Best stimulator for combo post-thoracotomy pain and cervical radiculitis

[Agast]

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I have a patient with all left-sided pain after traumatic injuries, I was thinking of throwing in one lead for intercostal region and one for the cervical. Thoughts on which company would be the best? I tried medtronic once for intercostal neuralgia and it didn't help.

 

[Ducttape]

im missing something.... why don't you let nociceptive trauma pain heal by itself without stimulation?

 

[Agast]

im missing something.... why don't you let nociceptive trauma pain heal by itself without stimulation?

This is trauma from 10+ years ago, she had a thoracotomy with chronic post thoracotomy pain

 

[Ferrismonk]

In general I like Nevro, but Boston has an IPG that can run two paddles if you want to go that route.

 

[myrandom2003]

Agreed, probably Boston for the trial at least. Cover multiple levels in the neck thoracic

 

[Orin]

I have a patient with all left-sided pain after traumatic injuries, I was thinking of throwing in one lead for intercostal region and one for the cervical. Thoughts on which company would be the best? I tried medtronic once for intercostal neuralgia and it didn't help.

How high was the thoracotomy?

I've done great with Medtronic, but go with what you're most comfortable with, or if you need to cover multiple regions, use the Boston system with the Infinion leads or that Nuvectra system that can do 3 leads to one IPG.

You could also consider PNS for the intercostal and SCS for the cervical.
You could also talk to your Nevro rep about placement with HF10 leads as they appear to place in a region that'll cover cervical for high thoracic wall pain too.

 

[drusso]

Abbott BurstDR. Stimulate the medial thalamic fibers...

 

[BobBarker]

Looks like one to try BSX but I would use the montage system as I don’t think the Wavewriter will ever get full body MRI.

Would not rec cervical ABT as the patient will never be able to have a MRI again.

I don’t know where you would place the lower lead for Nevro.

MDT would be fine as well.

Nuvectra would work well but their stock and market cap are in the toilet. I worry about their viability. And currently would have to send the patient to Europe for a MRI

 

[paindoc007]

Nuvectra would work well but their stock and market cap are in the toilet. I worry about their viability. And currently would have to send the patient to Europe for a MRI

I was also thinking that. To lose 70-80% of your market cap in 6 months is impressive. Thank goodness I didn’t invest. Wonder who’s gonna buy them out and when

 

[Timeoutofmind]

Looks like one to try BSX but I would use the montage system as I don’t think the Wavewriter will ever get full body MRI.

Would not rec cervical ABT as the patient will never be able to have a MRI again.

I don’t know where you would place the lower lead for Nevro.

MDT would be fine as well.

Nuvectra would work well but their stock and market cap are in the toilet. I worry about their viability. And currently would have to send the patient to Europe for a MRI

Abbott is not MRI compatible?

My rep told me the SCS leads with proclaim 7 is full body MRI labeling, I believe

 

[Orin]

Abbott's prime cell is full body if you can get the device into MRI mode

Conditions for MRI Support and Safety

Receive MRI support for Abbott neuromodulation systems by looking at device product manuals.

www.neuromodulation.abbott

 

[BobBarker]

ABT is only mri compatible with leads placed t7 or below.

 

[lobelsteve]

Place one lead in the cord and destroy the spinothalamic tract from C5 down. Don’t have to worry about brand or going permanent.

 

[Agast]

How high was the thoracotomy?

It spans T9, T10, T11. I thought about peripheral stim but I don’t want to do 2 batteries.

 

[Agast]

Place one lead in the cord and destroy the spinothalamic tract from C5 down. Don’t have to worry about brand or going permanent.

Swing and a miss

 

[lobelsteve]

Swing and a miss

Cervical radiculitis? Do tell. Pain docs use terms like this when there is nothing on exam or MRI. Was there prior acdf? Severe foraminal stenosis and surgery refused for some reason? Without adequate concordance between history, physical, and imaging, the needle gets put down.

