Defining FBSS when considering SCS?

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cameroncarter

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I was taught that FBSS is persistent radiculopathy after surgical decompression and that SCS could be offered to treat the radiculopathy in this group.

Leaving NANS I was shocked to see how many are placing SCS in patients with any pain (even if mostly to fully) axial pain after surgery.

Thoughts? Am I too conservative or are they too liberal?
 
cameroncarter said:
I was taught that FBSS is persistent radiculopathy after surgical decompression and that SCS could be offered to treat the radiculopathy in this group.

Leaving NANS I was shocked to see how many are placing SCS in patients with any pain (even if mostly to fully) axial pain after surgery.

Thoughts? Am I too conservative or are they too liberal?
Click to expand...
I’m a bit surprised that you’re shocked. Scs is way over utilized for marginal at best indications.
 
Taus said:
I’m a bit surprised that you’re shocked. Scs is way over utilized for marginal at best indications.
Click to expand...
lol one of the Abott reps said at dinner “only about 9% of patients who qualify for SCS will ever receive it.” Essentially advocating for 10x utilization
 
i r/o adjacent level disease (ESI, send to surgeon)SI joint dysfunction
Assess to see if screw lucency or hardware issue with X-ray or CT (send to surgeon)
If refractory pain despite this or patient does not want additional surgeries, SCS is reasonable.

For solely axial pain, I warn that it won’t work as well but admit I sometimes offer if they’re miserable
Agree, best results has been in patients who have neuropathic component

Make sure to optimize non opioid adjunct, PR, dry needling, etc.
 
I dislike SCS but there are obviously ppl it helps, and axial back pain after surgery is included in that group, a fact I begrudgingly admit.

FBSS is persistent back pain in a pt who has undergone back surgery. I leave it at that simple definition.
 
MitchLevi said:
I dislike SCS but there are obviously ppl it helps, and axial back pain after surgery is included in that group, a fact I begrudgingly admit.

FBSS is persistent back pain in a pt who has undergone back surgery. I leave it at that simple definition.
Click to expand...

[mention]MitchLevi [/mention] [mention]SpineandWine [/mention] I think we all agree revision surgery and extending fusions isn’t the answer but that’s what happens a lot of times when I send these people back to surgeons….in the grand scheme SCS is safer but I don’t think overutilizing this is right either.

What’s been your success rates with SCS post surgical axial pain?
 
cameroncarter said:
[mention]MitchLevi [/mention] [mention]SpineandWine [/mention] I think we all agree revision surgery and extending fusions isn’t the answer but that’s what happens a lot of times when I send these people back to surgeons….in the grand scheme SCS is safer but I don’t think overutilizing this is right either.

What’s been your success rates with SCS post surgical axial pain?
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Speaking for myself, axial BP post fusion is at best 50/50.

If you’re up against the wall with a fusion extension, trying SCS is reasonable bc you explant it if you’re unsatisfied with it. Many are unsatisfied with it in that scenario, but in my experience many more are unsatisfied with more pedicle screws.
 
MitchLevi said:
Speaking for myself, axial BP post fusion is at best 50/50.

If you’re up against the wall with a fusion extension, trying SCS is reasonable bc you explant it if you’re unsatisfied with it. Many are unsatisfied with it in that scenario, but in my experience many more are unsatisfied with more pedicle screws.
Click to expand...

I’d suggest both fusion and SCS are worse than that in providing “good” relief for predominantly axial low back pain.

My personal 15 yr experience is that patients with >95% axial pain (no or mild radicular pain) achieve good 5 yr relief of axial pain (75%+ improvement) only 20% of the time via fusion and 5% of the time via SCS.

If we’re talking more realistic modest (50%) relief of axial pain x 5 years, then post fusion axial pain relief increases to 40% and post SCS increases to 10%.

Overall, both fusion and SCS are $hit for providing good relief of axial low back pain
 
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bedrock said:
I’d suggest both fusion and SCS are worse than in providing “good” relief for predominantly axial low back pain.

My personal 15 yr experience is that patients with >95% axial pain (no or mild radicular pain) achieve good 5 yr relief of axial pain (75%+ improvement) only 20% of the time via fusion and 5% of the time via SCS.

If we’re talking more realistic modest (50%) relief of axial pain x 5 years, then post fusion axial pain relief increases to 40% and post SCS increases to 10%.

Overall, both fusion and SCS are $hit for providing good relief of axial low back pain
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75% is a pretty high level of relief to define success
 
MitchLevi said:
75% is a pretty high level of relief to define success
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That’s why I included two groups in my post.

But if you did a survey of patients about a theoretical surgery to relieve pain , and asked if 25%, 50%, 75% or 100% would constitute “good” (but also realistic) amount of pain relief that a modern surgery could provide, I expect most patients would not choose 25% or 50% for what they considered to be “good” pain relief outcome following a 21st century surgery.
 
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In regard to SCS… my take is I really really really drive home “success is a 50% pain reduction AND it’s not forever”

I literally have them come in for a visit just to go over this.

