps or stims or
3. In a fellowship learning pumps and stims

Additional requirement: base residency in PMR, anesthesiology, neurosurgery, radiology, ortho surgery. Other background residencies are considered by exception.

Hi Algos,

I have never taken an ISIS lumbar course, but have:
1. Completed an ACGME fellowship
2. Attended the first ISIS stim workshop in whistler

It sounds as if I am no longer qualified to attend the second ISIS stim workshop? Confused.

 

[Aether2000]

Exceptions may be made on a case by case basis...yours sounds like a good one!