Repeat Surgery vs SCS with post surgical foraminal stenosis

[Timeoutofmind]

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I see this a lot

Someone has had a back surgery, still has radicular pain

Formaminal stenosis on MRI (moderate or severe lets say), at a different level

Does not want anymore back surgery, period.

No weakness

Has failed injections, antineuropathic meds.

I typically do not offer SCS. It just seems like the indicated procedure is a nerve decompression, so that is what they should get, not an SCS which is just going to mask the pain. And I dont even know how good SCS is at masking pain in the face of an ongoing compressive lesion.

Its one thing if they have seen a surgeon and he says its going to be some big risky revision etc, but a lot of the time they wont even see a surgeon, as they are not interested

What do you think?

 

[Ducttape]

aren't opioids masking the pain? gabapentin/lyrica/TCAs?

SCS has been effective at improving functioning. think of it that way instead of "masking" the pain.

the world is virtually saturated with patients who see surgeons who think that "fixing" the condition will make them better. and your "simple foraminotomy" will most likely lead to a fusion.

 

[244913]

I see this a lot

Someone has had a back surgery, still has radicular pain

Formaminal stenosis on MRI (moderate or severe lets say), at a different level

Does not want anymore back surgery, period.

No weakness

Has failed injections, antineuropathic meds.

I typically do not offer SCS. It just seems like the indicated procedure is a nerve decompression, so that is what they should get, not an SCS which is just going to mask the pain. And I dont even know how good SCS is at masking pain in the face of an ongoing compressive lesion.

Its one thing if they have seen a surgeon and he says its going to be some big risky revision etc, but a lot of the time they wont even see a surgeon, as they are not interested

What do you think?

I would stim away

 

[Timeoutofmind]

aren't opioids masking the pain? gabapentin/lyrica/TCAs?

SCS has been effective at improving functioning. think of it that way instead of "masking" the pain.

the world is virtually saturated with patients who see surgeons who think that "fixing" the condition will make them better. and your "simple foraminotomy" will most likely lead to a fusion.[/

By this logic u could justify starting with SCS vs surgical referal for a virgin back that had foraminal stenosis...but I don’t think that is anyone’s practice

 

[Ducttape]

that's not anyones practice because the spine surgery associations are so good at convincing insurance companies that their procedures are the gold standard.

also, in fact, I would prefer not to use stim as the initial treatment, because then the success rate would go down, significantly, as everyone and their mother (literally) would get stim and we would have very questionable candidates for such.

currently, with all that we have to go through to get a stim approved, we weed out much of the inappropriate candidates. using stim as the initial treatment would not do this.

 

[emd123]

I see this a lot

Someone has had a back surgery, still has radicular pain

Formaminal stenosis on MRI (moderate or severe lets say), at a different level

Does not want anymore back surgery, period.

No weakness

Has failed injections, antineuropathic meds.

I typically do not offer SCS. It just seems like the indicated procedure is a nerve decompression, so that is what they should get, not an SCS which is just going to mask the pain. And I dont even know how good SCS is at masking pain in the face of an ongoing compressive lesion.

Its one thing if they have seen a surgeon and he says its going to be some big risky revision etc, but a lot of the time they wont even see a surgeon, as they are not interested

What do you think?

This is what I tell people. "That's fine if you don't want to see a surgeon. You don't have to. But if you're asking to get a spinal cord stimulator, you're going to end up seeing a 'surgeon' (whether that's you, or an outside implanting surgeon, is irrelevant) and we need a surgeon's opinion as to whether we can cure this and have other better options, or not. If not, then fine. We can also see if he thinks the stimulator is a better idea. But either way, you at least need to get that evaluation before we commit to going down the stimulator pathway. You don't have to commit to full blown fusion, or any other open back surgery necessarily, just because you get a consultation. But we at least need to get a spine/neurosurgeon's opinion, so we know what our full range of options are."

Most patient's are okay with that. If they insist on being unreasonable, and won't take the steps you need to determine if the stimulator is the best option or not, then they're not a good candidate for a stimulator.

A Pain MD who implants horrible candidates for stimulators, ends up poisoning the well and ruins the reputation of us all and our treatments. We have a guy like this in my town, and it's tough to get anyone to agree to a stim anymore, because this one guy has inappropriately implanted so damn many over the years that haven't panned out, or required explantation, that the treatment has a reputation in town of being a crappy one. All because of this one guy.

