Perc SCS in patients with FBSS?

IPSIS: Formerly the Spine Intervention Society
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Sure, why not? I’m a huge stim skeptic, but if that’s me I’m trying it.
 
MitchLevi said:
Sure, why not? I’m a huge stim skeptic, but if that’s me I’m trying it.
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I presume the question was regarding entering at the level of prior surgery. I haven’t done it… but I guess if there was no decompression, and just instrumentation for another reason (ie deformity), it’s technically doable.
 
I’ve done this and it’s not bad. As long as there’s a lamina and LF you’re perfectly safe to do it, just be aware you’re losing XRAY to the metal and it’s a tad harder to see.
 
lobelsteve said:
This is malpractice.
I do not care about the wires. Placing a battery on top of the spine is ftarded/cruel.
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Send that thing out laterally. I did a course at NANS one yr and one of the cadaver lab instructors was teaching one incision for everything. I don’t recommend that.
 
in each case, they drove the leads through part if not all of the surgical area.

case 1 - c3-t1 posterior fusion and c4-7 anterior fusion. lead entry T3-4 and threaded to C6 (couldnt go further)

case 2 - T4-L5 posterior fusion, entry T12-L1 and up to T7.

case 3 - T9-S1 posterior fusion, on apixiban, entry T1-L1 and leads to T8-9.

case 4 - C56 posterior fusion and C56 ACDF, entry T3-4 and leads to C3.

case 5 - t9-s1 thoracolumbar fusion, entry T11-12 and leads to T6. no benefit with trial.

case 6 - L5S1 laminectomy, DISH. multiple entry attempts, dural puncture needing blood patch, then went directly to paddle leads at T10 with no other trial.


in none of these patients was follow up longer than 3 months.

truthfully, im not sure the point of the article other than to say "hey, we are willing to try to drive a lead in previous surgical field."
 
cameroncarter said:

Is this a common practice?
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It's not common practice and hence why this is published as a case series/report.
It's not that uncommon though. Academic docs need to have something to talk about as they can't just use the usual dinner/drink talk to write guidelines.

Agree the IPG positioning is not great
Agree the metal makes visualization miserable.

I normally spend some time with a MARS MRI and CT to see if there are access windows, epidural fat, etc. I much prefer retrograding in over trying to access in the fusion beds.

It's a trial. You are meant to try. Failing placement should be an expected and acceptable outcome, I would suggest, at least 1 - 5% of the time if you're in the community and 5 - 15% if you're in an academic center.
 
Orin said:
It's not common practice and hence why this is published as a case series/report.
It's not that uncommon though. Academic docs need to have something to talk about as they can't just use the usual dinner/drink talk to write guidelines.

Agree the IPG positioning is not great
Agree the metal makes visualization miserable.

I normally spend some time with a MARS MRI and CT to see if there are access windows, epidural fat, etc. I much prefer retrograding in over trying to access in the fusion beds.

It's a trial. You are meant to try. Failing placement should be an expected and acceptable outcome, I would suggest, at least 1 - 5% of the time if you're in the community and 5 - 15% if you're in an academic center.
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Can you share more of your approach in this? In post-fusion patients I find MRI's are near unreadable with degree of metal artifact.
 
so if there is a patient who is fused, say T6-L5, do you consider stim? Risk of dural puncture due to possibly scared/adhered epidural space? Do you go straight to pump?
 
lobelsteve said:
Neither is a good idea.
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so then what do you do for these patients?
oral meds only?
SgtThunderfistMD said:
I thought pumps were a thing of the past. "Straight to pump" implies it's along an algorithm you follow
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why would they be a thing of the past?
meds > injections > stim > pump is typically what I tend to think of in terms of increasing invasiveness/risk in what I can offer.
 
oral non-opioid meds, PT, lifestyle changes, pain psych, difficult conversation (learn to accept the pain, which goes along with ACT therapy)
your thinking, while noble in the endeavor, seems very algorithmic
pumps don't help people (excluding baclofen pumps for spasticity)
most pain doctors have gone away from pumps
 
Status Sciaticus said:
so then what do you do for these patients?
oral meds only?

why would they be a thing of the past?
meds > injections > stim > pump is typically what I tend to think of in terms of increasing invasiveness/risk in what I can offer.
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I got nothing. They aren’t going to get better and they might not want to get better.
 
