SCS for Lower Abd Pain/Pelvic Pain

[PinchandBurn]

Where are you guys placing leads for capturing lower abd mainly, some pelvic pain?

L1 or 2?

I dont want to really do retrograde anything. Thoughts would be great.


Basically a pt in her 40s. Not abusing meds. Has seen Psych, no psychopathology. Had hypogastric blocks somewhere eles, they helped for a week or so. I did two TAP blocks they help but again just for duration of local.

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[Jcm800]

Where are you guys placing leads for capturing lower abd mainly, some pelvic pain?

L1 or 2?

I dont want to really do retrograde anything. Thoughts would be great.


Basically a pt in her 40s. Not abusing meds. Has seen Psych, no psychopathology. Had hypogastric blocks somewhere eles, they helped for a week or so. I did two TAP blocks they help but again just for duration of local.

Sounds like an awful idea. If I was new out of fellowship I would have done that, not now, never.

 

[Ducttape]

ive done a couple of trials of mid epigastric pain. Got good coverage both times, leads were at top of T6.

neither went to perms - one didnt like the feeling, one decided not to have more procedures.

 

[PinchandBurn]

Sounds like an awful idea. If I was new out of fellowship I would have done that, not now, never.

Agree and disagree.


I'm going to be very upfront and strict with the trial. If it works nearly 80% then I may consider permanent. Otherwise, no go.

The patient has had everything else. She's not the normal Pelvic Pain pt, so I'm giving her the benfit of the doubt.....

 

[SSdoc33]

Maybe heeding the advice of some of the senior posters on this board would be wise.

 

[PinchandBurn]

Maybe heeding the advice of some of the senior posters on this board would be wise.

I agree. the concerns are valid.

I acknowledge that typically some of these patients have associated psychopathology.

This patient doesnt have that problem from what I have detected so far.

 

[lobelsteve]

I agree. the concerns are valid.

I acknowledge that typically some of these patients have associated psychopathology.

This patient doesnt have that problem from what I have detected so far.

The dx is one of psychosocial construct. Post past physical emotional and sexual abuse hx. What. You forgot to ask. Tsk. Tsk. How many ex husbands. I'm guessing 2.

 

[PinchandBurn]

The dx is one of psychosocial construct. Post past physical emotional and sexual abuse hx. What. You forgot to ask. Tsk. Tsk. How many ex husbands. I'm guessing 2.

Nope...asked about those of course. Actually never married. I actually do H and P and tk fam/soc histories. This is probably why I dont see 50pts a day.

 

[PinchandBurn]

Maybe heeding the advice of some of the senior posters on this board would be wise.

It's evidence based:
http://www.ncbi.nlm.nih.gov/pubmed/22521096

 

[sweetalkr]

two other doctors in my clinic had this exact situation.

how they ended:

1) first guy came off the oxycontin 50mg bid, then 2 months later he was back on percocet. then 2 months later on the same dose of narcotics

2) other lady demanded scs explant within 4 months.

both by a new guy out of fellowship

 

[lobelsteve]

What happened at the other clinic after the hypogastrics?

 

[facets]

She is in her 40's and never been married? That's somewhat pathological, unless she's gay.

QUOTE=PinchandBurn;13078363]Nope...asked about those of course. Actually never married. I actually do H and P and tk fam/soc histories. This is probably why I dont see 50pts a day.[/QUOTE]

 

[Ducttape]

two other doctors in my clinic had this exact situation.

how they ended:

1) first guy came off the oxycontin 50mg bid, then 2 months later he was back on percocet. then 2 months later on the same dose of narcotics

2) other lady demanded scs explant within 4 months.

both by a new guy out of fellowship

for some reason, what i find interesting, is the oxycontin 50 dosage.

 

[lobelsteve]

for some reason, what i find interesting, is the oxycontin 50 dosage.

40 aint enough and 60 is just too much.


Pinch: Just do the trial and stop perseverating over it. If it works, implant it.
When it fails at 6 months, explant it.

I don't think it will work or it is worth the healthcare costs, but I'm not paying or the patient. From the science standpoint it is probably not supported. Literature for this is lacking.

 

[lobelsteve]

for some reason, what i find interesting, is the oxycontin 50 dosage.

40 aint enough and 60 is just too much.


Pinch: Just do the trial and stop perseverating over it. If it works, implant it.
When it fails at 6 months, explant it.

I don't think it will work or it is worth the healthcare costs, but I'm not paying or the patient. From the science standpoint it is probably not supported. Literature for this is lacking.

 

[Ducttape]

40 aint enough and 60 is just too much.


Pinch: Just do the trial and stop perseverating over it. If it works, implant it.
When it fails at 6 months, explant it.

