Best SCS technology for axial, non surgical back pain?

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likeaboss

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Which stim is best for someone with axial low back pain, who hasn't had back surgeries?


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Is this goina be the go to before or after RFing those things?
 
likeaboss said:
So first we denervate the multifidi with RFA to help with pain, and then we stimulate / activate the multifidi to help with pain?


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Kind of like how some physicians prescribe Xanax to counteract the effects of their Adderall therapy.
 
likeaboss said:
Which stim is best for someone with axial low back pain, who hasn't had back surgeries?


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That’s like asking for the cure to cancer .

Nevro + RFAs
+ L2 white rami communicans block -jk
 
"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.
 
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.
 
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Green Grass said:
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.
Click to expand...

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.
 
SommeRiver said:
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.
Click to expand...


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?
 
painfree23 said:
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?
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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.
 
SommeRiver said:
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.
Click to expand...

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?
 
It's not wrong to stim those pts if they have "stim-able" pain pathology.
 
painfree23 said:
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?
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I stopped implanting those high risk patients after I had a few infections. RA meds, etc. anecdotal but didn’t need the aggravation
 
Ronin1 said:
I stopped implanting those high risk patients after I had a few infections. RA meds, etc. anecdotal but didn’t need the aggravation
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What about the trials? I wonder bc there’s just some tape and tegederm over the leads
 
SommeRiver said:
If you trial - You are saying this pt is worthy of implant if the trial works.

Don't trial unless you're okay to implant it.
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Sorry, I meant did you have infections for the trials or the perms?
 
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.
 
SommeRiver said:
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.
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You might want to be aware of epidural infections after implants. It happens. And much more important than the pockets.
 
lobelsteve said:
You might want to be aware of epidural infections after implants. It happens. And much more important than the pockets.
Click to expand...

Of course. My wording could be better but the pocket is far more common.
 
SommeRiver said:
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.
Click to expand...

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
 
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.
 
Agast said:
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.
Click to expand...
what?
 
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.
 
Ducttape said:
as a side note.... see if your opinion on antibiotics change when you "give" someone get massive diarrhea.....
Click to expand...

Haha.

I've had some rural pts tell me they were "runnin off" for a day or two.
 
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.
 
SommeRiver said:
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.
Click to expand...

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.
 
SommeRiver said:
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.
Click to expand...


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
 
hawkeye2009 said:
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
Click to expand...

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.
 
SommeRiver said:
Yeah, but multiple failures too.
Click to expand...

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?
 
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.
 
bedrock said:
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?
Click to expand...

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.
 
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