Status Sciaticus said:
so then what do you do for these patients?
oral meds only?

why would they be a thing of the past?
meds > injections > stim > pump is typically what I tend to think of in terms of increasing invasiveness/risk in what I can offer.
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Can’t help everyone unfortunately, and I would encourage you to avoid pumps unless you’re seeing terminal cancer pain.

Prob the best thing I’ve ever done is learn to tell ppl they’re going to hurt indefinitely. Remember, pain is elective in 99.9% of cases, and it is a normal phenomenon. Life hurts for most ppl after a certain point in life, and you can’t add tread back to the tire. Acceptance is huge, and if you can figure out a slick way to impart that to your pts you’ll be an amazing doctor, AND you’ll make more money bc you will learn who needs those extra 10 min of your time and who does not.
 
Yes, when people are complaining about their pain that we can’t fix I just reinforce that this is a normal part of the human condition.

“This is just the task that you were given. We are all given different tasks in life. But you are here, you are of sound mind, you don’t have a wheelchair and you aren’t leaning on your granddaughter to get around.”


Also, helps that I try to keep all of the profoundly disabled patients in the practice so they see people in much worse shape at every visit.
 
MitchLevi said:
Can’t help everyone unfortunately, and I would encourage you to avoid pumps unless you’re seeing terminal cancer pain.

Prob the best thing I’ve ever done is learn to tell ppl they’re going to hurt indefinitely. Remember, pain is elective in 99.9% of cases, and it is a normal phenomenon. Life hurts for most ppl after a certain point in life, and you can’t add tread back to the tire. Acceptance is huge, and if you can figure out a slick way to impart that to your pts you’ll be an amazing doctor, AND you’ll make more money bc you will learn who needs those extra 10 min of your time and who does not.
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What is your reasoning to avoid pumps for non-cancer pain?
 
In my experience the pumps have the best benefits to risk profile for cancer patients, “legacy” patients rotating off a high dose MME, and managed in a place with legitimate 24/7 care with extensive ability to manage all complications (pump refills, medication ordering, medication rotation) etc.
 
I don’t know anyone who does pumps.

Clarify - Universities do them, rarely private practice guys but a dude I went to residency with does them for cancer pts.
 
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MitchLevi said:
They don’t work and they require maintenance.
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Status Sciaticus said:
What is your reasoning to avoid pumps for non-cancer pain?
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Not critizing you status, but it is well established that pain pumps are no longer appropriate for any patient other than terminal cancer pain.

The vast majority of private pain physicians do not offer pain pumps to anyone other than terminal cancer patients.
 
bedrock said:
Not critizing you status, but it is well established that pain pumps are no longer appropriate for any patient other than terminal cancer pain.

The vast majority of private pain physicians do not offer pain pumps to anyone other than terminal cancer patients.
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Good option for a terminal cancer patient at an academic pain center. Terrible option with any other patient/any other practice setting.
 
I’ve known several colleagues who were drug into lawsuits related to the pump or complications from it. No way would I touch pumps
 
Taus said:
Being on call as a pain fellow is a great way to confirm you never want to manage pumps outside maybe terminal cancer.
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By month 2 of fellowship I realized I hate pumps. They are only maybe 5% of my call burden, but of that burden, have made up 99% of the annoyance.

Hard pass on ever touching one of these things again after fellowship.
 
MitchLevi said:
I don’t know anyone who does pumps.

Clarify - Universities do them, rarely private practice guys but a dude I went to residency with does them for cancer pts.
Click to expand...
i "did" pump trials, would refer out for the implants and managed pumps. i took over a practice with several of them.


interestingly, none of the pump patients ever went back to work or developed a significant degree of functionality. even though SCS is likely to fail, i do a few SCS patients that work full time.


and its a fine line of when the pump is best treatment for cancer pain. for those in hospice, actually a PICC line with external pump works just as well.
 
I do trials and implants - I now have another pain MD who has a compounding pharmacy he gets $$ from do fills and management - life is must better. I do enjoy implanting them but yes the management is horrid.
 
