LinkedIn SCS

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callmeanesthesia said:
I had one that entered like the LinkedIn case above, but it was because of body habitus. I had the 6” needle pushed down as parallel to her back as I could. The lead dove all the way into the gutter but I was able to get it to come back to midline a level up. Thankfully she didn’t have nerve root irritation and is having good relief. Maybe another pillow under the chest would have helped.
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Coude helps with that. I hate using it though. It's too loud.
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MitchLevi said:
Hibiclens x 4d BID.
Vanc allergy (I use Vanc powder in every implant but couldn't this time).
Clinda 900 IV.
Thorough irrigation.
Ioban of course.
I'll see her in follow up a few days from now and she's got a short leash for PO clinda or even Bactrim.

Not only the infxn Hx but also she had a large seroma. The seroma and the jxnl kyphosis is why I entered at T11. Otherwise, I would have entered at T12-L1 as she has lamina.

Not an ideal case on any level.

Thin thoracic, obese lumbar and buttock.

These are the cases I'm interested in discussing, not the ones that began this thread.
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Why no Tyrx or CanGaroo? Vanc powder is cheap but I'm not sure very effective. The rifampin/minocycline envelope has excellent data.
 
Orin said:
Why no Tyrx or CanGaroo? Vanc powder is cheap but I'm not sure very effective. The rifampin/minocycline envelope has excellent data.
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Vanc is far cheaper and gets your MRSA ancef may not. Ioban, chlorhexidine, pt selection, faster surgeries, MRSA swab with decolonization protocol, cauterizing bleeders, minimizing tissue handling, preop BG/HbA1C, Irrigation, changing top gloves, reducing in/out of room goes a long way.

Tyrex study: n=6983 implants; control=42 infections 1.2%, Tyrex=25 infections 0.7%; I'd hardly say thats substantial 1.2 vs 0.7%, thats where they get the 40% reduction from. When you look at the numbers you realize its 1% rounding up or down. The tyrex pouches only last like 90 days on the shelf as well I believe.
 
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soccrwz said:
Vanc is far cheaper and gets your MRSA ancef may not. Ioban, chlorhexidine, pt selection, faster surgeries, MRSA swab with decolonization protocol, cauterizing bleeders, minimizing tissue handling, preop BG/HbA1C, Irrigation, changing top gloves, reducing in/out of room goes a long way.

Tyrex study: n=6983 implants; control=42 infections 1.2%, Tyrex=25 infections 0.7%; I'd hardly say thats substantial 1.2 vs 0.7%, thats where they get the 40% reduction from. When you look at the numbers you realize its 1% rounding up or down. The tyrex pouches only last like 90 days on the shelf as well I believe.
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How expensive is tyrx....never used it
 
soccrwz said:
Vanc is far cheaper and gets your MRSA ancef may not. Ioban, chlorhexidine, pt selection, faster surgeries, MRSA swab with decolonization protocol, cauterizing bleeders, minimizing tissue handling, preop BG/HbA1C, Irrigation, changing top gloves, reducing in/out of room goes a long way.

Tyrex study: n=6983 implants; control=42 infections 1.2%, Tyrex=25 infections 0.7%; I'd hardly say thats substantial 1.2 vs 0.7%, thats where they get the 40% reduction from. When you look at the numbers you realize its 1% rounding up or down. The tyrex pouches only last like 90 days on the shelf as well I believe.
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Did the tyrx study include all patients? I suspect if you were to look at a high risk cohort the difference may be more pronounced.
 
soccrwz said:
Vanc is far cheaper and gets your MRSA ancef may not. Ioban, chlorhexidine, pt selection, faster surgeries, MRSA swab with decolonization protocol, cauterizing bleeders, minimizing tissue handling, preop BG/HbA1C, Irrigation, changing top gloves, reducing in/out of room goes a long way.

