Non-operative shoulders...

[Timeoutofmind]

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I get a lot of ortho referrals.

Decent amount of non operative shoulders

For instance a lady age 50 with BL massive rotator cuff tears, non operative as per more than one ortho. Basically cant use her shoulders at all without major pain. Pretty debilitating.

What do you guys do for these people?

I am not sure that I am a big fan of thermal RF of suprascapular given that she is only 50, would have to be repeated many times, nearness of suprascapular artery, and risks of deafferentation pain etc...

I have done a peripheral nerve stim (bioness stimrouter) to axillary nerve for a similar patient after a positive test block, but frankly the stim results kinda sucked.

Any other ideas?

Just tell her she is doomed to a life of pain and debility?

 

[Biohazard685]

Why is she non operative? High BMI? Co-morbidities? How did she respond to ssnb?

 

[willabeast]

I get a lot of ortho referrals.

Decent amount of non operative shoulders

For instance a lady age 50 with BL massive rotator cuff tears, non operative as per more than one ortho. Basically cant use her shoulders at all without major pain. Pretty debilitating.

What do you guys do for these people?

I am not sure that I am a big fan of thermal RF of suprascapular given that she is only 50, would have to be repeated many times, nearness of suprascapular artery, and risks of deafferentation pain etc...

I have done a peripheral nerve stim (bioness stimrouter) to axillary nerve for a similar patient after a positive test block, but frankly the stim results kinda sucked.

Any other ideas?

Just tell her she is doomed to a life of pain and debility?

See if she knows how to do shoulder strengthening exercises. If she doesn't, that may be the problem.

 

[No Pain All gain]

I’ve had surprisingly good results w Bioness to axillary and suprascap.


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[lobelsteve]

Thermal rf. PT. Repeat.

 

[Orin]

I have done a peripheral nerve stim (bioness stimrouter) to axillary nerve for a similar patient after a positive test block, but frankly the stim results kinda sucked.

Any other ideas?

Just tell her she is doomed to a life of pain and debility?

I've had great response to axillary stim for the classic post-stroke shoulder pain. I've got a handful on my docket for chronic non-operative shoulder pain. In talking with the reps during my implants,

Could you tell me more about why you feel the suprascapular case failed?

In terms of options, I'm not sure what this patient has failed.
In terms of hope, I'm an eternal optimist. There's always stem cells and PRP right?

 

[bedrock]

I've had great response to axillary stim for the classic post-stroke shoulder pain. I've got a handful on my docket for chronic non-operative shoulder pain. In talking with the reps during my implants,

Could you tell me more about why you feel the suprascapular case failed?

In terms of options, I'm not sure what this patient has failed.
In terms of hope, I'm an eternal optimist. There's always stem cells and PRP right?

1-Can you discuss how you technically place the lead for axillary stim?
2-When you do stim for classic non operative shoulder, do you stim just SS or SS + axillary?

 

[Timeoutofmind]

Why is she non operative? High BMI? Co-morbidities? How did she respond to ssnb?

Non operative because the tears are huge and have been there too long so everything is all retracted is my understanding

Good response to SSNB

 

[Timeoutofmind]

I've had great response to axillary stim for the classic post-stroke shoulder pain. I've got a handful on my docket for chronic non-operative shoulder pain. In talking with the reps during my implants,

Could you tell me more about why you feel the suprascapular case failed?

In terms of options, I'm not sure what this patient has failed.
In terms of hope, I'm an eternal optimist. There's always stem cells and PRP right?

The suprascapular implant failed because not good pain relief despite reasonable coverage. Seemed like very mechanical/activity related type pain, not much at rest.

When you say "what this patient has failed", what else would you offer?
PT? Meds? SASDB inj?

 

[Taus]

Why were they were not inclined to do arthroplasty?

 

[Timeoutofmind]

Why were they were not inclined to do arthroplasty?

She would need a reverse TSR I would assume. That is a good thought. I sent a note to the surgeon seeing what he thinks about that.

She has had several shoulder surgeries and now recently three shoulder scopes I know, with RTC repairs, acromioplasty, etc. She has very poor quality tissue which is not healing with repair is what his note says.

 

[lobelsteve]

Thermal RF. And more thermal RF to SSN

 

[drrosenrosen]

Thermal RF. And more thermal RF to SSN

Do you do this under US, Steve, or fluoro? 5 or 10mm active tip? 80deg/90s?

 

[Timeoutofmind]

Here is what he said
"She is really too young for reverse shoulder replacement but I have discussed with her going to the medical College to see if she could have a latissimus transfer. She is thinking it over as far as I am aware. Thanks for your help."

 

[Orin]

1-Can you discuss how you technically place the lead for axillary stim?
2-When you do stim for classic non operative shoulder, do you stim just SS or SS + axillary?

The easiest thing to do is watch one of the youtube animation videos for the Stimrouter showing how you target the axillary nerve in the quadrangular space. I'm pretty anal about getting good motor stimulation throughout the procedure for that nerve in the stroke patients.



For PNS, my thought process is to block first and then stim it if the block helps. I don't like putting two leads in, so I prefer to figure out which one is most involved and target that for the shoulder people.

There are some who could argue about the use of dorsal column stimulation. It's an option and may be worth a trial before doing more surgeries. I'd rather consider that as compared with bilateral PNS systems, but you're looking at C2 leads probably.

Medications are an option if they haven't tried them. Duloxetine is generally my go to as it has FDA approval for chronic MSK pain.

How did she do with PT while the SSNB was working?

 

[lobelsteve]

Do you do this under US, Steve, or fluoro? 5 or 10mm active tip? 80deg/90s?

fluoro, bottom of notch after touching scapula. 10mm tip, 80 degree for 90 sec.

