Over neuromod

[paindoc34]

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Feeling so jaded by SCS and PNS lately. I'm taking more systems out (from other docs) than placing. These are patients that are tired of having it in and systems "just not working/never worked".
I only place perms for slam dunk trials. But it seems like most other pain docs put these in for everyone who walks through the door. I'm often the last stop for a lot of patients, and find myself with many patients who want explants. Not a whole lot of profit for me, but it helps patients trust me I think and build rapport. Unfortunately not sure what to do with them after because they are set on med management since they "have tried everything".
What do you guys do for these patients after? Should I just send back to their implanting doc for explant? Often times the patients were discharged...

 

[clubdeac]

Feeling so jaded by SCS and PNS lately. I'm taking more systems out (from other docs) than placing. These are patients that are tired of having it in and systems "just not working/never worked".
I only place perms for slam dunk trials. But it seems like most other pain docs put these in for everyone who walks through the door. I'm often the last stop for a lot of patients, and find myself with many patients who want explants. Not a whole lot of profit for me, but it helps patients trust me I think and build rapport. Unfortunately not sure what to do with them after because they are set on med management since they "have tried everything".
What do you guys do for these patients after? Should I just send back to their implanting doc for explant? Often times the patients were discharged...

you've only got a few options once explanted. Here's my algorithm:

If axial lbp: aggressive rehab, NSAIDs, muscle relaxants, cymbalta etc. and if facetogenic - mbb then RFA; discogenic w/modic changes BVN. If intractable then pump, ketamine infusions or scrambler therapy

If appendicular > axial: neuromodulators like lyrica, neurontin, cymbalta. Lumbar ESIs or LSBs. If intractable then pump or ketamine infusions

 

[BobBarker]

And we have a young colleague on LinkedIn who has done 100 implants and trials in his first 6 months in fellowship.

 

[BobBarker]

I wouldn’t let patients coming in from outside wanting explant affect your trial and perm decision making for your own patients. You might not have trialed any of the ones you are explanting.

 

[drusso]

Are they tender to palpation over or near the distribution of the cluneal nerves?

 

[pmrmd]

And we have a young colleague on LinkedIn who has done 100 implants and trials in his first 6 months in fellowship.

I saw that too. 100 since August is insane. Busy practice blah blah. No dude it’s a questionable practice.

 

[Ducttape]

needle jockeys, and we wonder why Big Insurance wants to limit the procedures we offer.


review for missed standard treatments (imo not ketamine, pumps or scrambler) such as MBB/RFA, but for the most part, if these patients have truly undergone multimodal care and procedures, then the "next step" may be quality of life and functioning maintenance, and pain psychological approaches for those in which everything has failed.


oh and cluneal nerve blocks because...

 

[clubdeac]

needle jockeys, and we wonder why Big Insurance wants to limit the procedures we offer.


review for missed standard treatments (imo not ketamine, pumps or scrambler) such as MBB/RFA, but for the most part, if these patients have truly undergone multimodal care and procedures, then the "next step" may be quality of life and functioning maintenance, and pain psychological approaches for those in which everything has failed.


oh and cluneal nerve blocks because...

Have you looked at the data for scrambler?!? Where’d my guy go. You chased him off the forum. Shame shame shame

 

[drmamba]

I wouldn’t let patients coming in from outside wanting explant affect your trial and perm decision making for your own patients. You might not have trialed any of the ones you are explanting.

I’m glad you commented on that thread on LI and did so with professionalism.

 

[interjectionreflection]

I’m glad you commented on that thread on LI and did so with professionalism.

Got a link to the thread?

 

[Agast]

I’m glad you commented on that thread on LI and did so with professionalism.

Oh my stars, the poor boy isn’t even listed on the website at the place he states he works. Just the neurosurgeon, his MD wife and the PAs. If he ever realizes what he’s gotten himself into, the neurosurgeon will just replace him with someone else and it will be like he never existed.

 

[BobBarker]

It is a terrible thing. The county isn’t even that populated. The same as my county in Oklahoma. Oneida County, NY

 

[Ducttape]

hey, Oneida county has a lot to do!

there's a BK, Starbucks and Panera Bread at the Oneida I-90 Eastbound rest stop.

