Algorithm for picking stim company

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paindoc007

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Hey Guys,

Just wondering if people out there had a specific algorithm for which stimulator company to use. I've had good experience with Nevro for axial LBP as well as conventional stim revisions. But what about the other companies? Is there one company that you've found more beneficial for certain problems/conditions?
 
drusso said:
Eenie-meenie-miney-mo...
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Haha that simple huh? I know reliability of the reps are half the battle, but is there anything to this st jude burst vs Medtronic LD/HD vs bostons technology for certain conditions?
 
Drug Rep and service / availability.

Did prefer MDT dice they were MRI compatible but now have had great results with SJM.
 
A lot of it is going to depend on the rep. None of them are good enough to overcome awful reps/ service.
 
Nevro has great level 1 data and demonstrated superiority over traditional stim. These results were repeated from what was done in Europe a few years earlier. These results have shown stable at two years follow-up. I know what stim I'd put in my own mother. Second choice is St. Jude. MRI compatible, with restrictions, and burst is parasthesia free as well as can be placed with non-rechargeable battery. For me, I don't care what the reps say or what anyone else says or experiences have been for that matter. I try to stick to an evidence based approach. Using that approach the choices are quite clear I think.
 
if neuropathic limb pain, you can go either St Jude burst/DRG or Nevro, and make the decision based on MRI compatibility AND the rep.......

If axial spine pain is the primary complaint, then Nevro really is the clear choice unless the Nevro rep literally refuses to show up.
 
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gdub25 said:
Nevro has great level 1 data and demonstrated superiority over traditional stim. These results were repeated from what was done in Europe a few years earlier. These results have shown stable at two years follow-up. I know what stim I'd put in my own mother. Second choice is St. Jude. MRI compatible, with restrictions, and burst is parasthesia free as well as can be placed with non-rechargeable battery. For me, I don't care what the reps say or what anyone else says or experiences have been for that matter. I try to stick to an evidence based approach. Using that approach the choices are quite clear I think.
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With the new wave of stims getting ready to come out in the next year, I won't put as much stock in the SENZA trial. I think you can say that with stringent selection criteria, 10K holds at 24 months, and I like the fact that it is the only thing we have compared to another manufacturer, but it is not compared to a system that is being widely used now. With technological advancement the study becomes obsolete as a comparison to available SCS. Therein lies the challenges and why you get so many people who swear by one system, tends to be based more upon which rep is most readily available, they like, and happened to be most exposed to in training/first courses. I think where the better systems shine is in the challenging cases. For a slam dunk like CRPS or radicular pain, the all work great. FBSS with mainly axial, that is where the men and the boys are separated.
 
Most patients I speak to do not like parasthesia. It is why they did not use their conventional system more often.

I switched a lot of older systems to BurstDR and had better usage.

They decreased their medication intake because they used their system for 24hrs.
 
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Tapspatellas said:
Therein lies the challenges and why you get so many people who swear by one system, tends to be based more upon which rep is most readily available, they like, and happened to be most exposed to in training/first courses. I think where the better systems shine is in the challenging cases. For a slam dunk like CRPS or radicular pain, the all work great. FBSS with mainly axial, that is where the men and the boys are separated.
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i think you are making some assumptions... some are true for sure, but for me, i am not using the company with the rep i "like" the best. the local Medtronic rep is more personable and ive known him for a long time. id go out for a drink with the ANS rep over any of them.
the Nevro rep is a nice guy, dont get me wrong, but not who is most available, nicest, etc.

i agree with your last line, tho.

my trial to implant rate which was roughly 60% is now about 90% with HF10. the 30% difference is primarily due to paresthesias. they really bother people.
 
I'm not seeing the Nevro bang in my practice. Their lack of flexibility and transparency with programming is a pain. I'd rather use the other guys and be able to offer some paresthesia and paresthesia free stimulation options.

I do think T9/10 midline placement is real useful for axial low back, but that's not patentable.

If cost/compatibility wasn't an issue, I'd probably put together something with Bosci's leads, Bosci's inject suture thing, Abbot's lead anchors, Medtronic's MRI coverage, Bosci's battery features with Medtronic's battery size, Nevro's charger, Abbot's patient programmer, and Medtronic's Tyrx envelope.
 
