DRG- experiences and pricing

[bedrock]

I'm going to be doing DRG cases in my new practice. I was insulated from these costs previously.

I'm sorry to start another price thread but most of my pricing question is on DRG, as it is unique technology (in contrast to regular stim), so I don't know how much leverage I have to drop the prices since only one company offers this tech.

My Abbott rep is quoting DRG IPG for 21,800 and perm leads for $2,000 each, so it appears to be $4000 for a 2 lead implant. DRG trial leads are $1600 for a two lead kit.



This is where I really need the help and advice of the group. All these prices are high compared to regular stim, yet only Abbott offers DRG so I lose leverage there. However, hardly anyone else offers DRG in my area, so I have leverage in that many of these DRG cases simply won't happen without me.

What do you guys think about prices above? For those doing DRG, what kind of prices have you been able to negotiate?

---

Members don't see this ad.

 

[Ferrismonk]

Unfortunately I can't comment on prices, but everyone I've talked to states that DRG isn't worth it because it takes so much longer to place the leads appropriately and you don't get paid more for that time or extra for the leads.

 

[bedrock]

Unfortunately I can't comment on prices, but everyone I've talked to states that DRG isn't worth it because it takes so much longer to place the leads appropriately and you don't get paid more for that time or extra for the leads.

Agree on the financial considerations with DRG as it will definitely take longer. I only offer DRG in situations where it is vastly superior to regular stim such as post hernia pain, phantom limb, CRPS limited to the foot, etc.

 

[lobelsteve]

Agree on the financial considerations with DRG as it will definitely take longer. I only offer DRG in situations where it is vastly superior to regular stim such as post hernia pain, phantom limb, CRPS limited to the foot, etc.

Please share your vastly superior literature on drg over other treatments or scs for those dx.

 

[SommeRiver]

After my DRG course I bought 5 leads.

They're still sitting on the shelf 2 yrs later.

If that rep wasn't annoying to me I'd probably place them...Since I can't stand him any longer I'll probably sell them.

 

[bedrock]

Please share your vastly superior literature on drg over other treatments or scs for those dx.

Exactly how many DRG trials/implants have you performed?

 

[lobelsteve]

Exactly how many DRG trials/implants have you performed?

Zero. Not worth the time/risk as compared to conventional SCS.

 

[Ronin1]

Accurate trial showed DRG superiority to conventional stim

 

[lobelsteve]

Accurate trial showed DRG superiority to conventional stim

I know. Tim and Bob’s show. Ill have to dig out the tables.

 

[pmrmd]

My last permanent 2-lead DRG total cost was $23,600. The only time I use Abbott is for DRG and that’s rare so I think you can get them down a bit.

 

[paindoc007]

I don’t do DRG. But my friend who does say they average like 10 min of fluoro time. Is that typical? He doesn’t do many so prob not efficient

 

[Asclepius186]

I’m confused? Pain fellow here. You have to pre-purchase DRG leads? Is that normal? What?

 

[BobBarker]

No, it is not normal. But ABT tried to force some docs to do that.

 

[SommeRiver]

No, it is not normal. But ABT tried to force some docs to do that.

I had to, but we were ready to go on a few pts who I ultimately changed to dorsal column bc they had foraminal stenosis.

I fail to see a reason to switch to DRG considering it takes longer to place, we still don't know what happens 10 yrs down the road when the foramen tightens up, and I personally had a big name at NANS lie to my face about his DRG experience (won't ever forget that).

Oh, and I also recently spoke to one of the pioneers in stim who made some lunch table comments about DRG that further drove me away from it. I won't give his name, and he's done a lot of it. There are risks with DRG that don't exist with dorsal column.

The DRG training course had dudes in there talking off label about axial back pain with T12 leads, which Abbott should have shut that down hard.

Also, I see persistent post surgical knee and hip pain almost daily (large ortho group), and maybe one out of hundreds of those pts could I say was CRPS.

So when I ask how you're getting DRG covered for knee pain post replacement when it is RARELY CRPS, they didn't really have an answer.

Yet it works so beautifully in those pts...