If they don’t have their family with them they have to come back so their family understands this.

Once I started doing this when the complained their pain is at a 5 and it “didn’t work” I remind them they were at a 10 before so it is “working.”

I tell them they’re not getting younger and I just hopefully bought them a window. It won’t last forever. Take advantage of it.

In short, I try to set expectations.
 
cameroncarter said:
I was taught that FBSS is persistent radiculopathy after surgical decompression and that SCS could be offered to treat the radiculopathy in this group.

Leaving NANS I was shocked to see how many are placing SCS in patients with any pain (even if mostly to fully) axial pain after surgery.

Thoughts? Am I too conservative or are they too liberal?
Click to expand...

I feel similar as a fresh pain doc out of fellowship. Where I trained we only ever did SCS for radicular/neuropathic pain.

But in the last six months I’ve done 3 trials and 1 perm for primarily axial back pain. My favorite was truly miserable after staged L1-S1 fusion and numerous disc replacements, kyphos, etc. She had tried and failed everything, and didn’t want opioids. She had very realistic goals and said she understood there were no guarantees, but that even a 25% reduction in pain would be worth it for her personally.

She had an amazing trial and is excited for perm.

I guess I’m saying that if a patient has tried and failed everything else, and has realistic expectations, I don’t see the harm in trialing for axial low back pain.

But I also realize I haven’t been doing this nearly as long as everyone else. Maybe I’ll have a different opinion in 5-10 years.

Also, maybe I drank the flavor aid, but I can see how things like BurstDR would work better for axial low back pain vs old parenthesis based systems.
 
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TheNolano said:
I feel similar as a fresh pain doc out of fellowship. Where I trained we only ever did SCS for radicular/neuropathic pain.

But in the last six months I’ve done 3 trials and 1 perm for primarily axial back pain. One of them was truly miserable after an L1-S1 fusion and numerous disc replacements, kyphos, etc. She had tried and failed everything, and didn’t want opioids. She had very realistic goals and said she understood there were no guarantees, but that even a 25% reduction in pain would be worth it for her personally.

She had an amazing trial and is excited for perm.

I guess I’m saying that if a patient has tried and failed everything else, and has realistic expectations, I don’t see the harm in trialing for axial low back pain.

But I also realize I haven’t been doing this nearly as long as everyone else. Maybe I’ll have a different opinion in 5-10 years.

Also, maybe I drank the flavor aid, but I can see how things like BurstDR would work better for axial low back pain vs old parenthesis based systems.
Click to expand...
I used to think this way. Been in practice 11 years. Started to do more scs for primarily axial pain years ago when the Nevro data came out. Several home run trials. Vast majority did poorly after implant. Did several burstDR and other flavor of the week, similar experience. I went back to doing scs only for primarily neuropathic limb pain.

For a patient with mixed axial and limb, as is generally the case in fbss….. I tell them it MAY help with the component of their axial pain that is there all the time, regardless of position or activity, but highly unlikely to help their mechanical axial pain. But still only do trial if they’d be content with primarily helping their limb pain.
 
SpineandWine said:
i r/o adjacent level disease (ESI, send to surgeon)SI joint dysfunction
Assess to see if screw lucency or hardware issue with X-ray or CT (send to surgeon)
If refractory pain despite this or patient does not want additional surgeries, SCS is reasonable.

For solely axial pain, I warn that it won’t work as well but admit I sometimes offer if they’re miserable
Agree, best results has been in patients who have neuropathic component

Make sure to optimize non opioid adjunct, PR, dry needling, etc.
Click to expand...
We're almost identical in our process. Everyone of them sees a surgeon after I have ruled out other causes.

I tell patients the following: "SCS can be great for leg pain and if we get a little better in the back, that's awesome. I never have said SCS can be great for back pain and if we get a little better in the legs, that's awesome." Now with that said, I typically follow this up with, if you have hardware in place and are absolutely miserable, a trial is completely reasonable but to temper expectations.
 
Taus said:
I used to think this way. Been in practice 11 years. Started to do more scs for primarily axial pain years ago when the Nevro data came out. Several home run trials. Vast majority did poorly after implant. Did several burstDR and other flavor of the week, similar experience. I went back to doing scs only for primarily neuropathic limb pain.

For a patient with mixed axial and limb, as is generally the case in fbss….. I tell them it MAY help with the component of their axial pain that is there all the time, regardless of position or activity, but highly unlikely to help their mechanical axial pain. But still only do trial if they’d be content with primarily helping their limb pain.
Click to expand...
TheNolano said:
I feel similar as a fresh pain doc out of fellowship. Where I trained we only ever did SCS for radicular/neuropathic pain.

But in the last six months I’ve done 3 trials and 1 perm for primarily axial back pain. My favorite was truly miserable after staged L1-S1 fusion and numerous disc replacements, kyphos, etc. She had tried and failed everything, and didn’t want opioids. She had very realistic goals and said she understood there were no guarantees, but that even a 25% reduction in pain would be worth it for her personally.