MitchLevi said:
They don’t work and they require maintenance.
Click to expand...
I've had largely the opposite experience, thus far. Maybe that will change.

CleanUp said:
In my experience the pumps have the best benefits to risk profile for cancer patients, “legacy” patients rotating off a high dose MME, and managed in a place with legitimate 24/7 care with extensive ability to manage all complications (pump refills, medication ordering, medication rotation) etc.
Click to expand...

Thats been my experience as well. The non-cancer ones I recommend it to are typically those that on very high doses of narcs and having side effects. Obviously they all get trialed to see if it works.
bedrock said:
Not critizing you status, but it is well established that pain pumps are no longer appropriate for any patient other than terminal cancer pain.

The vast majority of private pain physicians do not offer pain pumps to anyone other than terminal cancer patients.
Click to expand...
I dont take anything as criticism unless its ad hominem attacks or political bashing. I'm just here to learn from everybody.
My understanding is that they are indicated as a last resort for non-cancer pain.
You dont trial patients to at least see if they can get pain relief?
 
Trials aren’t real, whether you’re talking pumps or stimulators, so when you move to surgically implant a pt with a device it’s important to consider the maintenance of the pump. You have to trust that pt completely, bc they cannot miss an appt for any reason. Refills have to be done every 2-3M on avg, and that’s an event in and of itself, especially if you have plans to be busy and run a higher volume clinic.

It is probably true you’re going to make more money for yourself and your practice by not using your time managing these things. Pump refill visits soak up staff and time that is better spent gathering RFAs, which are probably pound for pound the most effective treatment in our field, and one that pays well and carries zero risk.

Pumps fail btw. Catheters kink and clot off, and like I said earlier the pt selection is critical. A terminal cancer pt is the way to go IMO. I’d recommend that to my mother, but I would not recommend a pump to my mother for any other reason. CRPS and failed back are terrible indications. We had insane experiences with Prialt during my fellowship.

Pts on high dose opiates are on high dose opiates by choice, and an IT pump is not an indication for that IMO. Taper the pt down, but don’t throw a pump in there bc you think they need that much MED but are having side effects. That’s backwards actually.
 
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A trial of IT opioid will always help depending on the dose of meds you use.

That gives no information as to the long term benefits or side effects from the treatment.

And almost all of them will have a window of benefit before issues of long term use start showing up but it is too late then.
 
MitchLevi said:
Trials aren’t real, whether you’re talking pumps or stimulators, so when you move to surgically implant a pt with a device it’s important to consider the maintenance of the pump. You have to trust that pt completely, bc they cannot miss an appt for any reason. Refills have to be done every 2-3M on avg, and that’s an event in and of itself, especially if you have plans to be busy and run a higher volume clinic.

It is probably true you’re going to make more money for yourself and your practice by not using your time managing these things. Pump refill visits soak up staff and time that is better spent gathering RFAs, which are probably pound for pound the most effective treatment in our field, and one that pays well and carries zero risk.

Pumps fail btw. Catheters kink and clot off, and like I said earlier the pt selection is critical. A terminal cancer pt is the way to go IMO. I’d recommend that to my mother, but I would not recommend a pump to my mother for any other reason. CRPS and failed back are terrible indications. We had insane experiences with Prialt during my fellowship.

Pts on high dose opiates are on high dose opiates by choice, and an IT pump is not an indication for that IMO. Taper the pt down, but don’t throw a pump in there bc you think they need that much MED but are having side effects. That’s backwards actually.
Click to expand...

Does it really take that much time?
Follow up visit, refill same visit. 99214 + 25 mod for the refill and adjustment.


Ducttape said:
A trial of IT opioid will always help depending on the dose of meds you use.

That gives no information as to the long term benefits or side effects from the treatment.

And almost all of them will have a window of benefit before issues of long term use start showing up but it is too late then.
Click to expand...
Trial indicates the medication works. But yes, dosing will likely escalate as the years go on.
Long term detriments are definitely present, neurohormonal changes, and osteoporosis for sure.
 
