Burst V HF for arm CRPS or nerve injury

[Timeoutofmind]

Have a couple of people like this.

What do you guys think?

Less recharge burden with Burst and MRI compatible are huge pluses.

But I really dont know if it works as well as HF for these indications. I am pretty sold on HF over tonic for FBSS but this is a different issue.

Thanks!

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[Ducttape]

I recently met with the St. Jude rep, touting DRG stim.

course (and the main reason im perturbed by St. Jude atm), they touted DRG stim for everything from CRPS to joint pain, but said "just refer him to the guy you know who does them"...

 

[Timeoutofmind]

I recently met with the St. Jude rep, touting DRG stim.

course (and the main reason im perturbed by St. Jude atm), they touted DRG stim for everything from CRPS to joint pain, but said "just refer him to the guy you know who does them"...

Yeah but this is arm

you can only use DRG in the back not the neck, hence my question

 

[myrandom2003]

where would you place the lead for HF?
For fbss they like it at the t9/10 (or so I hear). When they came by my office they suggested only using for low back pain. (My info is dated by about 1 year when I last saw the rep. I'm not sure if anything really has changed other than their stock prices).

 

[Timeoutofmind]

where would you place the lead for HF?
For fbss they like it at the t9/10 (or so I hear). When they came by my office they suggested only using for low back pain. (My info is dated by about 1 year when I last saw the rep. I'm not sure if anything really has changed other than their stock prices).

You can do mapping/tonic if you wish during the rial in the OR. Otherwise they have algorithms and protocols for pain in different parts of the extremities that they can advise you on…

 

[deleted472101]

No MRI at cervical level for any SCS device correct?

I would use BurstDR only because I have received good cervical pain relief with parasthesia free
I would consider HF10 but haven't tried cervical yet

 

[NJPAIN]

I recently met with the St. Jude rep, touting DRG stim.

course (and the main reason im perturbed by St. Jude atm), they touted DRG stim for everything from CRPS to joint pain, but said "just refer him to the guy you know who does them"...

Yeah. Because YOU are not good enough to be trusted with the golden sword. That would be fine if there were a few select super doctors around the country allowed to do it . That is NOT the case. Really pisses me off.


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[BobBarker]

No MRI at cervical level for any SCS device correct?

I would use BurstDR only because I have received good cervical pain relief with parasthesia free
I would consider HF10 but haven't tried cervical yet

MDT and Stim Wave are MRI compatible with cervical leads

 

[bedrock]

nevro supposedly is already MRI compatible and should apply to cases previously implanted, once the final FDA approval comes through........according to the rep

 

[Timeoutofmind]

MDT and Stim Wave are MRI compatible with cervical leads

I am confused.

Are u saying Burst is MRI Combatable whole body, except that you cannot get an MRI of the cervical spine with cervical leads in place? Whereas with medtronic it is also full body MRI compatible and you can get an MRI of the cervical spine with cervical leads in place ?

 

[deleted472101]

There is a difference in placement. Check with rep

Abbott nothing above t7 and below something maybe 11

 

[lobelsteve]

Why does everyone need an MRI once SCS in place?
How is it going to change treatment for any condition?
If spinal pathology, CT myelogram works just fine, but in the folks I treat with SCS, no further surgical options are in existence.
If they are becoming frankly myelopathic or develop cauda equina, I can get a system out under local in 20 min and get MRI same day.

 

[Timeoutofmind]

Why does everyone need an MRI once SCS in place?
How is it going to change treatment for any condition?
If spinal pathology, CT myelogram works just fine, but in the folks I treat with SCS, no further surgical options are in existence.
If they are becoming frankly myelopathic or develop cauda equina, I can get a system out under local in 20 min and get MRI same day.