 

[BobBarker]

@Ducttape what is going on with this young doctor and his practice? Quick summary, young guy straight out of fellowship has on LinkedIn that he has already done 100 trials and implants. Works with (for) a single neurosurgeon. Who did all of the injections and RFA’s to get to that point? The PA’s is my suspicion, but I don’t know. Surgeons website is ok but a little odd, advertising “Tiger Woods surgery” aka ALIF like it is a new thing, section for foreign patients visiting for surgery. Has the neurosurgeon, his physician wife, a bunch of PA’s listed, but not the pain doctor. CNY brain and spine

 

[MitchLevi]

Wow. Sketchy. I think that's obviously a tall blade of grass waiting to be cut by the lawnmower.

 

[Dawkter]

Feeling so jaded by SCS and PNS lately. I'm taking more systems out (from other docs) than placing. These are patients that are tired of having it in and systems "just not working/never worked".
I only place perms for slam dunk trials. But it seems like most other pain docs put these in for everyone who walks through the door. I'm often the last stop for a lot of patients, and find myself with many patients who want explants. Not a whole lot of profit for me, but it helps patients trust me I think and build rapport. Unfortunately not sure what to do with them after because they are set on med management since they "have tried everything".
What do you guys do for these patients after? Should I just send back to their implanting doc for explant? Often times the patients were discharged...

I have never understood why we refer patients to the more invasive thing first and then offer the less invasive thing once that fails.

There are very few patients who I see that continue to benefit from SCS after the 1-2 year mark so I feel similar to you.

In my opinion, the most impactful procedure we offer patients is RFA.

 

[Ducttape]

i actually do not know anything about him.

there is a big group that is located in the adjacent city that has a pretty big catchment area. there is a teaching hospital in the other direction, but both are about 50 miles away.

he may have either become a new pain doc with all of these postsurgical patients that were never introduced to neuromodulation or less likely he may be poaching some business off of those other practices, but i know of one interventionalist in that area that does a lot of procedures (and a lot of pumps). so i would suspect the former.

 

[SpineandWine]

you've only got a few options once explanted. Here's my algorithm:

If axial lbp: aggressive rehab, NSAIDs, muscle relaxants, cymbalta etc. and if facetogenic - mbb then RFA; discogenic w/modic changes BVN. If intractable then pump, ketamine infusions or scrambler therapy

If appendicular > axial: neuromodulators like lyrica, neurontin, cymbalta. Lumbar ESIs or LSBs. If intractable then pump or ketamine infusions

Is this sarcasm or you still do pumps?

 

[Agast]

@Ducttape what is going on with this young doctor and his practice? Quick summary, young guy straight out of fellowship has on LinkedIn that he has already done 100 trials and implants. Works with (for) a single neurosurgeon. Who did all of the injections and RFA’s to get to that point? The PA’s is my suspicion, but I don’t know. Surgeons website is ok but a little odd, advertising “Tiger Woods surgery” aka ALIF like it is a new thing, section for foreign patients visiting for surgery. Has the neurosurgeon, his physician wife, a bunch of PA’s listed, but not the pain doctor. CNY brain and spine

I think it’s more like, the PAs are ordering all the procedures and doing most of the work up and he is spending most of his time in the procedure room. He is probably not having to write for pain meds which is enough to satisfy his threshold for concern.

 

[clubdeac]

Is this sarcasm or you still do pumps?

No I quit doing them in 2009 but if you’re a comprehensive pain specialist you should

 

[Ducttape]

I think it’s more like, the PAs are ordering all the procedures and doing most of the work up and he is spending most of his time in the procedure room. He is probably not having to write for pain meds which is enough to satisfy his threshold for concern.

probably, but usually a trial of an epidural of some sort is considered prior to approval for SCS.

 

[swamprat]

Axial back pain = fuse something

Radicular back pain = decompress something

So easy , no need for stim. 😆

 

[Centurion38]

The PA's are writing meds. The patients are probably given the choice of following a "comprehensive" pain treatment plan ie. SCS/PNS or no more meds. I'd bet a fair amount of Medicare and retirees in that area.

The wife is an EM doc who also runs an urgent care. The surgeon may own his own ASC and probably takes a bunch of the trials to paddle implant.