Status Sciaticus said:
Does it really take that much time?
Follow up visit, refill same visit. 99214 + 25 mod for the refill and adjustment.



Trial indicates the medication works. But yes, dosing will likely escalate as the years go on.
Long term detriments are definitely present, neurohormonal changes, and osteoporosis for sure.
Click to expand...
well, heroin and fentanyl work too to alleviate pain. you clearly are not prescribing or going to prescribe those agents.


so the shared collective experience is that pumps are tedious and time consuming, and patients develop tolerance and other complications, and arent that effective,.


yet you still want to do them?


yes, good fortune (to quote Mitch) to you.
 
Ducttape said:
well, heroin and fentanyl work too to alleviate pain. you clearly are not prescribing or going to prescribe those agents.


so the shared collective experience is that pumps are tedious and time consuming, and patients develop tolerance and other complications, and arent that effective,.


yet you still want to do them?


yes, good fortune (to quote Mitch) to you.
Click to expand...

The shared collective experience here, which is a small subset of pain physicians.
What makes them tedious or time consuming more so than other interventions like neuromod?

There are practices that are filled with hundreds of pump patients. You're saying they are all just fighting a lost cause?
 
I'm at a university practice that collectively manages about 50 pumps. Any improvements I've seen have been temporary. They account for an outsized portion of stress and procedure complications.

Personally I've gotten rid of my last opioid pump patient last year. Never trialed or implanted any. I still have about five baclofen pumps and while I think they do help, I'm likely not to take on any new ones.
 
okay, the collective experience of the SDN Pain Forum.

you can go ahead and think that you are more knowledgeable than myself. if you dont want to consider my advice, or Mitch's or Ready_User_1 or bubaghanush or clubdeac or BoardingDoc (as they have voiced opinions), then go ahead. you do you.

we will be around for the FO portion of FAFO...
 
Status Sciaticus said:
The shared collective experience here, which is a small subset of pain physicians.
What makes them tedious or time consuming more so than other interventions like neuromod?

There are practices that are filled with hundreds of pump patients. You're saying they are all just fighting a lost cause?
Click to expand...

This “shared collective experience” represents …………a couple hundred years of treating pain patients between the docs on the form.

Some humility might be useful, young padowan.

You won’t learn otherwise and quite importantly, no one will want to teach you anything.
 
Again, our opinions are our own, and you absolutely can trial, implant and manage pumps.

It is definitely something you can do, and it would not be out of the purview of your education and training.

If you like pumps, throw a few into a select group of pts, and then organize your clinic around those people, because that is how you manage them...You have to carve out an entire service line in your clinic for them, but again...You CAN do it.

You will find pumps nearly exclusively limited to university settings, and most PP doctors do not offer them.

There is a female KOL that used to manage several hundred pumps at one point, and I went to a course she taught. I see on OpenPayment she has been paid $150k by Medtronic.
 
Also, don’t recommend pumps unless as @MitchLevi pointed out you are willing to develop a full service line for these patients. We refer out to the docs here locally who have done that for select patients. I would say dip your toe in the water with cancer patients and then decide if it is for you.
 
I’d question the true indication for these multilevel HR surgeries over the cavalier perc lead placement … no way the hardware caused perfect spinal alignment IMO.
 
Ducttape said:
okay, the collective experience of the SDN Pain Forum.

you can go ahead and think that you are more knowledgeable than myself. if you dont want to consider my advice, or Mitch's or Ready_User_1 or bubaghanush or clubdeac or BoardingDoc (as they have voiced opinions), then go ahead. you do you.

we will be around for the FO portion of FAFO...
Click to expand...
Yes, that is what I am saying - that it is anecdotal evidence. If you have data of some sort, such as explant rates or failure of therapy, I'd happily read it and change my perspective accordingly.

Its seems a bit biased and hypocritical to hate on pumps but then keep implanting stims knowing that their therapy also has an expiration date.
bedrock said:
This “shared collective experience” represents …………a couple hundred years of treating pain patients between the docs on the form.

Some humility might be useful, young padowan.

You won’t learn otherwise and quite importantly, no one will want to teach you anything.
Click to expand...
I don't think I said I know better than any of you. I am simply asking for some objective information than he said, she said.