But as to your bigger question, which is, "Will a stimulator help radicular pain if there's an untreated compression or not?"

That all depends on whether they're a surgical candidate or not. If they are, and they have a shot at a legitimate cure (which will only be 50% of the time, of course) and reasonably performed surgery, then it's not the best option. If they truly don't, and they truly are not a candidate for curative surgery, then if it was my back, I'd rather have a stimulator than live with a compressed nerve root and nothing but a bunch of crappy medication options. A stim at least gives you a chance to block that pain signal some, if you can't eliminate it completely. But you need a good surgeon you trust, to give you an honest opinion on the appropriateness of surgery. Not a hack who cuts everything that moves. And not a guy who refuses to operate unless it's a 6 inch putt.

 

[lobelsteve]

Scs.

 

[Ronin1]

You are describing most of my FBSS stim success stories. Definitely offer a trial. The changes in programming and technology over the last few years have really changed the outcomes at least in my population

 

[BobBarker]

Stim.

And also stim if the have a fusion and recurrent foramenal stenosis at the same level.

 

[IN2B8R]

I see this a lot

Someone has had a back surgery, still has radicular pain

Formaminal stenosis on MRI (moderate or severe lets say), at a different level

Does not want anymore back surgery, period.

No weakness

Has failed injections, antineuropathic meds.

I typically do not offer SCS. It just seems like the indicated procedure is a nerve decompression, so that is what they should get, not an SCS which is just going to mask the pain. And I dont even know how good SCS is at masking pain in the face of an ongoing compressive lesion.

Its one thing if they have seen a surgeon and he says its going to be some big risky revision etc, but a lot of the time they wont even see a surgeon, as they are not interested

What do you think?

Just because a patient may have radicular symptoms and there maybe moderate or severe foraminal stenosis, decompression may or may not help with the pain. The reason being is that this maybe now a permanent intrinsic nerve issue, rather than from the compression itself--thus the best course of action would be a SCS trial. This is why it is quintessentially important to get a good H&P: if this is new foraminal stenosis (i.e, adjacent level disease) that is refractory to conservative measures and TFESI's only provide short-term pain relief, then likely a foraminotomy/laminotomy may help. If this is the same radiculopathy that lead to the first surgery and the problem still persists, then further surgery in the setting of the same radicular symptoms will unlikely help; i.e, this is likely a chronic nerve problem and not a direct result from the compression.... In any case, if the radicular pain has "chronified," it is now entirely neuropathic and is not the direct result of compression.











It

 

[sub_atomic]

Bringing this back to life! I'm only a few months out of fellowship and have been seeing a lot of radiculopathy pain in setting of post-surgical foraminal stenosis (moderate-severe) a fair bit.

What have your long term SCS outcomes been in this group?
I'm not sure what percent of these patients will go on need surgical decompression in the future.

 

[MitchLevi]

SCS

 

[Agast]

I feel like most spine surgeons are not terribly excited about a second operation after laminectomy unless there’s some sort of instability they have to address.

 

[MitchLevi]

I feel like most spine surgeons are not terribly excited about a second operation after laminectomy unless there’s some sort of instability they have to address.

Agree. Decompression and fusion. Otherwise, SCS and pain management.

Simple foraminal stenosis in my practice is don't operate in the vast majority of cases.

 

[SC Tian]

Positional radiculopathy pain from foraminal stenosis will respond poorly to stim, imo

 

[Dr. Ice]

Does scs REALLY work for these people? My results are mixed. Honestly, they do well with the trials but I’m such an incredible scs critic that I actually will make notation to follow up with them 6 months, 1 year, 18 months and many of them post implant are not very enthused…continue to think scs is really just a money maker and not much more.

 

[MitchLevi]

Does scs REALLY work for these people? My results are mixed. Honestly, they do well with the trials but I’m such an incredible scs critic that I actually will make notation to follow up with them 6 months, 1 year, 18 months and many of them post implant are not very enthused…continue to think scs is really just a money maker and not much more.

I'm EXTREMELY skeptical, and I've taken a lot of devices out. I've had several homeruns too.

Most pain doctors are clueless about their stim outcomes. It's a decent treatment option.