This guy is a businessman. He's running a spine clinic and a pill mill at the same time.

 

[Ducttape]

you can check their prescribing on the CMS website.

Centers for Medicare & Medicaid Services Data

data.cms.gov

 

[Mr. Subutex]

How does everyone feel about SPRINT? We had some good results when I was in training for folks that failed lumbar RFA for example

 

[Gnarvin]

How does everyone feel about SPRINT? We had some good results when I was in training for folks that failed lumbar RFA for example

I am giving it a try for axial low back pain in select cases. I have been using it for axial low back pain that seems mechanical, likely failed diagnostic MBB, and the patient is not a candidate for Intracept. Naturally, a lot of patients that meet all of those criteria often are fibro/nociplastic type patients. I am getting mixed results. I have had some patients that report 0 relief even though they feel the stimulation. I have had some that get 50-60% relief while the leads are in. I am waiting to see how long the relief lasts for the patients that do get some relief. I am overall not particularly impressed thus far but I need a bigger sample size really.

I am interested in getting trained in Reactiv8, also. I’d be curious to hear everyone’s experience with Reactiv8.

 

[mille125]

Have you looked at the data for scrambler?!? Where’d my guy go. You chased him off the forum. Shame shame shame

I am back. Life chased me off for 3 months. Definitely not you guys.

Scrambler (at least in my hands) is excellent in this case with no trauma and much less expense to the system......but would expect most here to understand.

 

[mille125]

Feeling so jaded by SCS and PNS lately. I'm taking more systems out (from other docs) than placing. These are patients that are tired of having it in and systems "just not working/never worked".
I only place perms for slam dunk trials. But it seems like most other pain docs put these in for everyone who walks through the door. I'm often the last stop for a lot of patients, and find myself with many patients who want explants. Not a whole lot of profit for me, but it helps patients trust me I think and build rapport. Unfortunately not sure what to do with them after because they are set on med management since they "have tried everything".
What do you guys do for these patients after? Should I just send back to their implanting doc for explant? Often times the patients were discharged...

These guys are going to kill our specialty. We already have way more scrutiny than others with WISER and all of these other directives coming out.

Just recently I have seen a guy do trigger points in every possible muscle and bill personal injury well over 30K for it. I have seen numerous docs implanting SCS on Medicare patients (Ie no auth) without in injections or therapy or anything.

I never thought I would say this, but I really hope that Medicare eventually prior auths SCS and PNS. It is unfortunately the only way to extinguish what far too many are doing and hurting patients and the specialty al the while.

 

[paingate21]

Where’s the LinkedIn link for the above physician?

 

[TrailRun]

I am giving it a try for axial low back pain in select cases. I have been using it for axial low back pain that seems mechanical, likely failed diagnostic MBB, and the patient is not a candidate for Intracept. Naturally, a lot of patients that meet all of those criteria often are fibro/nociplastic type patients. I am getting mixed results. I have had some patients that report 0 relief even though they feel the stimulation. I have had some that get 50-60% relief while the leads are in. I am waiting to see how long the relief lasts for the patients that do get some relief. I am overall not particularly impressed thus far but I need a bigger sample size really.

I am interested in getting trained in Reactiv8, also. I’d be curious to hear everyone’s experience with Reactiv8.

I may be wrong, but isn’t a sprint PNS to the lumbar region doing basically the same thing as reactiv8 ie stimulating the multifidus

 

[clubdeac]

I may be wrong, but isn’t a sprint PNS to the lumbar region doing basically the same thing as reactiv8 ie stimulating the multifidus

I think so but haven't done a deep dive into the physics including the waveforms, stim patterns etc. And all that sheet probably don't matter anyway

 

[mille125]

I may be wrong, but isn’t a sprint PNS to the lumbar region doing basically the same thing as reactiv8 ie stimulating the multifidus

I can do the same with axon therapy. Magnetic stimulation. No complications

 

[Mr. Subutex]

I may be wrong, but isn’t a sprint PNS to the lumbar region doing basically the same thing as reactiv8 ie stimulating the multifidus

I’ve asked reps about this, and they didn’t have a great answer. My best guess is both the medial branch and the multifidus. Of course, without having a barbed piece of metal in your back

 

[BobBarker]

These guys are going to kill our specialty. We already have way more scrutiny than others with WISER and all of these other directives coming out.

