Just matched but worried about perceived low procedural volume in the program and attendingship

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jayel

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If a fellow graduates with less than ideal numbers for more advanced procedures (spinal cord stimulator trials and placement, pump placements, etc) to be fully comfortable, what can s/he do to build competence? I was planning some of these procedures as an attending
 
Industry sponsored events. Trial and error. Honestly you won’t feel comfortable with everything pain is a huge field and you just can’t possibly learn it all in a year. I think they key is to be safe and don’t injure any1. My first few SCS trials took a while when I was on my own and I did a decent # in fellowship. First year out I learned ton. Good luck and congrats
 
jayel said:
If a fellow graduates with less than ideal numbers for more advanced procedures (spinal cord stimulator trials and placement, pump placements, etc) to be fully comfortable, what can s/he do to build competence? I was planning some of these procedures as an attending
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Most guys anticipate that new fellows will not be "ready for prime time" and anticipate "training" them. It is the way of the world now and is probably the rule, rather than the exception. A skilled guy in private practice can get you ramped up quickly.
 
1. Who cares about pumps...You don't want anything to do with them in real life. You think it's cool bc it is a surgical procedure but please take my word for it that you want nothing to do with them.
2. Whether you do 10, 25, or 100 stimulators as a fellow will not matter. Your first 20 implants as an attending will be chaotic in some way. They're going to migrate, and you'll have to learn on the fly how to deal with it. There WILL be a few cases where you're gonna have no clue WTF is going on bc the fluoro image doesn't look right. How come I don't have loss yet? You cases will take forever.
3. Single most important thing to learn in fellowship is which patients TO TREAT, and which patients to STAY AWAY FROM...Seriously. My fellowship was severely pain psych oriented, and I learned what happens when you try 20 different meds and an equal number of procedures. Stick someone 25x and try every medication you've heard of and end up back at square one with some pt sitting there staring at you breathing through their mouth asking why they hurt. So learn how to tell people you don't feel very comfortable adding another medicine or trying another procedure. Learn to tell people that you can't make them significantly better, but there are tons of pts that have problems you can't fix.
 
I didn’t have any competent interventionalists at my academic institution so I got sent out to the community and did lots of implants and kyphos with private practice physicians. Might explore that option as well.
 
Don't worry about pump/stim numbers. Seriously. Pumps are outmoded and shouldn't really be used anymore. Get a handful of stim cases, but you'll do a ton more when you're out. Just board more time to get them done. You'll tweak the procedures until they are "your" way anyway.
 
SommeRiver said:
1. Who cares about pumps...You don't want anything to do with them in real life. You think it's cool bc it is a surgical procedure but please take my word for it that you want nothing to do with them.
2. Whether you do 10, 25, or 100 stimulators as a fellow will not matter. Your first 20 implants as an attending will be chaotic in some way. They're going to migrate, and you'll have to learn on the fly how to deal with it. There WILL be a few cases where you're gonna have no clue WTF is going on bc the fluoro image doesn't look right. How come I don't have loss yet? You cases will take forever.
3. Single most important thing to learn in fellowship is which patients TO TREAT, and which patients to STAY AWAY FROM...Seriously. My fellowship was severely pain psych oriented, and I learned what happens when you try 20 different meds and an equal number of procedures. Stick someone 25x and try every medication you've heard of and end up back at square one with some pt sitting there staring at you breathing through their mouth asking why they hurt. So learn how to tell people you don't feel very comfortable adding another medicine or trying another procedure. Learn to tell people that you can't make them significantly better, but there are tons of pts that have problems you can't fix.
Click to expand...

Can someone make this a sticky?
 
A fellow will inevitably believe the stim reps bc they'll see the attendings talking to them in the hallway outside the OR and they'll be on a first name basis with them. That is a walking logical fallacy by way of an appeal to authority, so if you're a fellow and the attending is a "cool dude" who is "good at stim" and a great "proceduralist" who "always goes to NANS" you will believe the BS served to you by the reps and you'll crave more and more cases.

You'll start wanting to stim ppl before you've even gotten an MRI. That pain psych referral for stim candidacy is a "waste of time."

No matter how many cases you do that year will not be enough.

In real life you'll very quickly find out the reality about SCS - It is great for CRPS and chronic radiculitis, but it UTTERLY SUX for CLBP before or after back surgery.