Tyrex study: n=6983 implants; control=42 infections 1.2%, Tyrex=25 infections 0.7%; I'd hardly say thats substantial 1.2 vs 0.7%, thats where they get the 40% reduction from. When you look at the numbers you realize its 1% rounding up or down. The tyrex pouches only last like 90 days on the shelf as well I believe.
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High risk patients should get all that and an antimicrobial envelope I think, but you're correct it's a rare event that is made rarer by these techniques/tools.

Vanc powder has mixed data, but an equivalent at best effect. It's a messy thing to use I find, and has been associated with seromas around implants and hemodynamic collapse in spine cases. In this case, it's contraindicated due to allergy though.
 
anyone see the "exosome injection therapy" LinkedIn post?
 
Please share!!!
GIF by Brett Eldredge
 
Tboned said:
Please share!!!
GIF by Brett Eldredge
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This one was so bad it already got taken down.

Guy was injecting exosomes through the nose to access a venous plexus to “treat and prevent cognitive decline.”

Look up “the osteopathic center” on LinkedIn.
 
Asclepius186 said:
Did the tyrx study include all patients? I suspect if you were to look at a high risk cohort the difference may be more pronounced.
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Doesn’t define

N = 6,983 patients at an increased risk for pocket infection

The study is in defibrillators which go in the heart so more risk for endocarditis, these are also done in the hospital likely
 
Orin said:
High risk patients should get all that and an antimicrobial envelope I think, but you're correct it's a rare event that is made rarer by these techniques/tools.

Vanc powder has mixed data, but an equivalent at best effect. It's a messy thing to use I find, and has been associated with seromas around implants and hemodynamic collapse in spine cases. In this case, it's contraindicated due to allergy though.
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Put it in a cap, to hold. Andnd put it in with back of addisons, usually. Less messy but still some mess

Our experience suggests open laminectomy for SCS implantation surgery can be performed with a low postoperative SSI rate, with or without the use of powdered vancomycin. We found no evidence suggesting that the use of powdered vancomycin is unsafe or related to postoperative seroma formation.

Three seromas, all in the no-vancomycin group, accounted for a statistically significant difference in seroma formation between the 2 groups (P = 0.04)

The Role of Vancomycin Powder During Spinal Cord Stimulator Implantation: A Case Series and Review of the Literature

Of note vancomycin is called that because it “vanquishes” MSSA
 
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lobelsteve said:
www.linkedin.com

#drg #drg #mechanism #neuromodulation #minimallyinvasivesurgery… | Robert Moghim, M.D. | 20 comments

Chronic pancreatitis with left sided 8/10 pain with radiation into the back. Solution: Left DRG @ T11 and T12 Results: 95% ⬇️discomfort Sympathetic mediated pain and the #DRG. What is the mechanism of action of DRG and the sympathetic nervous system? Summary: The sympathetic chain...
www.linkedin.com www.linkedin.com

Am I too harsh?
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Would you be able to provide a better answer if someone asked you “why T9-10?”
 
Espn123 said:
Would you be able to provide a better answer if someone asked you “why T9-10?”
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I have a lady with multiple abdominal surgeries with diffuse pain across, mostly above the umbilicus but some extension lower. Bil T10 worked really well for her. Unfortunately she is emaciated and now experiencing significant pocket pain, the IPG is way too big for her.
 
Agast said:
I have a lady with multiple abdominal surgeries with diffuse pain across, mostly above the umbilicus but some extension lower. Bil T10 worked really well for her. Unfortunately she is emaciated and now experiencing significant pocket pain, the IPG is way too big for her.
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I was needling @stevelobel since I know he prefers nevro scs 🙂

All the newer scs unfortunately have to start with larger IPGs I believe for regulatory FDA reasons.

We will see the same thing with saluda - superior technology but the biggest ipg (like the original nevro battery, or the old axium drg)
 
Agast said:
I have a lady with multiple abdominal surgeries with diffuse pain across, mostly above the umbilicus but some extension lower. Bil T10 worked really well for her. Unfortunately she is emaciated and now experiencing significant pocket pain, the IPG is way too big for her.
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Should dorsal column her with Eterna. No pocket pain there, nor any reason to believe DRG is better in that case anyways.
 