Just recently I have seen a guy do trigger points in every possible muscle and bill personal injury well over 30K for it. I have seen numerous docs implanting SCS on Medicare patients (Ie no auth) without in injections or therapy or anything.

I never thought I would say this, but I really hope that Medicare eventually prior auths SCS and PNS. It is unfortunately the only way to extinguish what far too many are doing and hurting patients and the specialty al the while.

Prior auth for scs for Medicare won’t matter unless they change the ncd. It is literally 1/2 page and doesn’t have any real restrictions.

 

[mille125]

Prior auth for scs for Medicare won’t matter unless they change the ncd. It is literally 1/2 page and doesn’t have any real restrictions.

I think that you would be surprised.
In my expert witness work and in just seeing patients from other doctors, I see widespread violation of Medicare LCD/NCD. First and foremost, whether you agree with it or not, the LCD says that SCS is a treatment of last resort meaning other things must have failed.

I saw a patient just this week who had a 3 month history of mostly axial back pain. According to the patient, the doc first said that there is nothing they can do. Then later they ordered a Nevro SCS trial (which did not work). No Meds. No PT. No Chiro. No MBBs. Just SCS. This was from a well respected local doctor.. This happens quite often in Medicare patients that does not require prior auth. At a minimum it stops these actions.

Look,..I am not any advocate of prior auths in general. But this kind of activity is going to destroy our specialty.

 

[mille125]

I think that you would be surprised.
In my expert witness work and in just seeing patients from other doctors, I see widespread violation of Medicare LCD/NCD. First and foremost, whether you agree with it or not, the LCD says that SCS is a treatment of last resort meaning other things must have failed.

I saw a patient just this week who had a 3 month history of mostly axial back pain. According to the patient, the doc first said that there is nothing they can do. Then later they ordered a Nevro SCS trial (which did not work). No Meds. No PT. No Chiro. No MBBs. Just SCS. This was from a well respected local doctor.. This happens quite often in Medicare patients that does not require prior auth. At a minimum it stops these actions.

Look,..I am not any advocate of prior auths in general. But this kind of activity is going to destroy our specialty.

Some of these end up with complications too...

 

[BobBarker]

@mille125 That is so far out of bounds I really never considered someone doing that.

Can you make a separate thread about the expert witness work? How you got into it? How you got cases? How much it pays? My dad is a judge, my little brother is a very low level lawyer. I have a good understanding of basic law from hanging out with dad as a kid when he was in private practice.

 

[mille125]

@mille125 That is so far out of bounds I really never considered someone doing that.

Can you make a separate thread about the expert witness work? How you got into it? How you got cases? How much it pays? My dad is a judge, my little brother is a very low level lawyer. I have a good understanding of basic law from hanging out with dad as a kid when he was in private practice.

It happens more than you think. I have seen it about 3 times since start of 2025.

PM me on your questions about expert work...

 

[Ducttape]

it appears that some pain doctors out there dont care if they are later going to be accused of Medicare fraud when their money gets clawed back.


i personally dont feel putting restrictions and requiring prior auth will reduce recidivists (because they are only interested in $$$) but will make it more complex and challenging for others.

and i say this as someone who asks for stim auth only after someone has failed HEP and/or PT, at least 1 epidural (or not be a candidate), failed gaba, NSAID, SNRI and TCA (or contraindicated), doesnt have surgical option and seen pain psych.

 

[Dansk2011]

it appears that some pain doctors out there dont care if they are later going to be accused of Medicare fraud when their money gets clawed back.


i personally dont feel putting restrictions and requiring prior auth will reduce recidivists (because they are only interested in $$$) but will make it more complex and challenging for others.

and i say this as someone who asks for stim auth only after someone has failed HEP and/or PT, at least 1 epidural (or not be a candidate), failed gaba, NSAID, SNRI and TCA (or contraindicated), doesnt have surgical option and seen pain psych.

I think there are a lot that don't care. I have a seasoned doc I work with (20 years at least) who does only B&B injections most of which are facet injections despite the changes. Also does emgs and over bills. Doesn't care to change despite myself and one of the other younger docs telling him. And does no medications except recommending Tylenol. He's the highest producer in our practice.