I challenge any of you to submit to me a field more rife with fraud than neuromodulation. Can't use chiropractic either...

 

[JelloIsJigglin]

Sadly they dont allow extra foraminal placement for trials either, even though this approach is 10000000x easier and safer than their standard epidural approach.

 

[SommeRiver]

Sadly they dont allow extra foraminal placement for trials either, even though this approach is 10000000x easier and safer than their standard epidural approach.

I would think you're guaranteed to migrate in that situation. Have you done that before?

 

[Espn123]

Accurate trial showed DRG superiority to conventional stim

Hey

I had to, but we were ready to go on a few pts who I ultimately changed to dorsal column bc they had foraminal stenosis.

I fail to see a reason to switch to DRG considering it takes longer to place, we still don't know what happens 10 yrs down the road when the foramen tightens up, and I personally had a big name at NANS lie to my face about his DRG experience (won't ever forget that).

Oh, and I also recently spoke to one of the pioneers in stim who made some lunch table comments about DRG that further drove me away from it. I won't give his name, and he's done a lot of it. There are risks with DRG that don't exist with dorsal column.

The DRG training course had dudes in there talking off label about axial back pain with T12 leads, which Abbott should have shut that down hard.

Also, I see persistent post surgical knee and hip pain almost daily (large ortho group), and maybe one out of hundreds of those pts could I say was CRPS.

So when I ask how you're getting DRG covered for knee pain post replacement when it is RARELY CRPS, they didn't really have an answer.

Yet it works so beautifully in those pts...

I challenge any of you to submit to me a field more rife with fraud than neuromodulation. Can't use chiropractic either...

Zero. Not worth the time/risk as compared to conventional SCS.

yikes, really? There is more evidence for drg than most things we do regularly. That combined with a lot of collective experience leads me to fully believe that for some indications it is superior than scs.

 

[SommeRiver]

Hey



yikes, really? There is more evidence for drg than most things we do regularly. That combined with a lot of collective experience leads me to fully believe that for some indications it is superior than scs.

Yeah, really...I went through the DRG course and want nothing to do with it.

I am worried about leads in the L5-S1 foramen in 8 yrs...12 yrs...I worry about complications and adverse events in DRG, and there were twice as many AE in DRG over dorsal column in that study. It took DRG 32 min longer to implant...

I also have serious concerns about this treatment bc your Abbott rep will try to convince many of you to keep adding leads over time.

It is NOT uncommon to hear about pts with multiple leads...and no one is implanting my mother with 4 friggin DRG leads. That's a joke IMO.

DRG is superior to ALL dorsal column, or only when 4 leads are used? What about 2 leads?

A 1 or 2 lead dorsal column perm is pretty darn good, but is it better than 4 DRG leads?

How many leads were used in ACCURATE, or does that matter?

ACCURATE is vs traditional stim, but what about the newer, novel waveforms like HF10 or Burst?

I wonder why Abbott didn't run it against Burst? Those newer waveforms are superior to traditional, so what am I supposed to believe ACCURATE told me?

Dorsal column leads are fine in the posterior space...It isn't that common to lose canal space around T8-T11-ish...The foramen virtually always close over time to some degree...What happens then? You don't know bc no one knows how that works 10 yrs out.

 

[Espn123]

Yeah, really...I went through the DRG course and want nothing to do with it.

I am worried about leads in the L5-S1 foramen in 8 yrs...12 yrs...I worry about complications and adverse events in DRG, and there were twice as many AE in DRG over dorsal column in that study. It took DRG 32 min longer to implant...

I also have serious concerns about this treatment bc your Abbott rep will try to convince many of you to keep adding leads over time.

It is NOT uncommon to hear about pts with multiple leads...and no one is implanting my mother with 4 friggin DRG leads. That's a joke IMO.

DRG is superior to ALL dorsal column, or only when 4 leads are used? What about 2 leads?

A 1 or 2 lead dorsal column perm is pretty darn good, but is it better than 4 DRG leads?

How many leads were used in ACCURATE, or does that matter?

ACCURATE is vs traditional stim, but what about the newer, novel waveforms like HF10 or Burst?

