Epidural SCS trial on someone with peripheral field stimulator?

[Baron Samedi]

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So I'm a one guy shop without anyone to discuss cases with, so hoping for some insight.

I have a 50yo patient who has cervical peripheral leads placed 2016 for predominantly axial but some right arm pain as well. The device works okayish, giving him partial relief but he desires better relief and has concerns that its not MRI compatible. His most recent MRI was just prior to this device placement and was relatively normal with some mild disc degeneration.

Would there be any issue in me placing epidural trial leads with this device still in place? I'd think he could just turn his existing device off for the trial. The plan would be if his trial fails to just keep his existing device, or if its successful to remove the field stimulator and place a permanent SCS.

Also, his most recent MRI was 4 years ago and he cannot get a new one. Though it was benign and his symptoms haven't significantly changed, is getting a CT myelogram necessary?

I haven't encountered this before so would appreciate some insight.

 

[Ronin1]

I would just turn off existing device for the trial. At a minimum I would get a CT cervical and maybe thoracic depending on planned entry

 

[NOSfan]

I haven't encountered this before so would appreciate some insight.

From a technical aspect, as you indicated, just turn off peripheral IPG and trial.

Assume he has had other conservative care: neuromodulator, PT, ESI/TFESI and ? previous surgery. Would definitely not do epidural trial w/o recent imaging - CT to start would be fine. But, needs a through work-up before any consideration to epidural trial.

Also, insurance will not approve w/o CRPS or failed surgical cervical syndrome.

 

[lobelsteve]

In patients with relatively normal imaging and a stimulator already in place I find it easier to steal her car keys or wallet when they’re getting checked in then I can sell their assets when they’re not looking. It’s better than pretending to be a doctor and doing useless procedures to make a living.

 

[callmeanesthesia]

So I'm a one guy shop without anyone to discuss cases with, so hoping for some insight.

I have a 50yo patient who has cervical peripheral leads placed 2016 for predominantly axial but some right arm pain as well. The device works okayish, giving him partial relief but he desires better relief and has concerns that its not MRI compatible. His most recent MRI was just prior to this device placement and was relatively normal with some mild disc degeneration.

Would there be any issue in me placing epidural trial leads with this device still in place? I'd think he could just turn his existing device off for the trial. The plan would be if his trial fails to just keep his existing device, or if its successful to remove the field stimulator and place a permanent SCS.

Also, his most recent MRI was 4 years ago and he cannot get a new one. Though it was benign and his symptoms haven't significantly changed, is getting a CT myelogram necessary?

I haven't encountered this before so would appreciate some insight.

Is there history you didn’t include on why you are considering this? What is the indication for stim? Is this “cervical radiculopathy” with benign imaging and his neck has hurt for 20 years, and he’s on disability for it? If so how much opioid is he on, or does he want to be on, and how much does he smoke?
You may do him the most good by just removing his old device... you could maybe consider an RF.
If you’re set on this path, I’d say CT is adequate for screening, and turn the other device off.
If case is as you’ve described it and nothing more for indications, (axial neck pain with benign imaging) I think Lobel is right.

 

[Baron Samedi]

I'm not dead set on the plan, but it's specifically what he's asking for.

His MRI did show some mild degeneration with mild foraminal stenosis and at least a portion of his symptoms are radicular, though again its predominantly axial.

No opioids, nonsmoker, not on disability, highly motivated patient. Prior to the field stimulator he had tried just about everything in conservative care with PT, chiro, nonopioid medications, ESI, RFA, etc.

He feels like the current device gets him to the point where he can function and would likely not be interested in explant without a plan, but, again, wishes it was better and has become increasingly concerned about the MRI issue.

I'm open to other suggestions.

 

[lobelsteve]

Turf to pain/psych.

80% chance he is better for 6-12 mo. Then back to bseline. Pain without concordant findings on imaging is not an indication. Risk of cord stick or hematoma. Defend that if it were to happen.

 

[Orin]

Cervical stim is difficult and I can't tell you it'll be great for axial pain. There's some Nevro data suggesting AMAZING outcomes but I don't trust their results.

I would do a CT C/T-spine myelogram to give yourself some confidence and safety, but the old MRI is probably sufficient.
I agree that you'd do a trial first, turn off the PFNS, and then see.

lobelsteve is right that this may be a lot of expectation management, so I would ask him to "wash out" the PFNS for at least a week or two prior to the trial to help him get a good baseline. In an ideal world, you would also add have a dedicated PT evaluation for his cervical motion/flexibility/pain before/after the PFNS washout/during the trial. He may be someone to shift the goal posts on you after an implant.