 

[Timeoutofmind]

The easiest thing to do is watch one of the youtube animation videos for the Stimrouter showing how you target the axillary nerve in the quadrangular space. I'm pretty anal about getting good motor stimulation throughout the procedure for that nerve in the stroke patients.



For PNS, my thought process is to block first and then stim it if the block helps. I don't like putting two leads in, so I prefer to figure out which one is most involved and target that for the shoulder people.

There are some who could argue about the use of dorsal column stimulation. It's an option and may be worth a trial before doing more surgeries. I'd rather consider that as compared with bilateral PNS systems, but you're looking at C2 leads probably.

Medications are an option if they haven't tried them. Duloxetine is generally my go to as it has FDA approval for chronic MSK pain.

How did she do with PT while the SSNB was working?

I agree with all but SCS for mechanical shoulder pain seems like a stretch? Anyone ever had success with this? I have not seen any case reports ever of this.

 

[drrosenrosen]

fluoro, bottom of notch after touching scapula. 10mm tip, 80 degree for 90 sec.

Do you do any stim prior to burn?

 

[painfree23]

fluoro, bottom of notch after touching scapula. 10mm tip, 80 degree for 90 sec.

Do you have any pictures? I would love to do this

 

[Gauss]

Here is what he said
"She is really too young for reverse shoulder replacement but I have discussed with her going to the medical College to see if she could have a latissimus transfer. She is thinking it over as far as I am aware. Thanks for your help."

rubbish - 50 is not that young, reverse TSA is not unusual especially in RA population
send to major university or Mayo clinic

 

[lobelsteve]

Do you do any stim prior to burn?

Nope, just place in notch after contacting bone just inferior to notch. Hardest part is getting good view of notch. Arm at 90 deg abd in external rotation is usual. Will find pics of RF. Doing 1 per week or more.

 

[painfree23]

Nope, just place in notch after contacting bone just inferior to notch. Hardest part is getting good view of notch. Arm at 90 deg abd in external rotation is usual. Will find pics of RF. Doing 1 per week or more.

is C-ARM in AP? is this for shoulder pain? diagnostic blocks x 2?

sorry for all the questions but would love to offer this to some patients

 

[pastafan]

Do you do any stim prior to burn?

Lobel is better than me. I stim and as with regional block like twitch at .2-.4V.

 

[Orin]

I agree with all but SCS for mechanical shoulder pain seems like a stretch? Anyone ever had success with this? I have not seen any case reports ever of this.

Right. I'm in your camp, but I'd rather fail a trial than deal with a post-op shoulder.

Treatment of glenohumeral arthritis pain utilizing spinal cord stimulation

The basic science people tell me mechanical and arthritic pain also has a under appreciated neuropathic nature to it, so I'm tempted to try it

 

[bedrock]

Right. I'm in your camp, but I'd rather fail a trial than deal with a post-op shoulder.

Treatment of glenohumeral arthritis pain utilizing spinal cord stimulation

The basic science people tell me mechanical and arthritic pain also has a under appreciated neuropathic nature to it, so I'm tempted to try it

How do you get stim paid for basic non operative shoulder?. Any diagnosis codes, tricks to getting it authorized?

 

[lobelsteve]

Right. I'm in your camp, but I'd rather fail a trial than deal with a post-op shoulder.

Treatment of glenohumeral arthritis pain utilizing spinal cord stimulation

The basic science people tell me mechanical and arthritic pain also has a under appreciated neuropathic nature to it, so I'm tempted to try it

Your banker agrees. Your colleagues do not.

 

[lobelsteve]

is C-ARM in AP? is this for shoulder pain? diagnostic blocks x 2?

sorry for all the questions but would love to offer this to some patients

Patients are prone, II over top. Single dx block.

 

[thecentral09]

Nope, just place in notch after contacting bone just inferior to notch. Hardest part is getting good view of notch. Arm at 90 deg abd in external rotation is usual. Will find pics of RF. Doing 1 per week or more.

how is this billed for. I have done quite a few pulsed RF in fellowship, but never thermal. We did them under US which I know is unbillable

 

[Orin]

Your banker agrees. Your colleagues do not.

Right, it's probably a better bet to keep RFing it. No profitability there for anyone involved.

how is this billed for. I have done quite a few pulsed RF in fellowship, but never thermal. We did them under US which I know is unbillable

As it's a true ablation, you bill it as a 64640

 

[bedrock]

Right, it's probably a better bet to keep RFing it. No profitability there for anyone involved.



As it's a true ablation, you bill it as a 64640

Still hoping to hear your suggestions on how to get stim paid, when used for non operative shoulder.

 

[No Pain All gain]

Mononeuropathy of upper extremity


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[Orin]

Still hoping to hear your suggestions on how to get stim paid, when used for non operative shoulder.

Cervical SCS is generally more annoying to get insurance coverage for in my opinion, but the rationale is the same as for any neuromodulation case. The patient has a chronic pain state that is refractory to conservative treatment, is not a surgical candidate, failed injections, failed medications, etc and a stimulation trial is on the algorithm for treating refractory chronic pain.

In general though, it takes a lot of documentation and a phone call or two. The discussion is rather simple as a stim trial is still cheaper, safer, and less invasive than a shoulder surgery. If they've been operated on before, chronic post-operative pain G89.28 is a simple diagnosis to start with, although depending on the presentation, you can assess if they meet criteria for something simpler for approval like CRPS.

With PNS, if their pain responds well to a single shot nerve block, then it's a simpler discussion of neuromodulation for pain of peripheral nerve origin/mononeuropathy.

 

[lobelsteve]

So why did the L8680 codes go away?

I know, i know.

 

[painfree23]

Any fluoro pictures for the ablation?

 

[Ducttape]

Unfortunately, my LCD stipulates chronic neuropathic pain....