I wonder why Abbott didn't run it against Burst? Those newer waveforms are superior to traditional, so what am I supposed to believe ACCURATE told me?

Dorsal column leads are fine in the posterior space...It isn't that common to lose canal space around T8-T11-ish...The foramen virtually always close over time to some degree...What happens then? You don't know bc no one knows how that works 10 yrs out.

I appreciate your cautious approach. It does sound like your local Abbott support may not be the best. For indications like post-herniorrhaphy pain or post-tka (where foramina are likely to remain patent) I don’t think your argument holds. I don’t do more than 2 leads ever - treating focal pain...

 

[SommeRiver]

I appreciate your cautious approach. It does sound like your local Abbott support may not be the best. For indications like post-herniorrhaphy pain or post-tka (where foramina are likely to remain patent) I don’t think your argument holds. I don’t do more than 2 leads ever - treating focal pain...

I don't disagree that post-herniorraphy pain is a perfect indication for DRG. I don't open my doors for that bc I'm underwater in spine, but having said that...I don't care to offer the procedure despite the fact I'm trained to do it.

There's been a large hematoma near me, and I recently spoke to a stim guru at a conference (maybe 6 wks ago) who told me about a T-L jxn placement with paraplegia in the PACU. That MD tends to avoid DRG and has probably done several thousand stim cases of all types.

 

[bedrock]

I appreciate your cautious approach. It does sound like your local Abbott support may not be the best. For indications like post-herniorrhaphy pain or post-tka (where foramina are likely to remain patent) I don’t think your argument holds. I don’t do more than 2 leads ever - treating focal pain...

I am worried about leads in the L5-S1 foramen in 8 yrs...12 yrs...I worry about complications and adverse events in DRG, and there were twice as many AE in DRG over dorsal column in that study. It took DRG 32 min longer to implant...

ACCURATE is vs traditional stim, but what about the newer, novel waveforms like HF10 or Burst?

I wonder why Abbott didn't run it against Burst? Those newer waveforms are superior to traditional, so what am I supposed to believe ACCURATE told me?
Dorsal column leads are fine in the posterior space...It isn't that common to lose canal space around T8-T11-ish...The foramen virtually always close over time to some degree...What happens then? You don't know bc no one knows how that works 10 yrs out.

I had to, but we were ready to go on a few pts who I ultimately changed to dorsal column bc they had foraminal stenosis.

I fail to see a reason to switch to DRG considering it takes longer to place, we still don't know what happens 10 yrs down the road when the foramen tightens up, and I personally had a big name at NANS lie to my face about his DRG experience (won't ever forget that).

Oh, and I also recently spoke to one of the pioneers in stim who made some lunch table comments about DRG that further drove me away from it. I won't give his name, and he's done a lot of it. There are risks with DRG that don't exist with dorsal column.

You guys make some good points, particularly the concern for leads in the L5-S1 foramen over time. I have the same concern with cervical paddle implants. The dorsal thoracic epidural space is much safer than that either of those long term.

However there are indications for which traditional stim just isn't that good such as post like post-herniorrhaphy pain or post-tka pain. And neither of those foramina are particularly likely to close, particularly L3-L4. Most of those post TKA patients are already 62+ anyway, so you have a decent idea of whether or not their foramen are safe to use for the next 15-20 years.

Agree that I would love a trial comparing burst/HF 10 directly to DRG for things like focal foot CRPS. But for things like post hernia or TKA pain, DRG makes sense, because dorsal column stim just doesn't work well for those indications.

Somme, you don't need to name names, and feel free to PM me, but can you share some of the comments from the pioneers in stim who said things that drove you away from DRG?

 

[SommeRiver]

You guys make some good points, particularly the concern for leads in the L5-S1 foramen over time. I have the same concern with cervical paddle implants. The dorsal thoracic epidural space is much safer than that either of those long term.

However there are indications for which traditional stim just isn't that good such as post like post-herniorrhaphy pain or post-tka pain. And neither of those foramina are particularly likely to close, particularly L3-L4. Most of those post TKA patients are already 62+ anyway, so you have a decent idea of whether or not their foramen are safe to use for the next 15-20 years.