You may end up doing both dorsal column and PFNS. There was somebody saying they were having great results with that for axial back pain prior to the rollout of paresthesia free stim programs.

 

[SommeRiver]

You may end up doing both dorsal column and PFNS. There was somebody saying they were having great results with that for axial back pain prior to the rollout of paresthesia free stim programs.

Disagree. Please stop this.

To the OP - Stim in a pt with simple spondylosis is unethical and should never take place, especially in the cervical canal.

 

[bedrock]

So I'm a one guy shop without anyone to discuss cases with, so hoping for some insight.

I have a 50yo patient who has cervical peripheral leads placed 2016 for predominantly axial but some right arm pain as well. The device works okayish, giving him partial relief but he desires better relief and has concerns that its not MRI compatible. His most recent MRI was just prior to this device placement and was relatively normal with some mild disc degeneration.

Would there be any issue in me placing epidural trial leads with this device still in place? I'd think he could just turn his existing device off for the trial. The plan would be if his trial fails to just keep his existing device, or if its successful to remove the field stimulator and place a permanent SCS.

Also, his most recent MRI was 4 years ago and he cannot get a new one. Though it was benign and his symptoms haven't significantly changed, is getting a CT myelogram necessary?

I haven't encountered this before so would appreciate some insight.

Do you practice in LA/NYC/Miami?
This is a perfect example of unethical medicine that you see in such areas. It’s terrible to place an SCS for basically standard age related disc degeneration. And then to place a second SCS in the cervical space???

Bad idea.

 

[Orin]

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My bad, I guess they just say intractable pain in the arm and neck. I mean they do say their patients had pain refractory to conservative and surgical treatment, but I'm not sure what their imaging was like and if it was anything beyond the usual aging related changes.

The PFNS is weird tho, but since it is in already, use it if it helps.

I mean it's not like the dude has fibro right?

 

[SommeRiver]

Medical management only

 

[Ducttape]

I'm getting the feeling this is a MVC or WC case? please say no...

 

[Baron Samedi]

Neither, he is in the military.

I do appreciate the feedback and concerns, though the personal accusations were a bit much. This morning I dug further back into his record and found out something interesting -- during his field stimulation trial he actually had a trial lead placed in the dorsal column and failed to achieve coverage of his pain site. It looks like at that point they placed one peripherally and he got coverage and proceeded to implant.

No reason for me to think a repeat dorsal column trial would be helpful based on that, so I think that answers this question for me. It sounds like, based on feedback here, I am dodging a potential disaster anyways.

 

[Ferrismonk]

For perspective, I didn't even know "field stim" was a thing until this board. I'm also under the impression that "field stim" has been shown to be ineffective, or at least no better than the $30 TENS machine on Amazon.

I also would not recommend stim for axial pain, especially with essentially normal imaging.

 

[Baron Samedi]

I don't love field stim, though I did a ton of it in fellowship. Lead migration is annoying and the patients never seem to have long term satisfaction.

 

[deleted993114]

So I'm a one guy shop without anyone to discuss cases with, so hoping for some insight.

I have a 50yo patient who has cervical peripheral leads placed 2016 for predominantly axial but some right arm pain as well. The device works okayish, giving him partial relief but he desires better relief and has concerns that its not MRI compatible. His most recent MRI was just prior to this device placement and was relatively normal with some mild disc degeneration.

Would there be any issue in me placing epidural trial leads with this device still in place? I'd think he could just turn his existing device off for the trial. The plan would be if his trial fails to just keep his existing device, or if its successful to remove the field stimulator and place a permanent SCS.

Also, his most recent MRI was 4 years ago and he cannot get a new one. Though it was benign and his symptoms haven't significantly changed, is getting a CT myelogram necessary?

I haven't encountered this before so would appreciate some insight.

Nope-

However, I would question a traditional lead placement for neck pain.

If it lateralizes at all, test block his facets for an rf. Cervical rf (via a supine approach) is God's procedure and works extremely well. Posterior approach- not so much.

 

[SommeRiver]

Nope-

However, I would question a traditional lead placement for neck pain.

If it lateralizes at all, test block his facets for an rf. Cervical rf (via a supine approach) is God's procedure and works extremely well. Posterior approach- not so much.

You mean lateral entry for the RF?

 

[Baron Samedi]

I ended up starting him on Gabapentin and telling him he should make due with his field stimulator because it's the only thing that's given him even partial relief. The enemy of pretty good is better.