 

[Baron S]

Does scs REALLY work for these people? My results are mixed. Honestly, they do well with the trials but I’m such an incredible scs critic that I actually will make notation to follow up with them 6 months, 1 year, 18 months and many of them post implant are not very enthused…continue to think scs is really just a money maker and not much more.

Name a single treatment option in our specialty that doesn't have the same issue.

 

[MitchLevi]

Name a single treatment option in our specialty that doesn't have the same issue.

Name another treatment option that pays as much.

 

[Agast]

Also not uncommon to need an SI joint or piriformis injection in these older folks. Once their gait and posture becomes wonky they never quite correct it and it all blends into back pain and sciatica.

 

[sub_atomic]

I'm EXTREMELY skeptical, and I've taken a lot of devices out. I've had several homeruns too.

Most pain doctors are clueless about their stim outcomes. It's a decent treatment option.

Are you able to share which patients have good long term outcomes based on extent of post-surgical foraminal stenosis?
@lobelsteve @Ducttape

 

[lobelsteve]

I see multilevel severe foraminal stenosis a dozen times per day. It means nothing. Is it real, the Radiologist?
Treat the patient. If ongoing pain after surgery and no progressive deficits, neuropathics and SCS after home exercises and PT fail.
Years of success with that basic algorithm. Very few explants of my own since 2005.
My training was based on North's paper on SCS vs repeat surgery favoring SCS (10 generations of SCS technology ago).

 

[Dr. Ice]

Also not uncommon to need an SI joint or piriformis injection in these older folks. Once their gait and posture becomes wonky they never quite correct it and it all blends into back pain and sciatica.

You can add glut med, gtbs as well. I’m assuming all that stuff was already done

 

[Ducttape]

imo, the ones who have the best success are the ones who are less expectant of them going in.

those who have "resigned" themselves to chronic pain - expect to use SCS as an adjunct to modulate pain - are the ones i see have best outcomes.


as a caveat, those who dont expect any benefit and those that expect complete resolution dont get taken to trial.

 

[sub_atomic]

I see multilevel severe foraminal stenosis a dozen times per day. It means nothing. Is it real, the Radiologist?
Treat the patient. If ongoing pain after surgery and no progressive deficits, neuropathics and SCS after home exercises and PT fail.
Years of success with that basic algorithm. Very few explants of my own since 2005.
My training was based on North's paper on SCS vs repeat surgery favoring SCS (10 generations of SCS technology ago).

Steve- what about those patient for whom decompression helped for 12-18 months but they now have a recurrent NF stenosis that I believe to be culprit. Stim or surgery?

 

[lobelsteve]

Steve- what about those patient for whom decompression helped for 12-18 months but they now have a recurrent NF stenosis that I believe to be culprit. Stim or surgery?

If they have pain, SCS.
If they have progressive neuro deficit, surgical consult.

 

[CB1Antagonist]

My experience, postlam with spondylotic foraminal stenosis with normal strength SCS works well
post lam with adjacent level moderate or worse canal stenosis, SCS will not help

 

[MitchLevi]

My experience, postlam with spondylotic foraminal stenosis with normal strength SCS works well
post lam with adjacent level moderate or worse canal stenosis, SCS will not help

Pulled out a failed trial an hr ago for adjacent level severe stenosis in a supramorbidly obese woman. L2-3 collapse s/p L3-5 fusion.

First failed trial in prob 2 yrs

 

[bedrock]

Pulled out a failed trial an hr ago for adjacent level severe stenosis in a supramorbidly obese woman. L2-3 collapse s/p L3-5 fusion.

First failed trial in prob 2 yrs

Sounds like that patient needs to lose a ton of weight. Then surgical L2-L3 decompression has a prayer of working and of a surgeon offering it to them.

 

[MitchLevi]

She's soooo big.

Hubbed the Tuohy and opened the 6" but didn't need it. Entered T11-12 and T12-L1.

BTW - This pissed me off - Before the case started, I told the rep to make sure we have a 6" needle. Before we opened the freaking kit, they dumped that 6" on the tray. Okay, that pissed me off. I never said open it.

First lead goes in and before the second kit is opened I hear the second 6" needle opened and dropped and I never used the first one.

 

[lobelsteve]

She's soooo big.

Hubbed the Tuohy and opened the 6" but didn't need it. Entered T11-12 and T12-L1.

