SCS Case Question

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Timeoutofmind

Timeoutofmind

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Pt with h/o 6 spine surgeries cervical and lumbar, including fusions both places. Not on meds really, as has a h/o problems with opioids and doesnt want them.

Pain is all axial.

Totally normal guy. He was impressively miserable in the office.

Referred for SCS.

Seems he would need both cervical and lumbar coverage...I was going to do Nevro as it is axial.

I guess the question is how the heck to proceed.

Start with cervical and hope you get some lumbar benefit? If not, and he ends up needing lumbar, then I have given him four procedures (2 trials, 2 perms), instead of one.

But trialing two locations at once seems kinda crazy. I was thinking I could enter four times at T12-L1 and thread two of the leads up cervical, and two for lumbar coverage...
Could take a similar approach for perm with just one T12-L1 incision...only difference being that two IPGs would be needed...so I guess I could tunnel BL?

Other option for trial would be to place leads cervical for 3 days, and then have him come in and pull them down to lumbar coverage for 3 days...Still begs the question how I would proceed on the perm?
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When this situation arises, I have asked the patient to pick which pain is worse and proceed with the trial for that area. Does nevro have approval for cervical at this point?
 
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but the problem with boston is that nevro is going to be better for axial pain, particularly lumbar.

Nice that you only need one IPG, but if doesn't work as well, then you haven't really helped the patient that much.
 
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Boston works fine. Don't put two generators that have to be charged everyday in the patient. It is too much of a burden.
 
If not already done, despite "being referred for scs", does it seem reasonable clinically to look into mbb/rf at an adjacent segment for c or L spine? Consider cymbalta. Maybe problem will be solved if one or both are better.


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Taus said:
If not already done, despite "being referred for scs", does it seem reasonable clinically to look into mbb/rf at an adjacent segment for c or L spine? Consider cymbalta. Maybe problem will be solved if one or both are better.


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Click to expand...

Agreed. I love stim and get a fair number of patients sent specifically for a trial but if they haven't been through the conservative stuff I will take them through that before moving forward with a trial.
 
Another option with Nevro is one lead lumbar and one lead cervical, both midline. They only use one of the leads at a time normally anyway so with one battery you could stimulate both leads since they are in different locations. Question would be if battery would last long enoug between charges since you'd be doubling the energy output by using two leads instead of just the one. I would trial with two entry sites at T12-L1. If PT does well I would implant the cervical lead up higher in hopes of less migration risk and tunnel it down to pocket.

Also, I'm confused about "is Nevro approved for cervical". None of the stim devices are FDA on label for cervical are they? Nevro did present preliminary results for neck and upper extremity at NANS and results were good.
 
I'd do a Boston Precision Spectra as well. 2 up and 2 down, one IPG. I've heard good results with Nevro for cervical, just not sure about a single lead with axial complaints, I'd like to have more programming options with dual leads.
 
You can also try a Y connector and connect 2 leads to one port of St. Jude/Medtronic which can be programmed independently so no need to put any additional IPG. Nevro daily charging is a chore for most patients and I have been using the St. Jude non rechargeable system more and more with good results.


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axial pain huh... why don't you do pump instead. Would work a lot better, especially in an opioid naive patient
 
What about just placing 1 lead in the cervical region and the 2nd lead in the lumbar region covering the t 9/10 disc


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ssmallz said:
What about just placing 1 lead in the cervical region and the 2nd lead in the lumbar region covering the t 9/10 disc


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Click to expand...
That's actually what the nervo headquarters people recommended when I checked in with them...
I'm gonna explore if anything reasonable is left to RF and if not take this approach
 
Timeoutofmind said:
Can't tell if serious lol?
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I'm dead serious.... this is slam dunk pump patient. I don't care how much nevro claims to cover axial spine pain. I'm still skeptical. Granted I haven't used them yet
 
clubdeac said:
I'm dead serious.... this is slam dunk pump patient. I don't care how much nevro claims to cover axial spine pain. I'm still skeptical. Granted I haven't used them yet
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he didn't want opioids. why are you pushing something more sinister and dangerous?
 
clubdeac said:
I'm dead serious.... this is slam dunk pump patient. I don't care how much nevro claims to cover axial spine pain. I'm still skeptical. Granted I haven't used them yet
Click to expand...

Well if you're skeptical about Nevro axial coverage, but haven't used them yet, then your next step is fairly clear.
 
clubdeac said:
I'm dead serious.... this is slam dunk pump patient. I don't care how much nevro claims to cover axial spine pain. I'm still skeptical. Granted I haven't used them yet
Click to expand...