Before anyone tries to debate me that stim is great for axial LBP please know I've done enough at this point to have some successes, but by and large it simply isn't reliable for axial pain, and there is a good chance you're going to remove it in 18 months.

My first 20 or so implants were unbelievable. I was a legit fast dude in fellowship; no clue what I was doing as an attending. There was always something missing and the cases were never straightforward. I never had problems as a fellow. You simply have to learn on your own, and all I can say is just go slow, don't hurt anyone, and you'll be fine one day.

One of the most infuriating things I learned on my own was silk...WTF man, take that Ethibond and throw it in the trash...Why didn't we use silk in fellowship?
 
BobBarker said:
Because silk doesn’t have any inherent strength after a few months
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They're dissolved over 2 yrs, but they're inflammatory so they encapsulate the anchor points with scar tissue.
 
Your goal as a fellow isn't necessarily to perform a million repetitions of every procedure you might do. Your goal is to learn the principles of needle driving and fluoroscopy. There are many procedures you will try for the first time by yourself as a staff, but if you have the basic principles of safety down you can still do them with enough patience and self-guided learning. It's only a 1 year fellowship -- you can't do a million of everything.
 
SommeRiver said:
A fellow will inevitably believe the stim reps bc they'll see the attendings talking to them in the hallway outside the OR and they'll be on a first name basis with them. That is a walking logical fallacy by way of an appeal to authority, so if you're a fellow and the attending is a "cool dude" who is "good at stim" and a great "proceduralist" who "always goes to NANS" you will believe the BS served to you by the reps and you'll crave more and more cases.

You'll start wanting to stim ppl before you've even gotten an MRI. That pain psych referral for stim candidacy is a "waste of time."

No matter how many cases you do that year will not be enough.

In real life you'll very quickly find out the reality about SCS - It is great for CRPS and chronic radiculitis, but it UTTERLY SUX for CLBP before or after back surgery.

Before anyone tries to debate me that stim is great for axial LBP please know I've done enough at this point to have some successes, but by and large it simply isn't reliable for axial pain, and there is a good chance you're going to remove it in 18 months.

My first 20 or so implants were unbelievable. I was a legit fast dude in fellowship; no clue what I was doing as an attending. There was always something missing and the cases were never straightforward. I never had problems as a fellow. You simply have to learn on your own, and all I can say is just go slow, don't hurt anyone, and you'll be fine one day.

One of the most infuriating things I learned on my own was silk...WTF man, take that Ethibond and throw it in the trash...Why didn't we use silk in fellowship?
Click to expand...

+1 on the silk
 
It has too much attitude. I don't have any issues with it; it just doesn't tie as easily.
 
On a side note how do u guys anchor the trial lead? Ive been using stayfix but migration rate is horrendous. Any good suturing for the lead? If so what kind of suture do you use?
 
I now use stayfix for trial leads. I used to suture with silk.
 
TIVAndy said:
On a side note how do u guys anchor the trial lead? Ive been using stayfix but migration rate is horrendous. Any good suturing for the lead? If so what kind of suture do you use?
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Used stayfix for a while but switched to silk sutures because the stayfixes were coming loose. I looked through old posts here and someone had referenced some small butterfly dressings but just posted a pic and not where to get them or what they were called. Wanted to try them if whoever that was can weigh in. I don’t like suturing but I feel like every time I decide to try without I get migration, even with just steris and benzoin which I know a lot of people swear by.
 
TIVAndy said:
On a side note how do u guys anchor the trial lead? Ive been using stayfix but migration rate is horrendous. Any good suturing for the lead? If so what kind of suture do you use?
Click to expand...

I use Stayfix for cervicals and this for thoracic trials. It's the bomb. Trick is to make a little strain relief loop and use a couple steri-strips.

1571709454305.png


www.vitalitymedical.com

SorbaView Shield - Peripheral, Medium

Sobraview Shield...
www.vitalitymedical.com www.vitalitymedical.com
 
This is the easiest and best method and nothing anyone says will sway me otherwise. Suturing and fancy dressings are unnecessary.


1. Mastisol
2. 1” Steristrips lengthwise on both sides of the lead “sandwiching” it.
3. Steris horizontal across the lengthwise steris as close as possible to the base of the lead.

I don’t have trial lead migrations.
 
For trial leads I do a small tunnel with a 14G angiocath, then coil the redundant lead and secure it with dermabond, steristrips + mastisol, and cover the whole thing with gauze and tegraderm.
 
