• Funniest Story on the Job Contest Starts Now!

    Contest starts now and ends September 27th. Winner will receive a special user banner and $10 Amazon Gift card!

    JOIN NOW
  • Site Updates Coming Next Week

    Site updates are coming next week on Monday and Friday. Click the button below to learn more!

    LEARN MORE

Best SCS technology for axial, non surgical back pain?

About the Ads

ragnathor

Full Member
10+ Year Member
Jan 10, 2007
851
518
266
  1. Attending Physician
"axial low back pain" is too generic and will respond to different therapies based on its etiology.

Is it facetogenic? SI joint? discogenic? muscular? Nociceptive or neuropathic?

It shouldn't be a surprise one treatment doesn't work well for multiple/vague etiologies.
 
  • Like
Reactions: 1 user

Green Grass

Full Member
10+ Year Member
Feb 8, 2007
1,736
288
266
  1. Attending Physician
Just following the data - Nevro. That patient population is included in the SENZA-RCT and Al-Kaisy has data out there. They are also doing a US study dedicated to non-surgical low back pain.

Other companies will follow suit and I'm sure their results will be similar. Something along the lines of "80% of patients got 50% pain relief" since that seems to be the magic number to promise nowadays.
 
About the Ads

SommeRiver

Membership Revoked
Removed
Account on Hold
2+ Year Member
Apr 20, 2018
2,168
1,648
126
  1. Attending Physician
Just following the data - Nevro. That patient population is included in the SENZA-RCT and Al-Kaisy has data out there. They are also doing a US study dedicated to non-surgical low back pain.

Other companies will follow suit and I'm sure their results will be similar. Something along the lines of "80% of patients got 50% pain relief" since that seems to be the magic number to promise nowadays.

Right...Here's reality - Throw in a Nevro device on 100 pts with generic axial LBP and you'll see tons of failures, and most of those devices will be explanted within 24 months after a "probably good" trial.

Your real life experience will not match those studies...If we're talking about generic back pain.

If you're treating LBP with chronic radic, that's completely different in my experience.

This is the stuff ethical pain doctors should go nuts over bc stim is probably maneuvering itself towards overutilization, and when that happens we all start getting denials for legit pts.

I am seeing a pt soon for a 2nd opinion who got a trial for interscapular myofascial pain. It failed of course.
 
  • Like
Reactions: 1 users

painfree23

Full Member
2+ Year Member
Jan 26, 2017
1,264
334
116
Right...Here's reality - Throw in a Nevro device on 100 pts with generic axial LBP and you'll see tons of failures, and most of those devices will be explanted within 24 months after a "probably good" trial.

Your real life experience will not match those studies...If we're talking about generic back pain.

If you're treating LBP with chronic radic, that's completely different in my experience.

This is the stuff ethical pain doctors should go nuts over bc stim is probably maneuvering itself towards overutilization, and when that happens we all start getting denials for legit pts.

I am seeing a pt soon for a 2nd opinion who got a trial for interscapular myofascial pain. It failed of course.


You think overutilization will kick in? We r getting higher reimbursements this year compared to last?

Also, how does one get a stim approved for interscapular pain?
 

SommeRiver

Membership Revoked
Removed
Account on Hold
2+ Year Member
Apr 20, 2018
2,168
1,648
126
  1. Attending Physician
You think overutilization will kick in? We r getting higher reimbursements this year compared to last?

Also, how does one get a stim approved for interscapular pain?

You lie...You just walk the patient into telling you he or she has radicular pain and then place your leads a few levels higher.

I get referrals from outside pain doctors for implants or revisions and I have outright refused many of them.

I had a pt show up as a referral for implant with a Hx of liver failure on immunosuppressive Tx, 1 PPD smoker, and IDDM who FAILED THE TRIAL! Didn't work at all...Axial LBP. Told me the trial did nothing for her, yet here she sits in my clinic referred for the implant.

I've had several other cases too...I've had BMI > 50 with nml lumbar MRI sent for revision bc a previous implant wasn't working...It WAS working, as in the device was functioning properly...She had no relief and they wanted me to go in there and dick around with it...No thanks.

This is not too uncommon.
 
  • Wow
Reactions: 1 user

painfree23

Full Member
2+ Year Member
Jan 26, 2017
1,264
334
116
You lie...You just walk the patient into telling you he or she has radicular pain and then place your leads a few levels higher.

I get referrals from outside pain doctors for implants or revisions and I have outright refused many of them.

I had a pt show up as a referral for implant with a Hx of liver failure on immunosuppressive Tx, 1 PPD smoker, and IDDM who FAILED THE TRIAL! Didn't work at all...Axial LBP. Told me the trial did nothing for her, yet here she sits in my clinic referred for the implant.

I've had several other cases too...I've had BMI > 50 with nml lumbar MRI sent for revision bc a previous implant wasn't working...It WAS working, as in the device was functioning properly...She had no relief and they wanted me to go in there and dick around with it...No thanks.

This is not too uncommon.

Wow guess I’m naive and don’t see that stuff.