BTW - This pissed me off - Before the case started, I told the rep to make sure we have a 6" needle. Before we opened the freaking kit, they dumped that 6" on the tray. Okay, that pissed me off. I never said open it.

First lead goes in and before the second kit is opened I hear the second 6" needle opened and dropped and I never used the first one.

At least you tried. That is all we are asked to do.

 

[bedrock]

She's soooo big.

Hubbed the Tuohy and opened the 6" but didn't need it. Entered T11-12 and T12-L1.

BTW - This pissed me off - Before the case started, I told the rep to make sure we have a 6" needle. Before we opened the freaking kit, they dumped that 6" on the tray. Okay, that pissed me off. I never said open it.

I would definitely tell the rep that you aren’t paying for two needles that you didn’t ask him to open.

First lead goes in and before the second kit is opened I hear the second 6" needle opened and dropped and I never used the first one.

 

[SC Tian]

She's soooo big.

Hubbed the Tuohy and opened the 6" but didn't need it. Entered T11-12 and T12-L1.

BTW - This pissed me off - Before the case started, I told the rep to make sure we have a 6" needle. Before we opened the freaking kit, they dumped that 6" on the tray. Okay, that pissed me off. I never said open it.

First lead goes in and before the second kit is opened I hear the second 6" needle opened and dropped and I never used the first one.

They normally give us for free😉

 

[MitchLevi]

They normally give us for free😉

This case was at the hospital. If in my ASC I'm not paying for it.

 

[cameroncarter]

Pulled out a failed trial an hr ago for adjacent level severe stenosis in a supramorbidly obese woman. L2-3 collapse s/p L3-5 fusion.

First failed trial in prob 2 yrs

central stenosis at L2/3?

 

[MitchLevi]

central stenosis at L2/3?

Mmmhmmm.

Superior adjacent segment breakdown in a supramorbidly woman who no ones want to operate on.

She's a very negative woman in general BTW. Nothing ever works out in her favor.

 

[lobelsteve]

Mmmhmmm.

Superior adjacent segment breakdown in a supramorbidly woman who no ones want to operate on.

She's a very negative woman in general BTW. Nothing ever works out in her favor.

Makes it easier. Be mean to her so she goes somewhere else. No meds, no procedures will help.
If she buys into wanting to improve then she goes to aqautic and CBT. She starts Mounjaro and drops 50 lbs.

 

[MitchLevi]

She needs bariatric surgery.

 

[Ducttape]

weight loss is vitally important....

there are meta-analyses that suggest reduced back pain after bariatric surgery, but it is noted on each meta-analysis that there is a dearth of prospective data as to this question.

 

[bedrock]

Honestly it’s not the worst thing in the world that she failed her SCS trial. She needs to take active responsibility for her life and not expect procedures to do the work for her.

She needs to lose a ton of weight period. No other medical interventions matter.

And some pain now might extend her life by a decade later.

 

[PainBrain78]

Does scs REALLY work for these people? My results are mixed. Honestly, they do well with the trials but I’m such an incredible scs critic that I actually will make notation to follow up with them 6 months, 1 year, 18 months and many of them post implant are not very enthused…continue to think scs is really just a money maker and not much more.

Which would YOU prefer in that situation. Let’s pretend ESI does not provide long lasting relief.

Your options are:
A) surgery that’s not guaranteed to provide pain relief
B) narcotic medications for the rest of your life
C) a little fishing wire in your spine with no change in anatomy.

If I were the patient, if a family member was the patient, I would choose SCS 100%. If that stopped working down the line then I would talk with a neurosurgeon about a second surgery.

 

[Ducttape]

agree.

but patients see that little pill as the answer to life, the universe and everything.

She's soooo big.

Hubbed the Tuohy and opened the 6" but didn't need it. Entered T11-12 and T12-L1.

thats a skinny one.

just this week, i did an L23 epidural (covering for someone) where i hubbed a 6 inch Touhy. no tilt on c-arm....

 

[MitchLevi]

Front loaded

 

[lobelsteve]

Pickwickian.

 

[MitchLevi]

I do believe "front loaded" obesity is prob a little different on the back. This woman has a Volkwagon hanging off her front. Back is fighting that thing to stay erect (something I wasn't BTW).

 

[SSdoc33]

TMI