Ducttape said:
i think you are making some assumptions... some are true for sure, but for me, i am not using the company with the rep i "like" the best. the local Medtronic rep is more personable and ive known him for a long time. id go out for a drink with the ANS rep over any of them.
the Nevro rep is a nice guy, dont get me wrong, but not who is most available, nicest, etc.
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It isn't true for all, but I believe it is for most. There is a reason they are so aggressive early on, you will use what you are comfortable with, thus most exposed. Same reason you can't eat a free ham sandwich at a university program as a resident, but bet your a$$ the formulary decision makers are getting taken care of by pharma. You will prescribe Xtampza over OxyContin when that is what you were using in training. The companies and reps aren't dumb. Besides, for SCS the studies are not very helpful for deciding upon anything over another, other than Nevro over a precision plus, but we as good clinicians take what evidence we can and run, that is all we have. Maybe if all the manufacturers had the equivalent of an OMG the patient could truly decide what they like best, and we could better study the differences in the systems.
 
It baffles my mind why NEVRO can't get their sh-t together and hire a sales force that is not like members of the Addams Family. They are all bizarre, unreliable or both. I have a few trials coming up ( I have done two and implanted two) based on the superior technology for axial LBP but I am not looking forward to dealing with the sales force.


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NJPAIN said:
It baffles my mind why NEVRO can't get their sh-t together and hire a sales force that is not like members of the Addams Family. They are all bizarre, unreliable or both. I have a few trials coming up ( I have done two and implanted two) based on the superior technology for axial LBP but I am not looking forward to dealing with the sales force.


Sent from my iPhone using SDN mobile app
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That's unfortunate- the two in my territory are extraordinary.


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I guess I am just unfortunate enough to have what I have. Started with one that was strange and unreliable. Now have one that is reliable but completely off the wall bizarre. In 25 years and 4 stim companies only had a bad experience once before and it was briefly with SJM. That rep instantly did not pass my sniff test and I stopped using SJM for a short time until they agreed to send another rep. A year later SJM fired the rep when they found out he was texting pictures of his genitals to female members of physician's office staff. Must be the water here in NJ.
 
NJPAIN said:
I guess I am just unfortunate enough to have what I have. Started with one that was strange and unreliable. Now have one that is reliable but completely off the wall bizarre. In 25 years and 4 stim companies only had a bad experience once before and it was briefly with SJM. That rep instantly did not pass my sniff test and I stopped using SJM for a short time until they agreed to send another rep. A year later SJM fired the rep when they found out he was texting pictures of his genitals to female members of physician's office staff. Must be the water here in NJ.
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Don't drink the water in NJ. San Pelligrino is much nicer.
 
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paindoc007 said:
Hey Guys,

Just wondering if people out there had a specific algorithm for which stimulator company to use. I've had good experience with Nevro for axial LBP as well as conventional stim revisions. But what about the other companies? Is there one company that you've found more beneficial for certain problems/conditions?
Click to expand...
Specific formula is:

(Tolerable rep + quality of patient service + clinical data) ÷ lead cost.

I've tried all with last year. Boston is only loser as the leads are 400% more expensive and their reps lie more than most.
 
Not a fan of my current my medtronic and BS reps. Haven't used abbott in 15 years. Anyone have an opinion on them for trials? I don't do implants anymore.
 
Did a quick search and this is what popped up. In my defense the “best pain fellowship” thread is from 2004!

Quality of my stim reps have really gone down hill in last 10 years
 
nvrsumr said:
Did a quick search and this is what popped up. In my defense the “best pain fellowship” thread is from 2004!

Quality of my stim reps have really gone down hill in last 10 years
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If you want quality reps, then you probably need to meet the local reps to decide.
Or have your kids become your stim reps?
What is it that you're looking for in your reps specifically other than responsiveness and pricing?

All the devices have benefits, but none of them are rep independent. Biotronik and Abbott have some element of remote programming so they're in your office less. Saluda has ECAP feedback and field engineers doing things. Nevro and Saluda both have AI in the battery/programming to reduce need for rep interventions. You know the big dogs already I assume.
 