 

[gdub25]

I’d like to weigh in here. There’s a bunch of random suggestions here and rather than make my own I will instead point out the things I would consider in this case. SCS helps with neuropathic pain, this patients pain may be neuropathic given their trauma and if nothing else has helped them sure, I agree I’d try SCS. In this case the real decision making is going to be purely based on what is reasonable from a practical standpoint since there’s no evidence to lean on. Nevro has great evidence with long term efficacy over tonic but this has only been shown in low back and leg, upper limb and axial neck data to be published soon. I’m not sure it applies to this case and not sure there’s any good way to predict where to stimulate a patient like yours, you’d just have to guess and hope it works. You’d be limited to two leads only although being paresthesia independent lead placement wouldn’t matter too much in terms left vs right side so you could put one high and one low I suppose without worrying too much about laterality and migration. Burst I think needs to be critically evaluated by all of us. They say they stimulate the medial thalamus fibers as has been pointed out but that doesn’t equal pain relief? The Burst study showed very poor results and I don’t listen to the company when they say it works better in the real world nor do I read any of their studies that have been published since the Level 1 SUNBURST study. They are all run by paid Abbott consultants. Medtronic and Nuvectra are both Tonic SCS systems, current based, and Medtronic clearly has the advantage in MRI compatibility. Nuvectra has more contacts and can cover more area but Boston is also tonic, current based SCS with 16 contact leads that can cover a large area and Montage is MRI compatible. Boston also has the ability to use 4 leads with one battery so in terms of covering a large area Boston would be preferred. Would need to check on MRI compatibility if the leads are cervical with Boston, Abbott would be out, Nevro and Medtronic are both fine with that, Nuvectra is not MRI compatible at all.

In cases where we don’t have evidence to guide us we must think critically about why one system is preferable. Not just say company X because “in my experience it’s great” or something similar. In my opinion the pertinent issues for consideration in this case are the future need for MRI and covering all the areas of pain. Tonic based systems are all working with the same parameters (pulse width, amplitude, frequency) so to think one is better than the other in terms of pain relief is purely marketing by the company until they prove otherwise. Boston is the closest to convincing me they have something of value with their contouring programming but they still need to do a high level study however there’s enough evidence to at least get our attention at this point. Non-tonic systems include Nevro and Burst and between the two Nevro has better data and MRI compatibility.

 

[gdub25]

Cervical radiculitis? Do tell. Pain docs use terms like this when there is nothing on exam or MRI. Was there prior acdf? Severe foraminal stenosis and surgery refused for some reason? Without adequate concordance between history, physical, and imaging, the needle gets put down.

In general I agree with the idea that there are a lot of docs out there doing procedures in everyone that walks in the door. However I also think we need to offer patients treatments if they have legitimate reasons to hurt, polytrauma in this case, as long as it’s reasonable and we’ll thought out. Nothing else has helped this patient and the OP has the option to say “we can try SCS which might offer some relief” vs “I can’t help you, sorry”. It it’s my mom in the patients shoes I’m choosing a trial. It’s a safe treatment, get to try it for a week to see if it helps, just not that much to lose in my opinion.

 

[Agast]

Cervical radiculitis? Do tell. Pain docs use terms like this when there is nothing on exam or MRI. Was there prior acdf? Severe foraminal stenosis and surgery refused for some reason? Without adequate concordance between history, physical, and imaging, the needle gets put down.

She has neural foraminal stenosis and great relief with cervical ESI that doesn’t last. I’ve referred her for ACDF but it’s pain only so not urgent and she really hates the idea of more surgery. I don’t think it’s unreasonable to offer someone a cervical stim trial. Do you find that unreasonable?

Your contribution to my question was to imply that I don't do my due diligence for my own patients. That's not helpful, that's just rude.

 

[lobelsteve]

She has neural foraminal stenosis and great relief with cervical ESI that doesn’t last. I’ve referred her for ACDF but it’s pain only so not urgent and she really hates the idea of more surgery. I don’t think it’s unreasonable to offer someone a cervical stim trial. Do you find that unreasonable?

Your contribution to my question was to imply that I don't do my due diligence for my own patients. That's not helpful, that's just rude.

Your original post lacked sufficient detail. Does not want further surgery, yet you offer trial and implant to cover pain that may otherwise be fixed.
Trial denied.