BobBarker said:
This is the easiest and best method and nothing anyone says will sway me otherwise. Suturing and fancy dressings are unnecessary.


1. Mastisol
2. 1” Steristrips lengthwise on both sides of the lead “sandwiching” it.
3. Steris horizontal across the lengthwise steris as close as possible to the base of the lead.

I don’t have trial lead migrations.
Click to expand...


BobBarker said:
This is the easiest and best method and nothing anyone says will sway me otherwise. Suturing and fancy dressings are unnecessary.


1. Mastisol
2. 1” Steristrips lengthwise on both sides of the lead “sandwiching” it.
3. Steris horizontal across the lengthwise steris as close as possible to the base of the lead.

I don’t have trial lead migrations.
Click to expand...

thanks for the suggestions
i've seen above methods before. never incorporated in my practice, but maybe i should try it.
i have the luxury of in office c-arm so i've been taking films at the end of trials. the migration rate even though you think it didn't move is actually pretty significant.

recent article i found

A Retrospective Case Series of a Novel Spinal Cord Stimulator Trial Technique with Less Displacement and Migration of the Trial Leads - PMC

Spinal cord stimulation is an established treatment option for certain chronic pain conditions which have been previously unresponsive to conservative therapies or potentially for a subset of patients who have not improved following spine surgery. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

i don't think this is novel - just a tunneled trial that people do in europe.. but still nice to see a series
 
to the original poster - sorry to hijack the thread - i think all other people have responded with the pearls of wisdom - learn as much you can during fellowship. i went to almost all courses on weekends and learned different surgical techniques, procedure techniques even though our fellowship was high volume - this was very eye opening how different people had different methods. also job interviews i was able to scrub in and learn - this was an awesome opportunity too. in short - don't worry too much, learns the basics and anatomy and be safe. once you get the basics down it's really not that hard.
 
BobBarker said:
This is the easiest and best method and nothing anyone says will sway me otherwise. Suturing and fancy dressings are unnecessary.


1. Mastisol
2. 1” Steristrips lengthwise on both sides of the lead “sandwiching” it.
3. Steris horizontal across the lengthwise steris as close as possible to the base of the lead.

I don’t have trial lead migrations.
Click to expand...
I do this but no mastisol
I don’t see why u would need it? Never seen those steries move

Mastisol can be irritating

just another thing to muck up the clinical picture


Same reason I don’t use dermabond
 
BobBarker said:
This is the easiest and best method and nothing anyone says will sway me otherwise. Suturing and fancy dressings are unnecessary.


1. Mastisol
2. 1” Steristrips lengthwise on both sides of the lead “sandwiching” it.
3. Steris horizontal across the lengthwise steris as close as possible to the base of the lead.

I don’t have trial lead migrations.
Click to expand...

I use mastisol too. I haven't tried sandwiching the lead...sounds intriguing. Post a picture sometime.
 
TIVAndy said:
to the original poster - sorry to hijack the thread - i think all other people have responded with the pearls of wisdom - learn as much you can during fellowship. i went to almost all courses on weekends and learned different surgical techniques, procedure techniques even though our fellowship was high volume - this was very eye opening how different people had different methods. also job interviews i was able to scrub in and learn - this was an awesome opportunity too. in short - don't worry too much, learns the basics and anatomy and be safe. once you get the basics down it's really not that hard.
Click to expand...

Our program has a few reps that hang around every once in awhile, but other than this how can I get signed up for most of these courses? I'd like to not miss out on any.
 
Strongly encourage both the NANS fellow course AND the new attending course. Beware though, you'll be forced underneath a torrential downfall of lies and deception, but it is still good to see different people's methodology for entry point, approach angles, closure, etc...Tons of nuances and there are 50x ways to do good SCS work.

It is a GOOD treatment for failed back with persistent radic and very good at CRPS. Those are the most common Dx you'll implant/trial. Failed back is far and away the most common for me (two spine surgeons in my group and I'm the only guy doing SCS).

I do SCS for FBSS and the pt only has back pain and it simply is unreliable. You'll take out 80% of the implants you do for that Dx.
 
SommeRiver said:
Strongly encourage both the NANS fellow course AND the new attending course. Beware though, you'll be forced underneath a torrential downfall of lies and deception, but it is still good to see different people's methodology for entry point, approach angles, closure, etc...Tons of nuances and there are 50x ways to do good SCS work.