The patient in consideration for this thread title has limb pathology and may need serial scans, so I think it would be most appropriate to put an MRI compatible lead in upfront

 

[lobelsteve]

The patient in consideration for this thread title has limb pathology and may need serial scans, so I think it would be most appropriate to put an MRI compatible lead in upfront

If you do not know what you are treating, maybe SCS is not he right modality.
Serial MRI useful for MS patients, spine tumors. Don't see any role for CRPS. If nerve injury, EMG/NCV serially tells function of nerve.

 

[BobBarker]

No MRI anywhere with leads placed in the upper thoracic or cervical spine with St Jude. Not the knee, not the liver, not the breast.

MDT and Stim Wave (and Boston Montage maybe) do not have this restriction.

 

[Timeoutofmind]

If you do not know what you are treating, maybe SCS is not he right modality.
Serial MRI useful for MS patients, spine tumors. Don't see any role for CRPS. If nerve injury, EMG/NCV serially tells function of nerve.

It's a young girl with an aggressive but benign bone tumor near her elbow requiring many IR guided vascular sclerosing interventions and serial MRIs with ulnar nerve damage from all the destruction

 

[lobelsteve]

It's a young girl with an aggressive but benign bone tumor near her elbow requiring many IR guided vascular sclerosing interventions and serial MRIs with ulnar nerve damage from all the destruction

Boulis at Emory. He might place pns array, sparing her neck. Problem solved. Except for underlying pathology.

 

[Timeoutofmind]

Boulis at Emory. He might place pns array, sparing her neck. Problem solved. Except for underlying pathology.

What do u mean by PNS "array"?
How does this differ from a traditional PNS system ?
The reason I ask is that it seems many in pain management have abandoned the traditional PNS systems due to the many technical difficulties in tunneling in dicy areas and placing a large battery etc. in the extremities even when assisted by an orthopedic surgeon in terms of reasonable outcomes.

For that reason, I just offer people Bioness Stim Router vs DRG vs SCS depending on what seems appropriate. I give them the pros and cons and let them decide. Many young people do not want to wear an external IPG/battery and also would prefer to be paresthesia free who are in a similar situation to this patient and therefore prefer a SCS system in my experience

What are everyone's thoughts?

 

[Timeoutofmind]

Boulis at Emory. He might place pns array, sparing her neck. Problem solved. Except for underlying pathology.

And none of this is addressing burst vs HF for upper extremity CRPS!
Which one do you guys think is more reasonable? There is no direct outcomes data we can really discuss so it just seems like such a tough call to me

 

[myrandom2003]

it seems burst vs HF is a moot point. Especially since neither are approved if you need serial MRI capability of the upper extremity. St. Jude labeling states no MRI for any per lead above T7 and paddle above T10.
Nevro labeling allows for head, wrist, knee, ankle but not upper extremities.

 

[Timeoutofmind]

it seems burst vs HF is a moot point. Especially since neither are approved if you need serial MRI capability of the upper extremity. St. Jude labeling states no MRI for any per lead above T7 and paddle above T10.
Nevro labeling allows for head, wrist, knee, ankle but not upper extremities.

So only MDT than?

 

[deleted472101]

Do you need MRI for ulnar nerve followup?

No thoughts on BurstDR vs HF10
Both are not MRI
One need daily charge Nevro
One has two wave forms Abbott
One supposedly has less pocket site irritation Nevro

 

[bedrock]

it seems burst vs HF is a moot point. Especially since neither are approved if you need serial MRI capability of the upper extremity. St. Jude labeling states no MRI for any per lead above T7 and paddle above T10.
Nevro labeling allows for head, wrist, knee, ankle but not upper extremities.

Nevro with leads placed anywhere in spine should be compatible with full body MRI.
(Although final approval is pending with FDA, they passed all FDA tests) this approval will be retroactive to all implants already performed in US, per the rep.

 

[Ducttape]

Yeah. Because YOU are not good enough to be trusted with the golden sword. That would be fine if there were a few select super doctors around the country allowed to do it . That is NOT the case. Really pisses me off.