Agree that I would love a trial comparing burst/HF 10 directly to DRG for things like focal foot CRPS. But for things like post hernia or TKA pain, DRG makes sense, because dorsal column stim just doesn't work well for those indications.

Somme, you don't need to name names, and feel free to PM me, but can you share some of the comments from the pioneers in stim who said things that drove you away from DRG?

I posted at the same time you posted this and to repeat it, he basically said he does DRG, but prefers not doing it bc of an episode of paraplegia in the PACU. Dorsal column is just more reliable in terms of safety and bleeding. The foramen isn't uniform in terms of its vasculature.

Seems the T-L jxn tends to be where these bleeds occur, and not the lower lumbar levels.

Agreed on post hernia, not sure about post TKA because as I said in my first post, I see failed joint replacement daily as I work with 20+ ortho surgeons and I don't call those CRPS bc they NEVER meet criteria.

This came up in my DRG course - How are you getting this covered for persistent post joint replacement pain? You're just calling it causalgia or CRPS?

Again, I see this daily, and I'm in my 4th year out from fellowship and at this point I think I've seen enough post joint pts to catch at least a few causalgia pts, but I haven't...It just hurts.

I'll ask you - How do you get post TKR covered when all it is consists of pain without objective findings?

 

[BobBarker]

I asked at my course if they were doing lumbar sympathetics on these TKA patients... crickets.

 

[SommeRiver]

I asked at my course if they were doing lumbar sympathetics on these TKA patients... crickets.

Haha...Same.

Obviously, there are probably people in this forum who have done a lot of DRG cases and probably haven't ever had any issues.

 

[bedrock]

I posted at the same time you posted this and to repeat it, he basically said he does DRG, but prefers not doing it bc of an episode of paraplegia in the PACU. Dorsal column is just more reliable in terms of safety and bleeding. The foramen isn't uniform in terms of its vasculature.

Seems the T-L jxn tends to be where these bleeds occur, and not the lower lumbar levels.

Agreed on post hernia, not sure about post TKA because as I said in my first post, I see failed joint replacement daily as I work with 20+ ortho surgeons and I don't call those CRPS bc they NEVER meet criteria.

This came up in my DRG course - How are you getting this covered for persistent post joint replacement pain? You're just calling it causalgia or CRPS?

Yes, I was writing as you were writing. That episode of paraplegia is certainly concerning. Definitely riskier the higher you go.
Makes me wonder/worry about using DRG for ilioinguinal pain at T12, or for abdominal pain at T11-T12.

I do term it causalgia if it makes sense. DRG works well for many post TKA patients, not all of them, just like dorsal column stim for CRPS/chronic radic.

 

[Espn123]

I posted at the same time you posted this and to repeat it, he basically said he does DRG, but prefers not doing it bc of an episode of paraplegia in the PACU. Dorsal column is just more reliable in terms of safety and bleeding. The foramen isn't uniform in terms of its vasculature.

Seems the T-L jxn tends to be where these bleeds occur, and not the lower lumbar levels.

Agreed on post hernia, not sure about post TKA because as I said in my first post, I see failed joint replacement daily as I work with 20+ ortho surgeons and I don't call those CRPS bc they NEVER meet criteria.

This came up in my DRG course - How are you getting this covered for persistent post joint replacement pain? You're just calling it causalgia or CRPS?

Again, I see this daily, and I'm in my 4th year out from fellowship and at this point I think I've seen enough post joint pts to catch at least a few causalgia pts, but I haven't...It just hurts.

I'll ask you - How do you get post TKR covered when all it is consists of pain without objective findings?

If someone has pain post TKA along the medial aspect, and it’s a mixed nociceptive/neuropathic picture, I’m comfortable calling it causalgia and naming the saphenous nerve. This is covered, and is not subject to the budapest criteria that crps 1 is.

all this being said, if someone is not comfortable with drg, then they are doing the right thing by not doing it.

