Pump and Stim Implantation in Private Practice

[APDoc]

Just curious how many of you out there are performing IT pump implants and SCS implants in private practice. I am trying to decide if I only want to perform SCS trials after finishing fellowship, but wanted to hear everyone's opinion and views regarding the positives and negatives for implants (i.e. patient risk vs benefit, financial incentive vs burden, etc).

Thanks in advance!

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[lobelsteve]

SCS: trials and implants.
IT pumps: I only explant other people's mess.

 

[Mister Mxyzptlk]

I do both stims and pumps. Some things can't be covered by SCS.

 

[painchas]

No pumps for me as they are not being reimbursed in my community. Many patients floating around who cant get them filled anymore. I do fair number of trials in the office. It is all about time management for me as perms which I have never done require quite a bit of time which for me can be spent doing more productive income generating activities. More so when there is a post implant issue... seroma, infection, perc migration. I have a very good neuro who enjoys the paddle placement. Much less risk of migration with paddle. Better long term results in these folks to me. I want to advance the technology not limit the perception in my community. As I learned many years ago as an anesthesiologists.... for 99% of people on the planet PERCEPTION IS EQUAL TO REALITY. How skilled I am or how smart I am is a given, assumed and secondary.

 

[PMR 4 MSK]

What is the current thought on who is appropriate for pumps today?

To me, it's little more than an alternative opioid delivery system, and a very expensive, time consuming and problematic one.

 

[jsaul]

What is the current thought on who is appropriate for pumps today?

To me, it's little more than an alternative opioid delivery system, and a very expensive, time consuming and problematic one.

the patients I have seen in PP who already have pumps were put in by money hungry docs a few years ago who then let the patients go once it wasn't economical to continue to see them. and many were put in for such things as fibromyalgia, osteoarthritis, and lumbar stenosis. Pathetic and sickening.

There is a doctor that has the following alogorithem. A 65 year old comes in with axial back pain. the patient is only on nsaids. first he injects then if that fails, he does stim trial then after that fails- he goes to pump. This is what he does and he thinks it is the right thing to do. I couldn't believe it, but opioid naive patients taken straight to intrathecal delivery systems.

 

[SleepIsGood]

From what I've seen and talked to patients so far. It seems like baclofen pumps for patients with spasticity is life altering. So it seems like pumps are atleast good for these.

 

[Ligament]

Opioid pumps are great for terminal pain, just phenomenal.

Baclofen pumps are great for spasticity.

Opioid pumps for benign chronic pain work well for about 10% of patients, the rest it seems to make little improvement for. But it is still a valid therapy for these patients.

The old thought process was if the patient does not get pain relief or only minimal relief on orals, move to pump. The new adage is only move to pump if they get GREAT relief from reasonable oral doses but cannot tolerate side effects.

In the past two years, I have only had two patients that were good pump candidates.

 

[lobelsteve]

Anyone read Tim Deer's piece in Pain Physician this month?
I think he said we need to rethink the protocol, but was for more pumps are needed.

 

[hyperalgesia]

Opioid pumps are great for terminal pain, just phenomenal.

Baclofen pumps are great for spasticity.

Opioid pumps for benign chronic pain work well for about 10% of patients, the rest it seems to make little improvement for. But it is still a valid therapy for these patients.

The old thought process was if the patient does not get pain relief or only minimal relief on orals, move to pump. The new adage is only move to pump if they get GREAT relief from reasonable oral doses but cannot tolerate side effects.

In the past two years, I have only had two patients that were good pump candidates.

Totally agree.

 

[Aether2000]

I agree...do stims and pumps, but the pumps are very few now given that the reimbursement for refills makes it a break even proposition, and given that we have to wait 6-9 months to be reimbursed for the refill procedure and medicine by our medicare carrier. Pumps are great for terminal pain when you don't have to worry about a lot of refills remaining. My experience with chronic non-malignant pain is that they work well about 50% of the time...

 

[geauxg8rs]

The problem I have seen with pump refill patients (who we inherited because of a move) has of course been selection. Patient selection is one problem, selection of medication that is infusing is another. These docs just escalate to no end! Extreme concentrations of morphine/dilaudid/ or even fentanyl. Clearly no selection criteria used prior to trialing. Some patients would do better with intrathecal prozac. I have also seen stim for FM and stim for SI joint where the generator was placed right over said painful SI joint. These guys should lose their licenses!

 

[PMR 4 MSK]

The guys around me who implant pumps send all their medicare and medicaid patients to the hospital to be refilled by nursing staff - they let the hospital eat it, and I can't believe the hospital puts up with it. They keep the insured patients in their private clinics.

I agree completely on baclofen pumps being life-altering, I've seen that many times. I also agree on terminal/cancer pts and pumps, seems like a great application.

I just don't understand patients with chronic back pain being on pumps, and many still taking 4 vicodin a day for "break-through" pain. Most seem to get their hourly dose increased at every visit.

I sent a guy 6-9 months ago for a potential stim trial. They instead put a pump in him. At the last visit, the note says the patient is complaining of sedation, nausea and poor pain control, at about 5.5 mg MSO4/day. He's taking Percocet 10s 4-5x/day. So they raised the pump dose to 6 mg/day and add in a duragesic patch. WTF?!? He wasn't even on opioids when I sent him there.

This is same clinic that has a doc who injections 400 mg depomedrol for every ESI I have seen his documentation on.

 

[Jcm800]

What is the current thought on who is appropriate for pumps today?

To me, it's little more than an alternative opioid delivery system, and a very expensive, time consuming and problematic one.

no one. unless they have terminal cancer or if its for baclofen and spasticity/SCI...

 

[Jcm800]

implant,explant, revise both... i dont put pumps for non-malignant pain...

but these days if someone came and asked me to send them permanents for paddles or whatever, i would be happy. Here the NSGs dont really want to do them...

so for now, i still implant...and it is a big waste of time, but kinda fun...

 

[Mister Mxyzptlk]

Amazing how much geography matters. If I was experiencing what you guys are, I'd stop doing them too.

I don't mind having to deal with revisions and so forth, but the global period where you're draining seromas and reprogramming the hardware for free sucks.

 

[pjuer]

I stopped acceting pump patents and referrals except for baclofen and CA patients.

Years ago one of the neurosurgeons left the big tertiary medical center and I "inherited" his pump patients in the local area. Many were on several mg of MSo4 intrathecally along with Oxycontin 80 tid and breakthru meds. I guess he was treating their hypooxycontinemia. Took a long time to wean these people off their orals.

 

[clubdeac]

I do trials but no implants b/c during fellowship my attending screamed at me during every case making me feel like a surgical ******. I get PTSD every time I pick up a suture

As far as pump candidates I agree, terminal CA, spasticity, and possibly those old fogies who get great pain relief from a little hydro or oxy but can't handle the side effects and sedation. They usually do just peachy on a very low low dose of IT morphine. But I don't deal with pumps so what I think is a moot point