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also, I am too selective and dont trial everyone and give them leading answers about how much better they must feel.

fyi i stand corrected about arm DRG. however, they are studying its use in the future. Dorsal Root Ganglion Stimulation for Hand and Upper Limb Pain - Full Text View - ClinicalTrials.gov

 

[epidural man]

stimwav can do sub-threshold, right?

Also, they are MRI compatible right?

So do stimwav, and do their version of high-density, sub threshold.

 

[deleted472101]

Bioness for peripheral nerve issue? I am not sure if possible since I don't know much of bioness yet nor about your patient

 

[BobBarker]

stimwav can do sub-threshold, right?

Also, they are MRI compatible right?

So do stimwav, and do their version of high-density, sub threshold.

Yes, all correct. Or you could do a stimwave peripheral sysyem. Supposedly, these are super easy like a catheter for a surgical block. I have a crappy ultrasound so probably not feasible for me.

 

[epidural man]

Bioness for peripheral nerve issue? I am not sure if possible since I don't know much of bioness yet nor about your patient

Bioness system isn't designed well - at least by the looks of what the rep showed me.

You can't put the lead through a needle - you have to use like a 7.5 French catheter - which is huge. They need to figure out how to get the lead through a smaller needle and make the placement easier.

 

[Orin]

It's a young girl with an aggressive but benign bone tumor near her elbow requiring many IR guided vascular sclerosing interventions and serial MRIs with ulnar nerve damage from all the destruction

How is this not a slam dunk intrathecal pump case? Send her over and there'll be a cervical catheter connected to a pump in her in a week.

DRG in the cervical spine has reports of paralysis due to vertebral artery injury.

You could be best served by Stimwave or Bioness deployed to the brachial plexus. It's a relatively straight forward ultrasound guided procedure. Both Stimwave/Bioness' peripheral devices are not ideal in some ways, but Stimwave has the most programming flexibility and is most like a stim lead in deployment. Stimwave's peripheral system isn't MRI approved yet, although their conventional leads are. Bioness' Stimrouter is.

There are reports out of Europe using Medtronic hardware for it in Neuromod, although again this would be off label and not MRI safe.
Peripheral Nerve Stimulation of Brachial Plexus Nerve Roots and Supra-Scapular Nerve for Chronic Refractory Neuropathic Pain of the Upper Limb. - PubMed - NCBI

If you're anesthesia trained, you might do best with SPR's percutaneous stim lead that's supposedly safe for 30 days. You could temporize with that, rotating between infraclavicular and supraclavicular approaches to the brachial plexus.
http://www.sprtherapeutics.com

Some folks would dissuade you from using stimulation to a site where a tumor is growing due to the theoretical risk of increased blood flow and possibly worsening the cancer. I'm not sure that's a real phenomena or academic mumbo jumbo, but just FYI.

 

[deleted472101]

How many catheters do you place cervical?

What medication do you use? Prialt or bupivicaine?

Any scare of granuloma and the cervical or thoracic regions.

Do you use Flowonix for the possible lower chances of granuloma?

Do you have trouble for the catheter being anterior in the cervical region and if so does that change effectiveness of the therapy?

 

[Timeoutofmind]

How is this not a slam dunk intrathecal pump case? Send her over and there'll be a cervical catheter connected to a pump in her in a week.

DRG in the cervical spine has reports of paralysis due to vertebral artery injury.

You could be best served by Stimwave or Bioness deployed to the brachial plexus. It's a relatively straight forward ultrasound guided procedure. Both Stimwave/Bioness' peripheral devices are not ideal in some ways, but Stimwave has the most programming flexibility and is most like a stim lead in deployment. Stimwave's peripheral system isn't MRI approved yet, although their conventional leads are. Bioness' Stimrouter is.