 

[lobelsteve]

Saphenous = Ferrari

 

[Espn123]

Saphenous = Ferrari

I wish I knew what that meant, and I wish I had a ferrari

 

[SommeRiver]

If someone has pain post TKA along the medial aspect, and it’s a mixed nociceptive/neuropathic picture, I’m comfortable calling it causalgia and naming the saphenous nerve. This is covered, and is not subject to the budapest criteria that crps 1 is.

Thanks for making my point.

 

[Espn123]

Thanks for making my point.

You are welcome. this is what’s on label, and what was studied for fda approval

 

[SommeRiver]

You are welcome. this is what’s on label, and what was studied for fda approval

I understand what you're doing, and I'm not calling you a bad guy.

...surely you understand why some of your colleagues would groan to hear you willy-nilly attribute persistent post surgical knee pain to saphenous causalgia for the simple fact the pt has medial knee pain post TKR?

Again, not saying you're a bad guy and I know you're just trying to help your pts bro...

 

[Espn123]

I understand what you're doing, and I'm not calling you a bad guy.

...surely you understand why some of your colleagues would groan to hear you willy-nilly attribute persistent post surgical knee pain to saphenous causalgia for the simple fact the pt has medial knee pain post TKR?

Again, not saying you're a bad guy and I know you're just trying to help your pts bro...

I understand that many don’t feel comfortable making a diagnosis of crps 2 or causalgia without the Budapest criteria. Different practices for different people. I always learn a lot on here myself.

 

[Orin]

I personally had a big name at NANS lie to my face about his DRG experience (won't ever forget that).

I've seen this from experts in PNS as well. In general, I fear the talking heads in our field often have little to no real experience.

I avoid DRG due to the placement/migration problems and the lack of longitudinal data. PNS first if unilateral/mononeuralgia. DRG later if SCS not acceptable.

 

[BobBarker]

In general, I fear the talking heads in our field often have little to no real experience.

Bingo. Earl Fender himself told me they had someone teaching vertiflex that had done one case. Happens all of the time with every new device and procedure.

 

[Gnarvin]

I honestly don’t understand people calling basically just persistent post-operative pain “causalgia.” I am just out of fellowship and was taught CRPS type 1 AND 2 are both subject to the same diagnostic criteria (Budapest). As far as I understand it, CRPS type 2 used to be called causalgia and thus causalgia is no longer a current term.

I have recently heard a doc call a lot of things “causalgia” despite them not meeting the criteria for CRPS and the doc said that causalgia doesn’t need to meet the criteria for CRPS.
I am genuinely confused and I know there is a lot of history behind the terms and diagnosis of CRPS that happened before I was in the field. I want to make sure that my understanding is correct in the current terminology.

 

[BobBarker]

You are correct. ABT Is trying to turn causalgia into something it isn’t. I think the company is teaching the reps that causalgia is something different than crps. My rep came to me a over year after training “Great news! We are on label now for all types of causalgia with DRG”.

 

[SommeRiver]

Causalgia requires definitive evidence of nerve injury.

TKR with pain afterwards does not meet that definition, and if you use medial knee pain as your criteria you're simply making zhit up (with good intention - I might can help this Mrs. Smith).

Of all the reps I've worked with, Abbott are hands down the worst in terms of pressuring physicians to use their devices.

I had one of them enter into my ASC and start talking to me about a pt WHILE I WAS DOING AN RFA ON A SEPARATE PT!!!!

I have many other stories of brazen assholery by several of their reps that I'm happy to discuss PM.

I am almost all Nevro now, and interestingly my trial to perm ratio went from about 99% to 85%, and I am positive that's bc the Nevro reps are being more transparent as to whether or not the trial works. Yes, I have a few Abbott perms running around out in town that aren't helping.

Edit - As the only pain guy doing stim in a large ortho group, I bet you I could do 5-6 DRG cases per month if I used causalgia as the Dx simply bc it hurts. I have 6 (maybe 7 actually) dorsal column cases this month so if I did 12 or so stim cases a month our CEO & CFO would give me back rubs QAM.

 

[lobelsteve]

8-23% of all TKR have ongoing knee pain without loosening or infection.

 

[SommeRiver]

8-23% of all TKR have ongoing knee pain without loosening or infection.