 

[Ducttape]

In general I agree with the idea that there are a lot of docs out there doing procedures in everyone that walks in the door. However I also think we need to offer patients treatments if they have legitimate reasons to hurt, polytrauma in this case, as long as it’s reasonable and we’ll thought out. Nothing else has helped this patient and the OP has the option to say “we can try SCS which might offer some relief” vs “I can’t help you, sorry”. It it’s my mom in the patients shoes I’m choosing a trial. It’s a safe treatment, get to try it for a week to see if it helps, just not that much to lose in my opinion.

I don't entirely agree. unproven therapy, for unproven condition. and expensive and has risks for patient. there are a lot of conditions for axial back pain that will not be improved or impacted by stimulation.

in addition, it is often difficult to parse out what degree of pain is in part psychological, and stim trials and other advanced interventional options will do nothing to address these conditions.

what gets me is that it is not okay to say "I cant help you." we can always help, but its not always through a needle or an opioid prescription. in truth, if I used your logic, then I would find it hard to refuse to prescribe opioids to, say, fibromyalgia because "it might offer some relief" theory...

 

[gdub25]

Risks/benefits with surgery vs risks/benefits with SCS. I personally believe both surgery and SCS could be possibly considered in some cases like this since both could treat the pain but Steve I agree and mostly recommend to patients that surgery is potentially a fix and is the option I favor. If there is legitimate reason to feel surgery isn’t the best option for the patient then SCS isn’t unreasonable. The trouble with this approach is that determining when surgery isn’t the best option gets sticky when SCS reimburses so well and docs own their surgery centers and the perception that surgeons will operate on anyone etc. In general I truly believe SCS is a useful treatment and is underutilized while surgery is over utilized and probably not as helpful as we like to think. However I also recognize the trouble that can come from this approach, especially with SCS companies training anyone that shows interest in implanting their devices despite the physicians background and expertise in the field. Holding ourselves accountable within the specialty, developing guidelines based on clinical evidence, and restricting the therapy to those actually trained would be a good thing but hard to implement.

 

[gdub25]

I don't entirely agree. unproven therapy, for unproven condition. and expensive and has risks for patient. there are a lot of conditions for axial back pain that will not be improved or impacted by stimulation.

in addition, it is often difficult to parse out what degree of pain is in part psychological, and stim trials and other advanced interventional options will do nothing to address these conditions.

what gets me is that it is not okay to say "I cant help you." we can always help, but its not always through a needle or an opioid prescription. in truth, if I used your logic, then I would find it hard to refuse to prescribe opioids to, say, fibromyalgia because "it might offer some relief" theory...

I see what your saying and agree, especially with the comparison to opioids and fibromyalgia. No doubt a lot of pain issues won’t be fixed with SCS but assuming the physician considers all those factors and is addressing all of them I believe SCS to be a reasonable option. I don’t say that loosely or in a broad sense however and agree that it’s unproven but again, if it’s my mom I’d choose to trail SCS. Risks are low enough that there isn't much to lose. I’d say the most worrisome thing for me would be a positive trial with implant that ends up not helping long term leading to wasted healthcare dollars which I really disagree with. You know, our specialty is hard and a lot of times it’s hard to know what the best choices are.

 

[nvrsumr]

Nice review by gdub. I learn a lot on this forum.

Wish I had a nickel for every pain patient I consult on with a stim implant that was no longer functioning though...

Stim is and has been overutilized for years. Should pay 10% of current reimbursement for implant at asc. Maybe I would hear less about how many angels can dance on the tip of the wire the week after nans.

I give credit to nevro for getting a superiority indication for HF and any other company with real mri compatibility. Everything else is fluff: current vs voltage, number of electrodes, 4 leads vs 2, preferential spinal tracts(dorsal column anyone)

That being said I probably only do 20 trials a year. I stick with Medtronic on my no narcs post lami patients and have a great trial to implant ratio.

 

[Ducttape]

is there any good evidence for what you are postulating?

how are you classifying neuropathic pain? since there is a radicular pain component for facet arthropathy or for sacroiliac dysfunction, are we recommending SCS for that? esp since facet arthropathy is transmitted through median branches, is that a candidate for SCS?

 

[DOctorJay]

I wouldn’t classify facet or sacroiliac pain as radicular but possibly “referred” into the leg. Wouldn’t use stim for that.