It is a GOOD treatment for failed back with persistent radic and very good at CRPS. Those are the most common Dx you'll implant/trial. Failed back is far and away the most common for me (two spine surgeons in my group and I'm the only guy doing SCS).

I do SCS for FBSS and the pt only has back pain and it simply is unreliable. You'll take out 80% of the implants you do for that Dx.
Click to expand...
I haven't done any explants yet, so forgive me, but wouldn't the trial rule out most of your potential poor outcomes?
 
Ferrismonk said:
I haven't done any explants yet, so forgive me, but wouldn't the trial rule out most of your potential poor outcomes?
Click to expand...

One would think that's the case, but no...I have had perfect trials fail implant, but it is much, much more common for FBSS with primary back and secondary leg pain. I'm telling you right now, you WILL explant a lot of those patients and it doesn't matter what the SCS brochure says...

It seems I'm the only one though! I must be doing my implants on the moon or something.

Edit - Saw her an hour ago. Prior to seeing me she had around 40 epidurals (she claims 40). Had a few back surgeries. Leg pain is better, but back and buttock still hurts. Sweeping is problematic. Again, the leg pain is better but I was very frank with her about back pain being unreliable with stim. She's happy overall, but this is the patient where nuance is required in discussing outcomes bc reps and "NANS doctors" will tell you stim worked for this patient...but please understand what that means bc she's still unable to do whole lot bc her back is killing her. Her legs are better, and she can walk better, but she's still limited.

So did stim work for her or not? Well, I could be a D-Bag and say I'm treating leg pain and this pt was 100% successful while leaving out the severe back pain that didn't get better. They lie and misrepresent the data.
 

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SommeRiver said:
One would think that's the case, but no...I have had perfect trials fail implant, but it is much, much more common for FBSS with primary back and secondary leg pain. I'm telling you right now, you WILL explant a lot of those patients and it doesn't matter what the SCS brochure says...

It seems I'm the only one though! I must be doing my implants on the moon or something.

Edit - Saw her an hour ago. Prior to seeing me she had around 40 epidurals (she claims 40). Had a few back surgeries. Leg pain is better, but back and buttock still hurts. Sweeping is problematic. Again, the leg pain is better but I was very frank with her about back pain being unreliable with stim. She's happy overall, but this is the patient where nuance is required in discussing outcomes bc reps and "NANS doctors" will tell you stim worked for this patient...but please understand what that means bc she's still unable to do whole lot bc her back is killing her. Her legs are better, and she can walk better, but she's still limited.

So did stim work for her or not? Well, I could be a D-Bag and say I'm treating leg pain and this pt was 100% successful while leaving out the severe back pain that didn't get better. They lie and misrepresent the data.
Click to expand...
RF for her? I see hardware - is she fused to the sacrum? SI joints? Pain with certain movements suggests arthritic type pain so no surprise it didn’t respond to stim. Although I hesitate to open this can of worms, what brand of stim?
 
callmeanesthesia said:
RF for her? I see hardware - is she fused to the sacrum? SI joints? Pain with certain movements suggests arthritic type pain so no surprise it didn’t respond to stim. Although I hesitate to open this can of worms, what brand of stim?
Click to expand...

It's more than mechanical pain to be honest. She has radicular pain in the left leg which is better, and I would say substantially better if not resolved. So that's a win. She does have mechanical pain in the back and perhaps some SIJ pain for all I can tell. The exam is of course positive for multiple provocative maneuvers. The leg pain was lateral thigh and calf. So while the leg is great the buttock and back are no different.

I realize that this isn't the PERFECT candidate for stim, but it is a REALISTIC candidate for stim. This is a real world patient that doesn't fit neatly in some little boutique box that is hand picked for an industry sponsored trial.

Device is Abbott.

Edit - No SI fusion. I did an SIJ injxn which helped the buttock pain, but no benefit for her leg. She's had over 3 dozen injxns in the last 6ish years and I'm simply not going to keep that going.
 
SommeRiver said:
It's more than mechanical pain to be honest. She has radicular pain in the left leg which is better, and I would say substantially better if not resolved. So that's a win. She does have mechanical pain in the back and perhaps some SIJ pain for all I can tell. The exam is of course positive for multiple provocative maneuvers. The leg pain was lateral thigh and calf. So while the leg is great the buttock and back are no different.

I realize that this isn't the PERFECT candidate for stim, but it is a REALISTIC candidate for stim. This is a real world patient that doesn't fit neatly in some little boutique box that is hand picked for an industry sponsored trial.