MitchLevi said:
Again, our opinions are our own, and you absolutely can trial, implant and manage pumps.

It is definitely something you can do, and it would not be out of the purview of your education and training.

If you like pumps, throw a few into a select group of pts, and then organize your clinic around those people, because that is how you manage them...You have to carve out an entire service line in your clinic for them, but again...You CAN do it.

You will find pumps nearly exclusively limited to university settings, and most PP doctors do not offer them.

There is a female KOL that used to manage several hundred pumps at one point, and I went to a course she taught. I see on OpenPayment she has been paid $150k by Medtronic.
Click to expand...
Thanks for the level headed response. If you see that a procedure is limited to university settings rather than PP, would that not imply that it is due to financial considerations or workflow limitations rather than the therapies themselves?

BobBarker said:
Also, don’t recommend pumps unless as @MitchLevi pointed out you are willing to develop a full service line for these patients. We refer out to the docs here locally who have done that for select patients. I would say dip your toe in the water with cancer patients and then decide if it is for you.
Click to expand...
Thats what I am currently doing.
 
first, it is actually on you to look up the data, not us. we have decided what to do. you are touting this great new therapy that has been around for 30+ years.

but to humor you and since my first patient seems to be a no show (and caveat, almost all the studies looked at baclofen pumps, not opioid, which i think can be an appropriate indication.)


1. in this retrospective analysis of baclofen pump, 37.5% had complications

pubmed.ncbi.nlm.nih.gov

Complications of Intrathecal Baclofen Pump Therapy: An Institutional Experience from Saudi Arabia - PubMed

The intrathecal baclofen pump (ITB) is one of the advanced treatment options in the management of spasticity. This retrospective cohort study was conducted to identify the complications of ITB treatment at a tertiary care rehabilitation facility. Various demographic and technical factors were...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov


in this study, 27% complication rate.

pubmed.ncbi.nlm.nih.gov

Uncovering the rate and risk factors of intrathecal baclofen pump-associated complications in the adult population - PubMed

The authors' analysis reveals a previously underrecognized association between ambulatory status at the time of ITB pump implantation and the incidence of catheter-related complications, and confirms the impact of time since surgery on the risk of developing any ITB-related complication. The...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

this study from Slovenia showed 27% again.

pubmed.ncbi.nlm.nih.gov

Twenty years of intrathecal baclofen therapy in Slovenia: a retrospective single-center analysis of complications - PubMed

Since the first implantation in July 2001, the intrathecal baclofen (ITB) therapy for patients with generalized spasticity has been used in Slovenia for 20 years. The aim of this retrospective study was to evaluate the rates of different complications, especially if catheter-related...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov


this meta-analysis showed out of 501 pumps, there were 203 medical complications.

pubmed.ncbi.nlm.nih.gov

Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis - PubMed

Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

3. are there risks? yes. per this study:
However, ITB pump surgery is associated with one of the highest rates of surgical site infection (SSI) in medicine, leading to significant morbidity and expense.
Click to expand...
pubmed.ncbi.nlm.nih.gov

A multicenter initiative to reduce intrathecal baclofen pump surgical site infection: a Cerebral Palsy Research Network quality improvement project - PubMed

This is the first multicenter QI initiative designed to reduce SSI in ITB surgery in children with CP. Ongoing enrollment and expansion of the protocol to other CPRN centers will facilitate identification of patient- and procedure-specific risk factors for SSI, and iterative plan-do-study-act...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Its seems a bit biased and hypocritical to hate on pumps but then keep implanting stims knowing that their therapy also has an expiration date.
Click to expand...
apples to oranges. expiration date for pumps exist. the concern is not the need to reimplant an expired pump or a SCS, it is the complication rate due to the placement of the device and the drug mechanism of action and its risks. please note that the above complication rates were for baclofen, and opioids have significantly more risk than baclofen


oh and N of 3 locally of the major opioid pump practices - there were only 4 - when i started that are now out of the pump business. 1 of them having had his license suspended, one of them fired from the system he was working in.


but you do you. good luck with your practice model.

please feel free to post your contact info so we can pass along the pump patients that dont have a pump doctor any longer.
 
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