Are the abbot leads easy to steer? Any big downsides to their devices once implanted?

I just want a pleasant rep. The electrons will work themselves out.

Recent example- rep opened the door unannounced to my procedure suite while I was mid rfa on a different patient just to let me know all done on my trial patient.

That’s not how we roll at my office.
 
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nvrsumr said:
Are the abbot leads easy to steer? Any big downsides to their devices once implanted?

I just want a pleasant rep. The electrons will work themselves out.

Recent example- rep opened the door unannounced to my procedure suite while I was mid rfa on a different patient just to let me know all done on my trial patient.

That’s not how we roll at my office.
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I do a handful of trials per year (5 last year, 1 this week). I use Abbot exclusively, mostly because the rep is great. I started doing them again last year after not having done any since fellowship really in 2017/18. So, not much to compare them to, but the leads are not especially difficult to steer. One potential downside is if you have a patient who is a bit of a mess for both lumbar and cervical, if you think they might end up with a stim for both, from what I've gathered the perm device does not have enough ports to connect to all the leads for both lumbar and cervical, so you'd have to have 2 batteries, which is not the case for Boston. No complaints on my end so far - I have seen a number of them after their perms periodically for other issues and the patients all seem happy with the devices.
 
Agree with others. Reps are as impt as the leads...
 
Abbott leads are easy to steer. They’re not as easy as Medtronic (the best steering lead in my opinion) and their anchors are cumbersome, but the therapy is good, they have good rechargeable and non rechargeable options, and the rechargeable isn’t like Nevro where you’re still charging every day. I use a pretty even mix of Boston, Medtronic and Abbott. I do 1-2 Nevro or Saluda a year.
 
Have had the most success with nevro..rep is meh, nice enough. Other companies have better reps but over a 90% trial to perm ration with nevro
 
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Better throw in a few more devices while you can. Hopefully these become more restrictive to get approved.
 
They shouldn’t be charging every day with Nevro if they are using the AI programming/IQ IPG. It should be about every two weeks. I use MDT the most due to MRI, leads steer well, they have coude tip introducer needles, easy anchoring, and they do have a non rechargeable IPG. Also, since I have many, many more shares patient with neurosurgery than the past and I know they prefer MDT.

I still use Nevro if they are primarily back pain and young enough to charge some. Boston and ABT occasionally, too. I maintain good relationships with all 4 companies as the reps for Boston and ABT a lot of times identify their patients and send them to me.
 
nvrsumr said:
Recent example- rep opened the door unannounced to my procedure suite while I was mid rfa on a different patient just to let me know all done on my trial patient.

That’s not how we roll at my office.
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Sounds like an expectations problem that would be simplified with communication. They see a lot of docs and although you're always their favorite, you probably should tell them how you like your shenanigans done. It's hard and feels repetitive when they change. I keep meaning to make an index card for them to keep with my preferences for scotch, needles, and trial duration, but much like everyone else, they can't read your mind yet.

My struggle is when they get my expectations and then don't meet them. Then I am just sad
 
Im pretty easy. Don’t bring lunches, no dinners, no expert talks, don’t text or call me. Just show up be nice and program. It’s pretty easy these days with T8 placements and high frequency stim.

Walking into a OR, exam, L&d or procedure room with a patient you have no relationship with seems like an obvious no no.

Anyway may be stuck with her. Abbot hasn’t gotten back to us. I’m not that busy only 4 trials next 2 weeks so maybe not worth returning a call.

I had my previous Medtronic reps for 12 years. Didn’t use anyone else. Was spoiled until they retired.
 
Yes, they get interested in anything over 10 trials a year. I have heard people think they are small fish with 20 trials a year. At that level, they are very, very interested and think they have a great chance of getting all of your business. It makes it easy on them and you. When you start doing 40-60 per year, most every doc starts using a few different companies. The reps get competitive and anxious. Many of the reps would rather do 20 trials a year and get all of the business vs 28 a year and have 12 competitive trials/reps in the office.
 
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