There are reports out of Europe using Medtronic hardware for it in Neuromod, although again this would be off label and not MRI safe.
Peripheral Nerve Stimulation of Brachial Plexus Nerve Roots and Supra-Scapular Nerve for Chronic Refractory Neuropathic Pain of the Upper Limb. - PubMed - NCBI

If you're anesthesia trained, you might do best with SPR's percutaneous stim lead that's supposedly safe for 30 days. You could temporize with that, rotating between infraclavicular and supraclavicular approaches to the brachial plexus.
http://www.sprtherapeutics.com

Some folks would dissuade you from using stimulation to a site where a tumor is growing due to the theoretical risk of increased blood flow and possibly worsening the cancer. I'm not sure that's a real phenomena or academic mumbo jumbo, but just FYI.

I have never found neoropathic pain syndromes to respond well to opioids, and I would assume the same intrathecal. Obviously prialt is an option, but I don't want to worry about the psychiatric overly in this late teenage girl. I would prefer neuromodulation. Again, this tumor is benign, and she has obviously very many years to live with this thing in place.
Thanks everyone for the input so far.

Anyway, I guess my original question still stands, at least in the context of a different patient. I do get a lot of peripheral nerve injury pts where I work.

Again, I have a different young patient with a severe ulnar nerve injury. Nothing surgical to be done at this point. He deferred the bioness PNS system as wants parasthesia free and does not want to wear a band. What do u think burst v HF for this guy?

Otherwise, I suppose I could really insist hard that SCS is much more invasive than these new PNS systems and see how he does with that? But they are the people who have to live with these devices so I'm hesitant to take such a strong approach.

 

[olafa]

Boston scientific is approved for MRI

 

[Orin]

Baclofen/spasticity more commonly gets a cervical catheter as compared with the pain folks. I see primarily failed back/abdominal/thoracic cancer. The last three have been T2-T3, T8, and T10-T11 for belly, back, and pelvis respectively.

The Polyanalgesic Consensus Committee reccs for IT therapy are quite clear about medication choices. There's a lot of theoretical and reported benefit to Prialt early, but I normally start with monotherapy with hydromorphone or morphine. Bupivacaine is not normally my first line agent but I add it in certain scenarios.

The granuloma fear is always there, but it is most probable in the mid-thoracic region. You've got a good bit more safety with low dose and monotherapy regimens. You can always pull the catheter right on out if it is causing any issues, and I have a low threshold for MRI or dye studies.

I don't use Flowonix due to their MRI scares. Their data on granulomas is likely due to their relative youth and the change in prescribing patterns for IT medications, though I like the idea they're selling with the spritzing.

The ventral/dorsal location of the tip is important, both with respects to how a granuloma would present and with effectiveness of the therapy. I prefer ventral for baclofen and dorsal for pain. The animal and human data with the therapies seem to show a definite rostral/caudal and dorsal/ventral targeting of the medications, but the dorsal/ventral medication gradient is less pronounced as compared to the rostral/caudal gradient.

I'd argue that the description of an aggressive lesion likely has both nociceptive and neuropathic characteristics, Regardless opioids do have some efficacy for neuropathic pain, they're just not worth the risks with systemic therapy.

Most people would say that the number needed to treat NNT is 2 - 4 folks, while the NNH is 4-8, so a very narrow window for therapeutic effect.
(Dr. Google says https://painhealth.csse.uwa.edu.au/...inHEALTH-NNT-and-NNH-for-pain-medications.pdf)

Prialt's a scary med, but the more I use it, the more I like what I'm seeing when it works. It doesn't always work though. It also has a very narrow therapeutic index and you have to remember that it takes a while to have effect/equilibrate . So you really have to titrate it in slow/small steps to avoid side effects (weekly at most with jumps of 0.5 - 1 mcg/day).

 

[Ducttape]

Most people would say that the number needed to treat NNT is 2 - 4 folks, while the NNH is 4-8, so a very narrow window for therapeutic effect.

please note, you are quoting NNT for opioids for acute pain, not chronic pain.

there is no known NNT for opioids for chronic pain. the Cochrane database study that they got this number for was pertaining acute pain processes.

we would be remiss if a young girl should be put on chronic opioid medications as a slam dunk. I hope you are talking about priat or bupivacaine as the slam dunk medication...

