Advisability of SCS in a stable HIV?

[algesia]

Middle age male with a long Hx of HIV mostly with CD4 > 250 and sporadic yearly dips < 200 complicated by HEP-C with stable liver function and coronary stents. The patient was diagnosed w/ CRPS secondary to non surgical crushing foot injury one year prior. Persistent pain and allodynia non responsive to PT. The patient is referred by ortho for consideration of SCS.

I could not find published guidance. Common sense tells me that it would be foolish to proceed. The concern is overlapping infection symptoms, notwithstanding immune suppression and long term epidural bleeding risk. Do you agree?

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[lobelsteve]

Go for it with ID recommendations first.
Leave expert advice to the experts.

 

[Timeoutofmind]

Middle age male with a long Hx of HIV mostly with CD4 > 250 and sporadic yearly dips < 200 complicated by HEP-C with stable liver function and coronary stents. The patient was diagnosed w/ CRPS secondary to non surgical crushing foot injury one year prior. Persistent pain and allodynia non responsive to PT. The patient is referred by ortho for consideration of SCS.

I could not find published guidance. Common sense tells me that it would be foolish to proceed. The concern is overlapping infection symptoms, notwithstanding immune suppression and long term epidural bleeding risk. Do you agree?

What do you mean long term epidural bleeding risk?

I wouldnt be too worried at that.

If the perm perc leads migrate (is he on anticoag)?

Agree with ID consult.

 

[emd123]

You have to ask ID on this. None of us know enough about HIV/AIDS in stim to be confident on this without asking them point blank: Is it okay if I put a spinal cord stimulator in this patient or not? If any doubts or hedging, don't do it. We're Pain doctors, not superheroes.

 

[Ducttape]

Why the concern? Is there an opportunistic organism involved? M
If any concern, be concerned about how well he adheres to HIV treatment.

 

[lobelsteve]

Do HIV patients get joint replacements or Pacemakers?

 

[SommeRiver]

I've done it. The guy showed up to remove his trial leads and he had pulled his leads out at home and then tried to put them back in himself.

Tattoo on his left flank depicting a gigantic homosexual orgy while the devil watched in amazement and all this took place under a large pentagram.

Great job pain psych clearing that guy. No red flags at all. Sent to me specific for a trial only.

Medically speaking, what's the inherent danger? Be sterile and use obsessively clean technique.

 

[lobelsteve]

I've done it. The guy showed up to remove his trial leads and he had pulled his leads out at home and then tried to put them back in himself.

Tattoo on his left flank depicting a gigantic homosexual orgy while the devil watched in amazement and all this took place under a large pentagram.

Great job pain psych clearing that guy. No red flags at all. Sent to me specific for a trial only.

Medically speaking, what's the inherent danger? Be sterile and use obsessively clean technique.

As far as patient selection, they gave the wrong guy the psych screen.

I just implanted a guy who showed up 3 weeks post op. I met him in preop sent by respected pain guy in neighboring town. Bad decisions.

 

[Orin]

Middle age male with a long Hx of HIV mostly with CD4 > 250 and sporadic yearly dips < 200 complicated by HEP-C with stable liver function and coronary stents. The patient was diagnosed w/ CRPS secondary to non surgical crushing foot injury one year prior. Persistent pain and allodynia non responsive to PT. The patient is referred by ortho for consideration of SCS.

I could not find published guidance. Common sense tells me that it would be foolish to proceed. The concern is overlapping infection symptoms, notwithstanding immune suppression and long term epidural bleeding risk. Do you agree?

I would prefer PNS but that's a bit dicier for CRPS so DRG/SCS is more reasonable albeit with higher risk due to the HepC assuming he doesn't qualify/clear with Harvoni. He would need to understand the risks and be more diligent with his ARV treatment. ID would have to bless things and help give guidance on pre-op/peri-op ABX coverage for him based on prior infections.

I would really make sure you've gone down all the medications and injections first though before you do that and give him an epidural abscess with some weird bug that he'd never clear. I'd rather LSB him every 2 weeks while the PTs are desensitizing his foot than stress for that first year about him getting infected.

 

[SommeRiver]

Middle age male with a long Hx of HIV mostly with CD4 > 250 and sporadic yearly dips < 200 complicated by HEP-C with stable liver function and coronary stents. The patient was diagnosed w/ CRPS secondary to non surgical crushing foot injury one year prior. Persistent pain and allodynia non responsive to PT. The patient is referred by ortho for consideration of SCS.

I could not find published guidance. Common sense tells me that it would be foolish to proceed. The concern is overlapping infection symptoms, notwithstanding immune suppression and long term epidural bleeding risk. Do you agree?

I don't think I read this close enough. CD4 dipping under 200 (full blown IMO) and Hep C. I probably wouldn't do it.

 

[VA Hopeful Dr]

I don't think I read this close enough. CD4 dipping under 200 (full blown IMO) and Hep C. I probably wouldn't do it.

Hep C is now easily curable, why hasn't he been treated?

 

[algesia]

Why the concern? Is there an opportunistic organism involved? M
If any concern, be concerned about how well he adheres to HIV treatment.

The concern are Hx of intermittent periods very low CD4 counts a couple of times year. Not only opportunistic infections hut HIV related fevers may cause frequent SCS infection worries. Guess I did not think through the point made of joint replacements and pacemakers however the benefit of SCS for CRPS is limited w/ not improvement in function. There is also the issue bleeding risk of clopidogrel once reinstated for the stents w/ the permanent implant. Is the risk/benefit favorable?

 

[SommeRiver]

The concern are Hx of intermittent periods very low CD4 counts a couple of times year. Not only opportunistic infections hut HIV related fevers may cause frequent SCS infection worries. Guess I did not think through the point made of joint replacements and pacemakers however the benefit of SCS for CRPS is limited w/ not improvement in function. There is also the issue bleeding risk of clopidogrel once reinstated for the stents w/ the permanent implant. Is the risk/benefit favorable?

AIDS =/= Stable HIV

Hep C is curable with Harvoni but until he gets it treated he has Hep C. That plus AIDS is a definite no go for me.

Risk / Benefit for me is no go.

 

[algesia]

Hep C is now easily curable, why hasn't he been treated?

 

[algesia]

Funds, SCS covered by PI MVA. HepC Tx unfunded.

Thanks everyone for your input.

 

[lobelsteve]

Story clears up more. Post pic of his crps foot. At 1 year, should have significant trophic changes.

 

[algesia]

Story clears up more. Post pic of his crps foot. At 1 year, should have significant trophic changes.

I agree, the patient is diagnosed and sent by a non-interventional pain Dr. in ortho practice, a long term referral source. The patient is sent to me for consideration of the implant, CRPS / sural neuritis/ litigation neuritis. Budapest criteria not met. Neuropathic drugs allegedly failed. I do have to provide a clear reason for declining.

 

[callmeanesthesia]

litigation neuritis

 

[lobelsteve]

I agree, the patient is diagnosed and sent by a non-interventional pain Dr. in ortho practice, a long term referral source. The patient is sent to me for consideration of the implant, CRPS / sural neuritis/ litigation neuritis. Budapest criteria not met. Neuropathic drugs allegedly failed. I do have to provide a clear reason for declining.

This is where the phone call helps out. Curbside consult ID, then call your referral source and tell them the patient is too high risk for infection in the first year.

 

[Ducttape]

in that case, if Budapest criteria not met, I would not consider SCS. serial LSBs and lots of desensitization/mirror therapy, maybe, but not SCS. but that's me.