I don't think it will work or it is worth the healthcare costs, but I'm not paying or the patient. From the science standpoint it is probably not supported. Literature for this is lacking.

probably...

but there is always the possibility that the patient is taking only one of the scripts and selling the other. i once saw a patient on 30 bid, who insisted on getting a script of 10 and a script of 20. at a random pill count, he could not produce the 20s...

 

[PinchandBurn]

40 aint enough and 60 is just too much.


Pinch: Just do the trial and stop perseverating over it. If it works, implant it.
When it fails at 6 months, explant it.

I don't think it will work or it is worth the healthcare costs, but I'm not paying or the patient. From the science standpoint it is probably not supported. Literature for this is lacking.

i usually have a neurosurgeon do the implant (so they deal with post op issues).

I've done the trial now, and it's 5 days in and shes actually doing very well. She isnt using any opioids at all. Both myself and the rep call her. She's moving, taking care of her self at home, and actually shopping,

I'm definitely still hesitant. My only concern with this is if I have a neurosurgeon implant it, are they able to explant in 6mo if needs to come out? Obviously the lami is a done deal, but where exactly are they suturing the paddle into, the ligamentum flvum vs dura??

In her, I'm considering implanting it myself with perc leads only because I'd want to 'reverse' it if doesnt work......


It's a tough call.


Steve- the hypogastrics at the outside place worked for 1 week. That was it.

 

[clubdeac]

I've done one of these cases and she's still getting about 50% relief > 1 yr out.... that's not to say she doesn't still complain and ask for something else to relieve the pain...

And sweets, you sure you weren't the "new guy out of fellowship?" Muaahahaha

 

[sweetalkr]

Deac, my first 3 implants were on a FBSS x 2 and a CRPS patient. I played it super safe my first failed was on a lead migration. simple rookie stuff. ab pain and stim? i won't touch it unless there is a damn good reason

 

[Ducttape]

Deac, my first 3 implants were on a FBSS x 2 and a CRPS patient. I played it super safe my first failed was on a lead migration. simple rookie stuff. ab pain and stim? i won't touch it unless there is a damn good reason

just out of curiosity, how many people are using it for unstable angina/chest pain?

 

[lobelsteve]

just out of curiosity, how many people are using it for unstable angina/chest pain?

Willing to try for angina pain, but not unstable angina.
Have had Cardiology in my group since I started in 2007. Interventional cardiology is new this year. Will get a trial done in the next few months for him, once maximally stented.

 

[Ducttape]

Willing to try for angina pain, but not unstable angina.
Have had Cardiology in my group since I started in 2007. Interventional cardiology is new this year. Will get a trial done in the next few months for him, once maximally stented.

to clarify, i should have used the term angina not responsive to medication therapy, instead of unstable angina, which of course implies some sort of acute coronary syndrome.

 

[PinchandBurn]

Willing to try for angina pain, but not unstable angina.
Have had Cardiology in my group since I started in 2007. Interventional cardiology is new this year. Will get a trial done in the next few months for him, once maximally stented.

I was thinking of colaborating with some of the Cards folks at my hospital for this.

I know it's doen a lot in Europe,etc. In fellowship we did one and the patient did well.

My concern is the patient maybe stented etc maximally, but what if it's really a Acute Coronoary type syndrome. The ptaient calls you and you tell him 'just turn up the stim' or something, and then he dies from a MI.....

Secondly, lots of these patients have pacemakers. My concern is the interaction between SCS and pacemaker. The manufactures 'advise' against it...... I know people still do it.

 

[PMR 4 MSK]

Also I see in places where cards doesn't want SCS, as they see it as another specialty stepping on their turf. Many times, groups don't do what is best for the patient, but what is best for themselves.

 

[sweetalkr]

i have approached cardiology before to do SCS for chronic angina, and the vascular surgeons are actually much more receptive to SCS for PVD than the cardiologists are for SCS. Not sure why...

 

[bedrock]

i have approached cardiology before to do SCS for chronic angina, and the vascular surgeons are actually much more receptive to SCS for PVD than the cardiologists are for SCS. Not sure why...

Likely for the reason pinch/burn mentioned. Cardiologist are worried they'll missed sign of a new infarct. In the vascular patients, the risks are much less if the SCS is covering up their pain.

 

[Ducttape]

Likely for the reason pinch/burn mentioned. Cardiologist are worried they'll missed sign of a new infarct. In the vascular patients, the risks are much less if the SCS is covering up their pain.

i dont believe the european data is showing that new infarcts are being missed at all with scs... unless you know for sure differently, ill try to look stuff up...

 

[Pain_doc]

What you'll be missing is the opportunity to place another stent.....

 

[sweetalkr]

+1