I don’t even offer he trial for “hx of liver failure OR immunosuppressive Tx“. I’m thinking about opening the doors for the those immunosuppressants (RA meds, SLE meds, etc) but worry dearly about infection. Thought?
 

Ronin1

SDN Lifetime Donor
2+ Year Member
Dec 14, 2017
373
268
136
Sunny Florida
Wow guess I’m naive and don’t see that stuff.

I don’t even offer he trial for “hx of liver failure OR immunosuppressive Tx“. I’m thinking about opening the doors for the those immunosuppressants (RA meds, SLE meds, etc) but worry dearly about infection. Thought?
I stopped implanting those high risk patients after I had a few infections. RA meds, etc. anecdotal but didn’t need the aggravation
 
About the Ads

SommeRiver

Membership Revoked
Removed
Account on Hold
2+ Year Member
Apr 20, 2018
2,168
1,648
126
  1. Attending Physician
In the world of SCS, trials or perms, the pocket is your major infxn risk. The leads hanging out during a trial are really not that big of a deal. Many ppl don't even give ABx during trials (no evidence for ABx use in trial unless I'm unaware of it), but I'm still doing Keflex or clinda...Trials simply don't get infected, or if they do it is exceedingly rare. I've never seen one.
 

lobelsteve

Full Member
Staff member
Volunteer Staff
15+ Year Member
May 30, 2005
16,896
6,979
426
Canton GA
www.stevenlobel.com
  1. Attending Physician
In the world of SCS, trials or perms, the pocket is your major infxn risk. The leads hanging out during a trial are really not that big of a deal. Many ppl don't even give ABx during trials (no evidence for ABx use in trial unless I'm unaware of it), but I'm still doing Keflex or clinda...Trials simply don't get infected, or if they do it is exceedingly rare. I've never seen one.
You might want to be aware of epidural infections after implants. It happens. And much more important than the pockets.
 

painfree23

Full Member
2+ Year Member
Jan 26, 2017
1,264
334
116
In the world of SCS, trials or perms, the pocket is your major infxn risk. The leads hanging out during a trial are really not that big of a deal. Many ppl don't even give ABx during trials (no evidence for ABx use in trial unless I'm unaware of it), but I'm still doing Keflex or clinda...Trials simply don't get infected, or if they do it is exceedingly rare. I've never seen one.

U just do antibiotics bc of the risk on trials? Ever think about not prescribing it, esp if u have never seen one?

I had one the other day I did, diabetic, it seems the tegederm creeped up and it wasn’t covering the leads at all when she came back for lead pull. Literally epidural leads hanging out ...I just cant imagine that’s less of a risk than a pocket
 
About the Ads

Agast

Full Member
10+ Year Member
Sep 14, 2009
1,762
1,773
276
the river lethe
  1. Attending Physician
I thought my patient was confused when she said she had her massive infection from a trial, but then I got her outside records. She’s got a big scarred divot in her lumbar area I’m assuming from the tuohy entry points.
 

SommeRiver

Membership Revoked
Removed
Account on Hold
2+ Year Member
Apr 20, 2018
2,168
1,648
126
  1. Attending Physician
I use ABx during trials and I can't talk myself out of it. I've had some really experienced neuromodulators tell me they don't, but I still do.

It seems very counterintuitive for me to say "no pocket no infxn," and obviously that is hyperbole, but the pocket is the most common site of infxn...So if no pocket why use PO ABx during a trial if I don't use PO ABx after an implant?

I've read studies that show increased infxn risk after implants on pts with PO ABx...But the biggest reason is dogma...I was trained that way.

I also use vancomycin powder and I've read that increases cell death despite the spine surgery literature that says to use it.

I use saline to irrigate, and I've had spine surgeons with 20 yrs experience say don't ever do that bc it pushes bugs into your tunnel and potentially into the epidural space along your leads...WTF...

Then again, hydroxychloroquine works for COVID-19 but doesn't work for COVID-19. Masks work but don't. ASx ppl can spread but they can't spread it...Who knows what to believe anymore.

Edit - Fun story. Had a pt with HIV sent to me for a trial. During his trial he pulled his leads out and tried to put them back in himself. Dude had a tattoo of a homosexual orgy on his left buttock and flank that was being supervised by Satan. The alpha male in the sex scene was imbued with a prodigious erection...Real big to the point it would be a curse unless you lived in a cartoon world. Compromised immune system and actually removed the leads and then stuffed them back inside himself. No infection.
 
  • Wow
Reactions: 1 users

Ferrismonk

Full Member
10+ Year Member
Dec 12, 2006
1,692
1,598
276
  1. Attending Physician
As long as Stim pays well, people will lie/cheat/steal to do the procedure. Cut reimbursement and you'll be surprised how many people suddenly no longer need stim. Medicaid in my state is a prime example.

Payment went up because those who own ASCs sit on the Medicare LCD committees. There is no ethics there, it's all about lining up factions of various specialties to get the biggest cut of the pie possible. You get ortho, neurosurgery, anesthesia, and pain to all agree stim needs more money and get GI, cardiology, ENT, gyn (who all own partial shares of ASCs) to all agree ASCs need more money, then you'll see why there are increases in those services.