Espn123 said:
Would you be able to provide a better answer if someone asked you “why T9-10?”
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The answer is T5-9 as that's where the splanchnic nerve originates. Which 2 of 5 you would choose is the conversation. I bet T11-12 so he could enter epidural space at or below conus to minimize risk.
 
when i did a few stims for pancreatitis, it was targetting T5-7.



what i find interesting is that most posters are not identifying themselves as physicians, but as entrepreneurs.


Healthcare Entrepreneur; Interventional Pain & Spine Physician; Founder-Colorado Pain Care;

Anesthesiologist/Pain management . Spinal cord Stimulation/ Peripheral Nerve Stimulation. SI join

Chief of Medical Education, Physician Partners of America

Area Vice President I Chronic Pain Therapies at Abbott

Co-Founder at Performance Pain & Sports Medicine


i guess it is because it is on linkedin?
 
Ducttape said:
when i did a few stims for pancreatitis, it was targetting T5-7.



what i find interesting is that most posters are not identifying themselves as physicians, but as entrepreneurs.


Healthcare Entrepreneur; Interventional Pain & Spine Physician; Founder-Colorado Pain Care;

Anesthesiologist/Pain management . Spinal cord Stimulation/ Peripheral Nerve Stimulation. SI join

Chief of Medical Education, Physician Partners of America

Area Vice President I Chronic Pain Therapies at Abbott

Co-Founder at Performance Pain & Sports Medicine


i guess it is because it is on linkedin?
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You want a net worth north of $10M? You cannot get there from here. You gotta own things and create a brand.
If you can live off a retirement of a measly $4M, keep plugging away and 401K in Index funds. Retire at 65 to maximize/
 
MitchLevi said:
Should dorsal column her with Eterna. No pocket pain there, nor any reason to believe DRG is better in that case anyways.
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Abbott people said DRG would be better. Didn’t want to blow my one chance at trialing her…if we had the luxury of multiple trials it would be different
 
bedrock said:
Yep. I’d love to see a situation in which an Abbott rep didn’t recommend DRG.

Because if they ever say dorsal column, they know they might lose the case to a competitor.
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They also want DRG to flourish, and the more leads out there in the community the more opportunity for extending the list of approved Dx.
 
lobelsteve said:
The answer is T5-9 as that's where the splanchnic nerve originates. Which 2 of 5 you would choose is the conversation. I bet T11-12 so he could enter epidural space at or below conus to minimize risk.
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Knowing the doc I would disagree but I see where you are coming from
 
lobelsteve said:
You want a net worth north of $10M? You cannot get there from here. You gotta own things and create a brand.
If you can live off a retirement of a measly $4M, keep plugging away and 401K in Index funds. Retire at 65 to maximize/
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some of these guys have 4 NPs per doc greasing the opioid wheels to get these patients to agree
 
Baron Samedi said:
I've done far more revisions at this point than even trials let alone implants. I've given up on the procedure entirely until they do something about preventing lead fracture/migration.
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I don't see how it would be possible to prevent migration of a DRG lead.

Of course, during one of my two NANS cadaver courses I've done, a well-known DRG guy told me he'd never seen one lead malfxn, fracture or migration in 79 pts.

The very mechanical nature of the system leads to migration.

The strain relief loop isn't enough. You have a long lead swirled about in the epidural space with the running end sitting in the foramen.
 
MitchLevi said:
I don't see how it would be possible to prevent migration of a DRG lead.

Of course, during one of my two NANS cadaver courses I've done, a well-known DRG guy told me he'd never seen one lead malfxn, fracture or migration in 79 pts.

The very mechanical nature of the system leads to migration.

The strain relief loop isn't enough. You have a long lead swirled about in the epidural space with the running end sitting in the foramen.
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Kinda wonder how much that doc is paid by Abbott.
 