AUTHORS' CONCLUSIONS:
Since the last version of this review, new studies were found providing additional information. Data were reanalyzed but the results did not alter any of our previously published conclusions. Short-term studies provide only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain. Intermediate-term studies demonstrated significant efficacy of opioids over placebo, but these results are likely to be subject to significant bias because of small size, short duration, and potentially inadequate handling of dropouts. Analgesic efficacy of opioids in chronic neuropathic pain is subject to considerable uncertainty. Reported adverse events of opioids were common but not life-threatening. Further randomized controlled trials are needed to establish unbiased estimates of long-term efficacy, safety (including addiction potential), and effects on quality of life.

 

[Orin]

please note, you are quoting NNT for opioids for acute pain, not chronic pain.

there is no known NNT for opioids for chronic pain. the Cochrane database study that they got this number for was pertaining acute pain processes.

we would be remiss if a young girl should be put on chronic opioid medications as a slam dunk. I hope you are talking about priat or bupivacaine as the slam dunk medication...

The link and numbers above are primarily about NNT/NNH for neuropathic pain, and it references an older Cochrane review from 2006. The updated version is from 2013. Opioids for neuropathic pain. - PubMed - NCBI

I think you're mixing acute vs chronic treatment with opioids with acute vs chronic pain treatment, as it is rare outside of things like PHN to have an acute neuropathic pain state, which was the initial question and the quoted numbers; but sure, I totally agree with what you're saying with regards to COT for pain in terms of the data.

Cancer pain's gotten so much tougher to treat as folks don't end up dead in a few months to a year anymore.

I'd argue that we'd be remiss if a young woman with focal cancer associated pain was on chronic systemic opioid therapy in lieu of chronic intrathecal opioid therapy, especially when we can do better. The slam dunk is the intervention, as stimulation wouldn't allow focal coverage for both a neuropathic and nociceptive pain and would likely benefit from a paddle lead to reliably cover the elbow/arm for someone who presumably is looking at 10 - 50 years of therapy.

We could argue about the right IT medications like we could stim patterns, but I'm fine with any or all, and love having the option to escalate if necessary. It's part of the reason I avoid one trick ponies like Nevro and reserve Bioness' PNS for simple things; limitations suck.

Regardless, I'm assuming they're already on a combination of anti-depressants, anti-epileptics, systemic or topical NSAIDs, and systemic opioids managed by the OP. But maybe no one follows the WHO ladder anymore and we're just stimming/pumping early to avoid medications?

 

[bedrock]

We could argue about the right IT medications like we could stim patterns, but I'm fine with any or all, and love having the option to escalate if necessary. It's part of the reason I avoid one trick ponies like Nevro and reserve Bioness' PNS for simple things; limitations suck.

Regardless, I'm assuming they're already on a combination of anti-depressants, anti-epileptics, systemic or topical NSAIDs, and systemic opioids managed by the OP. But maybe no one follows the WHO ladder anymore and we're just stimming/pumping early to avoid medications?

But the WHO ladder has changed. At SIS today, they stated that given all the improved options in stimulation therapies over the past couple years, DRG, nevro, better peripheral stim tech, etc, that for chronic neuropathic or sympathetically maintained pain, that SCS should be tried before round the clock opioid therapy. (not necessary before short acting low dose opioids, but definitely before you consider long-acting or higher doses of opioids.

Stim should be used earlier than it has in the past. The ladder has changed. Now back to the previous debate as to which kind of stim...................

 

[deleted472101]

I think people have definitely been pushing up interventions and Neuromodulation in the treatment cue.
Some for the good and some for financial gain.

I have lots of patient who do not want any medications chronically. I think this will only be a growing trend as the current population gets older.

 

[deleted472101]

To the original post, there is no guidelines to state either HF10 or BurstDR are better than one another. I respect anyone who uses either as they have been doing very well clinically.

I don't think you necessarily need an MRI conditional system in a patient to follow up on a peripheral nerve injury though.