She had an amazing trial and is excited for perm.

I guess I’m saying that if a patient has tried and failed everything else, and has realistic expectations, I don’t see the harm in trialing for axial low back pain.

But I also realize I haven’t been doing this nearly as long as everyone else. Maybe I’ll have a different opinion in 5-10 years.

Also, maybe I drank the flavor aid, but I can see how things like BurstDR would work better for axial low back pain vs old parenthesis based systems.
Click to expand...
agree with Taus said.

To Nolano, I appreciate it sounds like you’re trying to help your patients, but unfortunately long term you will see that SCS very rarely helps significantly long term with 90% or more axial spine pain.

These patients have great trials due to placebo effect and/or trial unique programming and both can’t be replicated long term for axial spine pain.
 
bedrock said:
agree with Taus said.

To Nolano, I appreciate it sounds like you’re trying to help your patients, but unfortunately long term you will see that SCS very rarely helps significantly long term with 90% or more axial spine pain.

These patients have great trials due to placebo effect and/or trial unique programming and both can’t be replicated long term for axial spine pain.
Click to expand...

Can you tell me (us) more about this? Do they sometimes use more energy consuming programming (during the trial) that is not feasible longterm?
 
If they've got really bad back pain and there aren't any other treatment options or revisional surgeries on the table, little harm in trying. My experience is that even straight up back pain patients get quite a lot of relief with Abbot, Nevro, and Saluda. Medtronic, is so so (haven't tried their new ECAP sytem). No serious experience with Boston.
 
1 Up said:
If they've got really bad back pain and there aren't any other treatment options or revisional surgeries on the table, little harm in trying. My experience is that even straight up back pain patients get quite a lot of relief with Abbot, Nevro, and Saluda.
Click to expand...

Unfortunately, the rest of us rarely see long term relief for axial low back pain from SCS.
 
bedrock said:
Unfortunately, the rest of us rarely see long term relief for axial low back pain from SCS.
Click to expand...
The same applies to many spine surgeries for back pain. Most interventional treatments for pain (surgery, minimally invasive interventions, injections, etc) have a limited duration of efficacy. But if you can give someone with severe life altering pain some relief for even a few years, you can alter the trajectory of their life in a positive way.

So long as the patient is honestly aware of the pros and cons, they can make the choice to proceed or not based on what's important to them.

I currently believe the most effective systems are the ones that require the least tinkering by the patient - even if their average magnitude of effect is less effective than the "best" systems in the field. Every time a patient has to charge, they're reminded they're a "chronic pain person." Every time they have to be reprogrammed, they're reminded of this too. It becomes a self fulfilling prophecy. So I think systems requiring the least intervention by the patient have tended to work best for me. From this perspective, really long battery life (Eterna), and dynamic adaptation (Saluda) are giving me the best results currently. I've also found systems with short duty cycles (short periods of stimulation interspaced by larger periods of quiescence) tend to be more durable. Nevro's and Medtronic's recharge burden is too high. Hopefully that will change with their new generation of products.

Currently, there are systems that are great at one or two elements of durability, but no system has them all. I'm hopeful that we're not far off from a single system with months long battery life, dynamic adaptation, and short duty cycles.
 
1 Up said:
The same applies to many spine surgeries for back pain. Most interventional treatments for pain (surgery, minimally invasive interventions, injections, etc) have a limited duration of efficacy. But if you can give someone with severe life altering pain some relief for even a few years, you can alter the trajectory of their life in a positive way.

So long as the patient is honestly aware of the pros and cons, they can make the choice to proceed or not based on what's important to them.

I currently believe the most effective systems are the ones that require the least tinkering by the patient - even if their average magnitude of effect is less effective than the "best" systems in the field. Every time a patient has to charge, they're reminded they're a "chronic pain person." Every time they have to be reprogrammed, they're reminded of this too. It becomes a self fulfilling prophecy. So I think systems requiring the least intervention by the patient have tended to work best for me. From this perspective, really long battery life (Eterna), and dynamic adaptation (Saluda) are giving me the best results currently. I've also found systems with short duty cycles (short periods of stimulation interspaced by larger periods of quiescence) tend to be more durable. Nevro's and Medtronic's recharge burden is too high. Hopefully that will change with their new generation of products.

Currently, there are systems that are great at one or two elements of durability, but no system has them all. I'm hopeful that we're not far off from a single system with months long battery life, dynamic adaptation, and short duty cycles.
Click to expand...
Ab$olutely
Lot of people thought about pain pumps this way too back in the day but for $ome reason, culture changed
 
I agree as well. I am putting in MDT Vanta since the recharge burden has gotten so high with Intellis. They need to bring back a restore sensor size rechargeable to lower the recharge burden. Intellis was fine 5 years ago, but whatever new programming they are doing is draining the battery much quicker.
 
I’ve already explanted a few Eterna IPGs. Had one a few months ago that died after maybe a yr or so.
 
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