Hospital for Special Surgery published maybe 3 yrs ago around 20-25%, and if I remember correctly they added language to the effect of probably a higher rate than that bc some doctors simply will not admit the knee continues to hurt.

It is very easy to blame it on an acute radic (happens to me all the time - Pt wakes up from surgery and has bad knee pain and miraculously had an acute exacerbation of their lumbar stenosis).

Your avg TKR pt is maybe 70 yo or so, and by the very nature of gravity and life on planet Earth they no doubt have stenosis...My knee replacement was perfect so you must have caught a radic during PT.

So, I see a lot of this and it is very common. Our more prolific total joint guys are very experienced and really good at their craft, but this happens all the time and I just can't call it causalgia (nor should any of you).

Also have to ask what pts needed the TKR to begin with, because 1/4 to 1/3 of these pts are probably not candidates.

 

[Espn123]

If someone has a TKA and has burning, tingling, and allodynia on the medial surface, is it wrong to deduce a saphenous nerve involvement? We aren’t talking about strictly mechanical post-surgical pain.

Every lens has a bias. The same argument could be made that we don’t know the longitudinal effects of 10,000hz.

The comments here are from those who don’t like the Abbott rep, don’t do drg, or have had technical concerns. These are all valid. There are others out there who do lots of drg, have great success, etc.

I’m pretty sure we are all trying our best to take care of our patients, despite differing opinions.

 

[Ducttape]

why not RFA it instead of implanting.


oh wait... I keep forgetting...

 

[SommeRiver]

If someone has a TKA and has burning, tingling, and allodynia on the medial surface, is it wrong to deduce a saphenous nerve involvement? We aren’t talking about strictly mechanical post-surgical pain.

Every lens has a bias. The same argument could be made that we don’t know the longitudinal effects of 10,000hz.

The comments here are from those who don’t like the Abbott rep, don’t do drg, or have had technical concerns. These are all valid. There are others out there who do lots of drg, have great success, etc.

I’m pretty sure we are all trying our best to take care of our patients, despite differing opinions.

Pain is very difficult to describe, and we both know pts use any and all adjectives to describe their pain but that doesn't obviate the need for DRG stimulation under the guise of causalgia.

Ppl jerk away from palpation all the time with mechanical pain.

Like I've said repeatedly, you're not a bad guy and you're trying to help people. I just don't agree with what I consider a loose application of something that I consider as not entirely harmless.

Ever taken a look at your Abbott rep's car? If not I encourage you to do so.

Agree with longitudinal HF10, but we have many decades of history stimulating the dorsal column.

 

[Espn123]

Pain is very difficult to describe, and we both know pts use any and all adjectives to describe their pain but that doesn't obviate the need for DRG stimulation under the guise of causalgia.

Ppl jerk away from palpation all the time with mechanical pain.

Like I've said repeatedly, you're not a bad guy and you're trying to help people. I just don't agree with what I consider a loose application of something that I consider as not entirely harmless.

Ever taken a look at your Abbott rep's car? If not I encourage you to do so.

Agree with longitudinal HF10, but we have many decades of history stimulating the dorsal column.

All Abbott reps are bad, and drg is not a good therapy 🙂

 

[SommeRiver]

All Abbott reps are bad, and drg is not a good therapy 🙂

You've been "gotten to!"

 

[lobelsteve]

You've been "gotten too!"

 

[Espn123]

That’s what the nevro rep told me too

 

[bedrock]

That’s what the nevro rep told me too

Because the nevro rep has not bias either????

 

[SommeRiver]

Because the nevro rep has not bias either????

I think that's his point.

 

[Ferrismonk]

How can a post TKA patient have causalgia? Direct nerve injury? That means the orthopod did something wrong!

 

[lobelsteve]

Legit Budapest criteria CRPS LLE patient new to me today. Not on opiates. Elavil 25mg qhs for sleep. Failed opiates, neuropathics, SNRI.
Had DRG trial, implant, and explant within 6 months at local competition. She kept hoping it would work.. Awaiting records. Will try PT, bisphos, clonidine, baclofen.