Slam dunk during the initial honeymoon period where they can't believe how much relief they have. Let the tolerance start to set in, dose escalation, start adding drugs to the mix, restart some oral opioids and the nightmare begins


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Good discussion, Bob is right, Nevro won't come to the VA. They skewrd.... greedy bastards. I over looked the part where you said he's had problems with opioids. I guess I would forget the pump then. However, had he no issues with opioids I think a pump would work better for pan spine pain.
 
clubdeac said:
Good discussion, Bob is right, Nevro won't come to the VA. They skewrd.... greedy bastards. I over looked the part where you said he's had problems with opioids. I guess I would forget the pump then. However, had he no issues with opioids I think a pump would work better for pan spine pain.
Click to expand...
Weird...
It seems to me there is basically an emerging medical consensus that opioid IT pumps are almost contraindicated for noncancer pain
 
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Timeoutofmind said:
Weird...
It seems to me there is basically an emerging medical consensus that opioid IT pumps are almost contraindicated for noncancer pain
Click to expand...

Make them less than 5% of your practice. Use them rarely. They do not salvage aberrant behaviors or headache inducing patients.
 
lobelsteve said:
Make them less than 5% of your practice. Use them rarely. They do not salvage aberrant behaviors or headache inducing patients.
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My worst nightmares over the last 25 years were pump patients. The ONLY ones with minimal problems were baclofen.


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Not sure why some many people have a bad taste with pumps because if you do them right they are ok.

They aren't for everyone just like SCS isn't the answer to everything.
 
Jigsaw said:
Not sure why some many people have a bad taste with pumps because if you do them right they are ok.

They aren't for everyone just like SCS isn't the answer to everything.
Click to expand...

I'm genuinely interested to hear how to do them right. I clearly must have done something wrong because any professionally satisfying experience with a pump never lasted more than a year or two max. I'm also interested in what your experience is regarding:

1. What diagnoses respond most favorably long term?
2. What is the longest experience you have had with a pump patient.






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Jigsaw said:
Not sure why some many people have a bad taste with pumps because if you do them right they are ok
Click to expand...
I'm a fan of the therapy, but I think a lot of folks haven't been doing them right. It's not a continuous spinal.

The problem folks have with pumps is that they're a lot more work and worry and you need to know more than just putting electrodes in an area.

Jigsaw said:
They aren't for everyone just like SCS isn't the answer to everything.
Click to expand...
Didn't they use to be the last ditch salvage option for everything?
Stim fail -> Pump
Pump fail -> Turn it up?

I think of it a lot like a stim in terms of need for proper placement, but it's far more powerful and flexible in terms of coverage, capabilities, type of pain, etc.
How many other tools do you have to bypass the BBB? Regardless, the whole ziconotide being first line for almost everything makes me confused.
 
1. What diagnoses respond most favorably long term?

i don't think there is one diagnosis to match this but is more up to the patient you have. Find one who wants pain relief (doesn't care if it is from opiates) and not to use the therapy as a Hail Mary play.

2. What is the longest experience you have had with a pump patient.

I have patient in my practice who is on there 2 or 3 pump. These are inherited. Plus I have my own since I began.


Just like with any treatment we as Pain Management physicians have in our war chest, there are failures to pumps trials or implant too.

Another thing is our definition of an SCS candidate is now different than it was just a few years ago now that we have Tonic, Burst, HF10 and DRG. I think pumps have also changed in their concept of thinking than it was used 5-10 years ago with the PACC guidelines.




-Manage patient expectations.
-Use PACC guidelines.
-Have a infrastructure in place in your office
-Have an infusion company do compounding and refills.
 
Orin said:
I'm a fan of the therapy, but I think a lot of folks haven't been doing them right. It's not a continuous spinal.

The problem folks have with pumps is that they're a lot more work and worry and you need to know more than just putting electrodes in an area.


Didn't they use to be the last ditch salvage option for everything?
Stim fail -> Pump
Pump fail -> Turn it up?

I think of it a lot like a stim in terms of need for proper placement, but it's far more powerful and flexible in terms of coverage, capabilities, type of pain, etc.
How many other tools do you have to bypass the BBB? Regardless, the whole ziconotide being first line for almost everything makes me confused.
Click to expand...

no offense, but typically it is continuous high dose opioid and placing meds intrathecally will not eliminate the most serious of the long term complications.

and there is a reason that we have a BBB...
 
Ducttape said:
no offense, but typically it is continuous high dose opioid and placing meds intrathecally will not eliminate the most serious of the long term complications.

and there is a reason that we have a BBB...
Click to expand...

None taken, just confused.
Typically you prescribe the medication regimen so if you aren't comfortable with continuous high dose opioids, don't do that.

Placing meds intrathecally reduce the risks of a lot of complications, but not all, and it definitely adds some serious ones.

There's also a reason we have skin, so should we not breach that?

PACC/NACC guidelines are a great framework but I suspect a lot of folks don't use/know them.
 
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