Device is Abbott.

Edit - No SI fusion. I did an SIJ injxn which helped the buttock pain, but no benefit for her leg. She's had over 3 dozen injxns in the last 6ish years and I'm simply not going to keep that going.
Click to expand...
I just meant is she fused L4-S1 - they almost all have SI pain. RF or PRP for the SI? Or if a steroid lasts her long enough the occasional SI joint injection
 
L4-S1 fusion, and yes I could RF the SIJ but what am I doing for her back? The patient is LLE, LBP, buttock pain.

There's a million ways I can think of doing a million things for her, but at the end of the day what she needs is containment bc she claims somewhere around 40 injxns prior to SCS.

If SCS is so great for FBSS, and "NANS doctors" swear by stim for back pain with failed back, why was this not completely effective for her? The dudes that teach the courses will tell you back pain after fusion is reliably treated by stim, as long as you use the device that's paying them.

So if I'm talking to a Boston Scientific doctor he will tell me WaveWriter will run all these programs for different things so the radic will be one program, the back pain another, and it will usually work. The Abbott guy will tell me Burst and all these "new" programs they're doing that are nothing more than turning Burst on for 60 seconds and off for 2 minutes. Nevro will tell me something different and you've never met a Nevro rep that didn't have a copy of Senza in his/her pocket.

Also what exactly is the mechanism by which PRP treats SIJ pain?
 
jayel said:
If a fellow graduates with less than ideal numbers for more advanced procedures (spinal cord stimulator trials and placement, pump placements, etc) to be fully comfortable, what can s/he do to build competence? I was planning some of these procedures as an attending
Click to expand...
Follow the current Pain Management guidelines to a T... Errors will happen within your first 5 years of practice. It is in your patients and your best interest to minimize them. Attend cadver workshops in Vegas(stim, Kypho, Rfa) and Napa....not Minnesota.
 
10KHertz said:
Follow the current Pain Management guidelines to a T... Errors will happen within your first 5 years of practice. It is in your patients and your best interest to minimize them. Attend cadver workshops in Vegas(stim, Kypho, Rfa) and Napa....not Minnesota.
Click to expand...

To which guidelines do you refer?
 
SommeRiver said:
L4-S1 fusion, and yes I could RF the SIJ but what am I doing for her back? The patient is LLE, LBP, buttock pain.

There's a million ways I can think of doing a million things for her, but at the end of the day what she needs is containment bc she claims somewhere around 40 injxns prior to SCS.

If SCS is so great for FBSS, and "NANS doctors" swear by stim for back pain with failed back, why was this not completely effective for her? The dudes that teach the courses will tell you back pain after fusion is reliably treated by stim, as long as you use the device that's paying them.

So if I'm talking to a Boston Scientific doctor he will tell me WaveWriter will run all these programs for different things so the radic will be one program, the back pain another, and it will usually work. The Abbott guy will tell me Burst and all these "new" programs they're doing that are nothing more than turning Burst on for 60 seconds and off for 2 minutes. Nevro will tell me something different and you've never met a Nevro rep that didn't have a copy of Senza in his/her pocket.

Also what exactly is the mechanism by which PRP treats SIJ pain?
Click to expand...
Theoretically tightens the ligaments. A couple small trials showing longer lasting benefit than steroid injection. For someone who is fused, honestly probably not worth it because the mechanical stress on the joint isn’t going away.

I agree with your thoughts on the stim though, and back to the OPs comments - reps and company courses will all try to tell you why their technology is best. It’s all marketing BS. Read the original studies and look at the actual outcome data in making your decision but take those studies with a grain of salt too. Be very selective in who you offer a permanently implanted device to, especially in your first few years. FBSS with persistent radic, or CRPS. non-smokers, no uncontrolled DM, not on high dose opioids.
 
Ducttape said:
They are coming back...

Not the heads I mean...
Click to expand...

I guess you haven't heard of that Russian dude who is supposed to get a head transplant. You see that?
 
A low volume thread has become Mesenchymal stem cell Wars.... nice
 
SommeRiver said:
EVERY time?
Click to expand...
I've done it 4 times, so I'm not exactly Mr. RegenMed, but yes, every time. My steroid injections last 3-6 months on average with a waning relief over time, SI RFA lasts about 6mo to a year, SI PRP hasn't needed any repeats since my first in May of this year (5 months). Still zero pain in the SI joints on everyone.
 
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