 

[nvrsumr]

I turn down so much legal work . I just can’t find a number that makes it stop hurting.

 

[mille125]

I think there are a lot that don't care. I have a seasoned doc I work with (20 years at least) who does only B&B injections most of which are facet injections despite the changes. Also does emgs and over bills. Doesn't care to change despite myself and one of the other younger docs telling him. And does no medications except recommending Tylenol. He's the highest producer in our practice.

Highest producer with just doing facets, ESIs, and EMGs?

 

[Dansk2011]

Highest producer with just doing facets, ESIs, and EMGs?

Yes. Believe it or not. 10 min emgs if that. No prescribing of any sort. Images are absolute garbage for procedures. From what I've seen, which is a good bit, zero use of contrast. But he doesn't care. If he did stim he would be the one not caring about indication. Sorry the point wasn't to complain, it was more to reiterate the fact that there are people out there that just don't care, so long as it makes money, and they are ruining it for everyone else.

 

[JBM16BYU]

Yes. Believe it or not. 10 min emgs if that. No prescribing of any sort. Images are absolute garbage for procedures. From what I've seen, which is a good bit, zero use of contrast. But he doesn't care. If he did stim he would be the one not caring about indication. Sorry the point wasn't to complain, it was more to reiterate the fact that there are people out there that just don't care, so long as it makes money, and they are ruining it for everyone else.

Anecdotally from doing the repeat EMG/NCS and US on individuals who have received 10 minute EMG’s previously, those 10 minute ones are usually abysmal and oftentimes over- or under diagnose the true problem. They just miss the mark. Many of them call things like carpal tunnel syndrome when the patients hands are freezing cold… or never actually do the needle portion and just shock as many nerves as they can in 10 minutes and call it a day.

 

[cowboydoc]

I may be wrong, but isn’t a sprint PNS to the lumbar region doing basically the same thing as reactiv8 ie stimulating the multifidus

Except Sprint is perc leads and temporary. Strongly advocate trial of Sprint for the same prior to even considering Reactiv8 with no trial.

 

[hopefulgasman]

Except Sprint is perc leads and temporary. Strongly advocate trial of Sprint for the same prior to even considering Reactiv8 with no trial.

any issues with lead fracture upon pull after 60 days? I have many patients who could benefit from SPRINT for their refractory axial LBP, but I have been hesitant to place leads due to hearing upon overwhelming instances of lead fracture with no option to remove the fragment.

 

[clubdeac]

any issues with lead fracture upon pull after 60 days? I have many patients who could benefit from SPRINT for their refractory axial LBP, but I have been hesitant to place leads due to hearing upon overwhelming instances of lead fracture with no option to remove the fragment.

Had one fracture with the old system but no issues with their new improved leads

 

[Orin]

Except Sprint is perc leads and temporary. Strongly advocate trial of Sprint for the same prior to even considering Reactiv8 with no trial.

The data and techniques are interesting in how they differ

Sprint is placed directly into the muscle
Reactiv8 is placed at the medial branch draping over the L3 TP

Sprint shows efficacy in 2-4 weeks
Reactiv8 shows efficacy in 2 - 4 months

I suggest either, but pragmatically speaking, Reactiv8 is covered by commercial payors for the unique ICD10 M62.85 of multifidus dysfunction, while Sprint's coverage is hit or miss. CMS patients I prefer SPR for first and convert to Reactiv8/Nalu/etc if needed for longer term, but that's less than 10-20% of the cases.

 

[cowboydoc]

any issues with lead fracture upon pull after 60 days? I have many patients who could benefit from SPRINT for their refractory axial LBP, but I have been hesitant to place leads due to hearing upon overwhelming instances of lead fracture with no option to remove the fragment.

Not yet.

 

[Orin]

Regarding fracture, the newer lead design reduces it, but you want to reduce shearing stress on the lead when you pull it out. I have been happy with it, even when I tunnel it some to keep it more secure.

Even if it fractures though, you're not going to chase the fragment or throw them off MRI conditionality. I wouldn't let this be a barrier to using the therapy.