Fwiw, this is also why primary care always get hosed. It's hard to build a voting block based on E/M visits.
 
D

deleted993114

Right...Here's reality - Throw in a Nevro device on 100 pts with generic axial LBP and you'll see tons of failures, and most of those devices will be explanted within 24 months after a "probably good" trial.

Your real life experience will not match those studies...If we're talking about generic back pain.

If you're treating LBP with chronic radic, that's completely different in my experience.

This is the stuff ethical pain doctors should go nuts over bc stim is probably maneuvering itself towards overutilization, and when that happens we all start getting denials for legit pts.

I am seeing a pt soon for a 2nd opinion who got a trial for interscapular myofascial pain. It failed of course.

Yes- Over utilization is becoming a problem with stim, just like rf in the past.

You can usually catch back on the table and shorter term during a trial; longer term coverage of back pain is not realistic. It certainly occurs, but not in the majority of patients by any means.

Low expectations is the key to happiness in life and success in neuromodulation.
 
  • Like
Reactions: 1 user
D

deleted993114

You lie...You just walk the patient into telling you he or she has radicular pain and then place your leads a few levels higher.

I get referrals from outside pain doctors for implants or revisions and I have outright refused many of them.

I had a pt show up as a referral for implant with a Hx of liver failure on immunosuppressive Tx, 1 PPD smoker, and IDDM who FAILED THE TRIAL! Didn't work at all...Axial LBP. Told me the trial did nothing for her, yet here she sits in my clinic referred for the implant.

I've had several other cases too...I've had BMI > 50 with nml lumbar MRI sent for revision bc a previous implant wasn't working...It WAS working, as in the device was functioning properly...She had no relief and they wanted me to go in there and dick around with it...No thanks.

This is not too uncommon.


Just say "no" to those high risk patients, as it is not worth the risk/aggravation. One of my partners implanted someone who was immunosuppressed and ended up with a fungal infection in the stim.

I used to remove/deal with/treat other people's mistakes and no longer do that, as it is a tremendous amount of work. Such cases are best served in a university setting.

Dont stim-

BMI > 40
immunosuppressed
poorly controlled diabetics
history of previous wound/surgical infections
history of MRSA
poor personal hygeine
 
  • Like
Reactions: 1 user

bedrock

Member
15+ Year Member
Oct 23, 2005
4,877
1,898
326
  1. Attending Physician
Just say "no" to those high risk patients, as it is not worth the risk/aggravation. One of my partners implanted someone who was immunosuppressed and ended up with a fungal infection in the stim.

I used to remove/deal with/treat other people's mistakes and no longer do that, as it is a tremendous amount of work. Such cases are best served in a university setting.

Dont stim-

BMI > 40
immunosuppressed
poorly controlled diabetics
history of previous wound/surgical infections
history of MRSA
poor personal hygeine

I agree with your list.
Question on the MRSA, are you referring to a patient who test positive for MRSA after some kind of infection or just someone that is MRSA postive after testing the nares, etc? Because a huge percentage of the population is MRSA colonized.
 

bedrock

Member
15+ Year Member
Oct 23, 2005
4,877
1,898
326
  1. Attending Physician
Yeah, but multiple failures too.

Thanks,

What has your success rate been for axial pain only with Abbott vs Nevro? I hear lots of people saying that the real world data does not support Nevro, but I'm curious if Abbott has been better, same, or worse than Nevro in real world applications for axial lumbar pain?
 

Orin

Full Member
10+ Year Member
Jul 27, 2009
1,241
586
266
You could always lean on the percutaneous implants without an IPG if you're worried about high risk patients. The perm implant for something like Stimwave is basically the same as a trial, albeit one more entry/tunnel site. I'm looking forward to seeing if Nalu is similar.
 

SommeRiver

Membership Revoked
Removed
Account on Hold
2+ Year Member
Apr 20, 2018
2,168
1,648
126
  1. Attending Physician
Thanks,

What has your success rate been for axial pain only with Abbott vs Nevro? I hear lots of people saying that the real world data does not support Nevro, but I'm curious if Abbott has been better, same, or worse than Nevro in real world applications for axial lumbar pain?

I don’t know TBH. I was only Abbott for awhile, now I'm back on Nevro. I'm incredibly underwhelmed with Abbott for axial LBP. I've won some and lost some, but the loss column is big enough that I'm really not doing stim for strictly axial pain any longer.

I have a gentleman I see who is BMI 43-45 with axial LBP and has multilevel and severe stenosis with facet dz. Nothing has worked. Sent to me for stim and instead I ablated him unsuccessfully. Again, nothing works and he is utterly miserable. Retired cop. Refuses Norco BID.

I may pull the trigger and stim him but at this point if there isn't any leg pain I'm not doing stim. Nothing worse than implanting someone and 3 months later they tell you it doesn't work.
 
About the Ads
This thread is more than 1 year old.

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.