I see numerous patients with traditional dorsal column implants either hate it, doesn’t work, “leads are perfect” which honestly lots of time they are well situated, can’t get in touch with rep, pain doc or surgeon doesn’t want to see me..etc. I used to do a bunch as a fellow. As long as I have been an attending, I’ve done 15 trials total. 10 went perm. Don’t know what happened after. I hope they aren’t seeing someone else cursing me for even recommending it.
 
A single superior and inferior loop with a 50cm drg lead is tough to keep in place.

When I implant I do 90cm leads (lose mri ability) and make multiple loops.

For groin, knee, and foot/ankle I can’t do anything else that works better. It’s 5% of my neuromod
 
Espn123 said:
A single superior and inferior loop with a 50cm drg lead is tough to keep in place.

When I implant I do 90cm leads (lose mri ability) and make multiple loops.

For groin, knee, and foot/ankle I can’t do anything else that works better. It’s 5% of my neuromod
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That might have been the case compared to conventional SCS but I’m not sure it holds up as superior compared to the modern dorsal column options such as high frequency stim. I did just enough DRG in fellowship to decide it was a big hassle but not enough to be good at doing it on my own, so I just do dorsal column. I don’t feel like my CRPS patients are suffering for it though. Some of my biggest SCS home runs have been in patients you wouldn’t think could get better. 10+ years of CRPS with deformity of the limb. Now getting 80+% improvement of pain and functionality.
 
Clinical bias. What we see in our practices distorts the truth through literature based on on our experience. Letting go of that emotional attachment and anything is possible. But based on literature, nothing really works.
 
callmeanesthesia said:
That might have been the case compared to conventional SCS but I’m not sure it holds up as superior compared to the modern dorsal column options such as high frequency stim. I did just enough DRG in fellowship to decide it was a big hassle but not enough to be good at doing it on my own, so I just do dorsal column. I don’t feel like my CRPS patients are suffering for it though. Some of my biggest SCS home runs have been in patients you wouldn’t think could get better. 10+ years of CRPS with deformity of the limb. Now getting 80+% improvement of pain and functionality.
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Happy for your patients.

For me scs doesn’t work for failed tka, post-hernia pain. Foot and ankle does some but not as good as drg in my practice.
 
Dr. Ice said:
I see numerous patients with traditional dorsal column implants either hate it, doesn’t work, “leads are perfect” which honestly lots of time they are well situated, can’t get in touch with rep, pain doc or surgeon doesn’t want to see me..etc. I used to do a bunch as a fellow. As long as I have been an attending, I’ve done 15 trials total. 10 went perm. Don’t know what happened after. I hope they aren’t seeing someone else cursing me for even recommending it.
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How have you done 10 DRG stim implants and not seen any of these patients back for a clinic follow up ?
 
Espn123 said:
Happy for your patients.

For me scs doesn’t work for failed tka, post-hernia pain. Foot and ankle does some but not as good as drg in my practice.
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callmeanesthesia said:
That might have been the case compared to conventional SCS but I’m not sure it holds up as superior compared to the modern dorsal column options such as high frequency stim. I did just enough DRG in fellowship to decide it was a big hassle but not enough to be good at doing it on my own, so I just do dorsal column. I don’t feel like my CRPS patients are suffering for it though. Some of my biggest SCS home runs have been in patients you wouldn’t think could get better. 10+ years of CRPS with deformity of the limb. Now getting 80+% improvement of pain and functionality.
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I’d definitely argue that traditional SCS is not good for post TKA, post hernia surgery pain.

Dorsal column scs It can be helpful for many but not all foot CRPS cases. Traditional stim also has a much better track record of not needing revisions compared to DRG.
Good enough that I’d start with dorsal column first for foot CRPS and only do DRG if that trial fails.
 
bedrock said:
How have you done 10 DRG stim implants and not seen any of these patients back for a clinic follow up ?
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Did dorsal column trials. Sent to surgeon for perm. Didn’t see them back afterwards. Surgeon was not in my practice
 
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