I am not sure what one would look for. If it was surgical then it would have been prior to younputting the system in.

EMG and NCS can show diagnostic data if needed in future.

 

[Ducttape]

The link and numbers above are primarily about NNT/NNH for neuropathic pain, and it references an older Cochrane review from 2006. The updated version is from 2013. Opioids for neuropathic pain. - PubMed - NCBI

I think you're mixing acute vs chronic treatment with opioids with acute vs chronic pain treatment, as it is rare outside of things like PHN to have an acute neuropathic pain state, which was the initial question and the quoted numbers; but sure, I totally agree with what you're saying with regards to COT for pain in terms of the data.

Cancer pain's gotten so much tougher to treat as folks don't end up dead in a few months to a year anymore.

I'd argue that we'd be remiss if a young woman with focal cancer associated pain was on chronic systemic opioid therapy in lieu of chronic intrathecal opioid therapy, especially when we can do better. The slam dunk is the intervention, as stimulation wouldn't allow focal coverage for both a neuropathic and nociceptive pain and would likely benefit from a paddle lead to reliably cover the elbow/arm for someone who presumably is looking at 10 - 50 years of therapy.

We could argue about the right IT medications like we could stim patterns, but I'm fine with any or all, and love having the option to escalate if necessary. It's part of the reason I avoid one trick ponies like Nevro and reserve Bioness' PNS for simple things; limitations suck.

Regardless, I'm assuming they're already on a combination of anti-depressants, anti-epileptics, systemic or topical NSAIDs, and systemic opioids managed by the OP. But maybe no one follows the WHO ladder anymore and we're just stimming/pumping early to avoid medications?

no, actually, im not.

the "study" that was reviewed actually did look at neuropathic pain and time course. i posted the conclusion from the 2013 study, and stated equivocal evidence for short term studies (ie acute to subacute pain), and "analgesic efficacy for chronic neuropathic pain is subject to considerable uncertainty."

 

[Timeoutofmind]

I think people have definitely been pushing up interventions and Neuromodulation in the treatment cue.
Some for the good and some for financial gain.

I have lots of patient who do not want any medications chronically. I think this will only be a growing trend as the current population gets older.

Also the NNT for many of these anyineuropathic meds is very high for many pain conditions...and there is a question of long term cognitive changes or early dementia for people on long term antidepressants.

 

[wmc24]

Yeah. Because YOU are not good enough to be trusted with the golden sword. That would be fine if there were a few select super doctors around the country allowed to do it . That is NOT the case. Really pisses me off.


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Sorry to bring back an old post, but any reason why they are withholding drg training for many of us? Really frustrating to me

 

[Ducttape]

we aren't good enough.

 

[NJPAIN]

It’s a reward to their busiest practices. But, they deny that and say it is for the good of mankind.


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[wmc24]

It’s a reward to their busiest practices. But, they deny that and say it is for the good of mankind.


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They have trained one member of my group, but no one else. Sounds like withholding a treatment is for the good of mankind.

 

[lobelsteve]

Marketing 101. You want what you cannot have.

 

[244913]

They have trained one member of my group, but no one else. Sounds like withholding a treatment is for the good of mankind.

I have found DRG effectiveness to be directly proportional to the amount of oral and intrathecal opioids the patient is on.

I did more DRG in fellowship than most US folks do in 4 years. Even with good technique, migration was more common than the reps would have you believe. Lead placement for foot (S1) very challenging.

Might also not be a great idea long term to stuff a bunch of junk in the neuroforamen. My observation has been that stenosis generally worsens - not improves- with age. They'll be a lot of folks dragging their feet down the road. Call it the "Abbot shuffle."

St. Jude can keep it.

- ex 61N

 

[Ducttape]

best part of their marketing is that it has forced me to use Nevro where I might have used St. Jude.


oh snap...

 

[Orin]

we aren't good enough.

No doubt they've been using it as a carrot, but looking at the study reports, it also appears a bit tougher than regular stim with a much higher complication rate early on.