Peripheral nerve stimulation, does it work?

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Wkrdoc

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I’m seeing more and more PNS implants, (Particularly on social media) and during my training, they were aborted completely due to lack of efficacy.

Now I’m seeing more failed devices come through my office placed by other physicians.

It’s been years since I’ve researched PNS devices (eg stimwave), has the technology changed and are they working better these days?
 
It really is shameful. There is an anesthesiologist that I know that has had some troubles in the past and now is a “pain specialist”. He posted about 10 PNS cases he did from the same day. Those leads are floating around nowhere near the nerves. Just like when a famous SoCal physician posted pictures of intercostal PNS on LinkedIn a couple years ago. Nowhere near the intercostal nerves and wouldn’t reply when softly called out on it. But would reply to the attaboy by andrea trescott.
 
Where are these leads??
5825D48B-EAD5-49CF-83A5-191868DEE4AE.jpeg
 
The hardware is on label now and sometimes better, but a lot of jokers are putting them in willy nilly. Then there's stuff like SPR's stimulator that just needs the electrode tip 1 - 2 cm near a nerve to work.

In talking to the device people, many physicians can't be bothered to get close to the nerve as it's too hard, overstimulates, is not necessary, etc, so much of this is truly peripheral field stim. There's a talking head over on the west coast that doesn't even bother with intraoperative stimulation as their ultrasound skills are that good, and it always works for their patients, so kudos to them?
 
Joe Montana apparently has had his life turned around by peripheral stim. But I bet he gets all the fentanyl spray he wants too.
 
Wkrdoc said:
I’m seeing more and more PNS implants, (Particularly on social media) and during my training, they were aborted completely due to lack of efficacy.

Now I’m seeing more failed devices come through my office placed by other physicians.

It’s been years since I’ve researched PNS devices (eg stimwave), has the technology changed and are they working better these days?
Click to expand...

I don't know. I now get paid the same amount regardless of what I do, so I don't have a financial incentive to do anything.

I still occasionally will do a "field stim" case if the pain is the size of a postcard and axial. I don't do it very often, but it has actually worked very well when I have used it. It's scope, however, is pretty limited. Anchoring anywhere but the midline results in leads migrating all over the place.

I'm still honing the lateral stim technique. We are finding that frequencies above 1000 are needed and higher placement T12/L1, L2 seems to work the best. Previously not a huge Nevro fan, but their system works best for this. Of course, it is "experimental" at this time. Nonetheless, it appears promising.
 
Wkrdoc said:
I’m seeing more and more PNS implants, (Particularly on social media) and during my training, they were aborted completely due to lack of efficacy.

Now I’m seeing more failed devices come through my office placed by other physicians.

It’s been years since I’ve researched PNS devices (eg stimwave), has the technology changed and are they working better these days?
Click to expand...

I have done a decent amount of PNS trials and subsequent implants (genicular nerve, superficial perineal nerve, ilioinguinal/iliohypogastric, femoral articulations branch, suprascular, etc) with very good results. I think the key is selecting patients that get good (but temporary) pain relief following an ultrasound or stim guide block of a specific peripheral nerve. I find this is a limiting factor because not too man Pain docs are experienced enough with neuroantomy and ultrasound guidance to find and block targeted peripheral nerves since they can be hard to localize.
Most people end up just doing a peripheral field stimulation.
 
Have not seen good long term results with SPR. In fact, I'd say it works as good as you'd expect the MOA to work. When it's in, it works. When you pull it, it doesn't. I've had better long term results with Bioness, which I'd expect. Have not tried Stimwave, so can't comment.
 
I do agree there are a lot of jokers doing field stim with PNS hardware.

It's not magical, but it is another option and for some of my anticoagulated patients with focal pain, it beats something in the neuraxis.
 
Green Grass said:
Have not seen good long term results with SPR. In fact, I'd say it works as good as you'd expect the MOA to work. When it's in, it works. When you pull it, it doesn't. I've had better long term results with Bioness, which I'd expect. Have not tried Stimwave, so can't comment.
Click to expand...

I have had good success with Stimwave.
 
PM&R90 said:
I have had good success with Stimwave.
Click to expand...
Do you get it covered by insurance, and what CPT codes/diagnoses do you use? And judging by the nerves you are talking about targeting, are you using it for arthritic pain?
I’m in an Ortho practice and I see a lot of end stage shoulders in non-surgical candidates. Would be nice to have something beyond serial SSNBs to offer them (I did see a poster for an RF that targets more terminal branches to avoid motor weakness - haven’t tried that yet)
 
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callmeanesthesia said:
Do you get it covered by insurance, and what COT codes/diagnoses do you use? And judging by the nerves you are talking about targeting, are you using it for arthritic pain?
I’m in an Ortho practice and I see a lot of end stage shoulders in non-surgical candidates. Would be nice to have something beyond serial SSNBs to offer them (I did see a poster for an RF that targets more terminal branches to avoid motor weakness - haven’t tried that yet)
Click to expand...
Or you can burn the heck out of it and not lose any functional strength.
Simopoulis out of Harvard published this years ago. And I have posted it in these forums.
 
lobelsteve said:
Or you can burn the heck out of it and not lose any functional strength.
Simopoulis out of Harvard published this years ago. And I have posted it in these forums.
Click to expand...
I have considered it - these patients have no ROM to lose. But the nerve block seems to work well enough for 2 months or so, that no one has taken me up on “hey, let me try this on you”
 
lobelsteve said:
Fluoroscopy. Drop into bottom of notch.
Click to expand...

Got any pics? I'm gonna start abating that nerve. I do a good bit of US, but never fluoro.

I do ablations at 85 deg for 2 min, what do you do for that nerve?

Bill for the block only, or can you get a CPT for the ablation?
 
callmeanesthesia said:
Do you get it covered by insurance, and what CPT codes/diagnoses do you use? And judging by the nerves you are talking about targeting, are you using it for arthritic pain?
I’m in an Ortho practice and I see a lot of end stage shoulders in non-surgical candidates. Would be nice to have something beyond serial SSNBs to offer them (I did see a poster for an RF that targets more terminal branches to avoid motor weakness - haven’t tried that yet)
Click to expand...

I work at a Department of Defense hospital, so I don’t have to worry about insurance coverage.
I almost always include “other chronic pain” as one of my diagnoses in addition to the structural pathology (rotator cuff pathology, labral tears, etc).
So far I have had good results with PNS stim of the suprascapular nerve For these types of lesions or post surgery failures.
 
Now that the articulate branches have been better described for shoulder and hip you should consider RF those instead.
 
N of 1 as well for suprascapular nerve Sprint PNS after chronic rotator cuff issues with no further operative options. Pt said she had great relief, and even 1 month after pulling the lead relief continues. Just placed saphenous one (adductor canal) for chronic knee pain who wants to avoid TKA. We shall see.

I personally chose to test ride PNS with Sprint because it’s very easy to place and temporary.
 
What is everyone's experience with the SPRINT system-- prolonged pain relief after 60 day removal?
 
Does sprint have an in-office placement code?
 
stsa84 said:
Well, with an n of 1, I've had 100% relief of lower back pain with Sprint PNS after failed RFA.
Click to expand...
How long ago was the RFA?
If recent, it totally makes sense to burn ‘em then stim ‘em
 
Tboned said:
How long ago was the RFA?
If recent, it totally makes sense to burn ‘em then stim ‘em
Click to expand...
6 months, giving medial branches theoretical time to grow back, if they were ablated in the first place. Facing surgery, he wanted to try PNS. He couldn't be happier.
 
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