SCS for neuroclaudication

[SIIMS]

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What has been your experience with SCS for patients with neuroclaudicatory pain?

More specifically pain that is radicular and only occurs with ambulation and relieved by flexion/sitting. (intermittent radicular compression)

Patients who have multilevel severe foraminal stenosis that may not benefit or want to consider a multilevel decompression and fusion surgery.

My experiences in fellowship were mostly with patients with persistent non-positional leg pain after surgery either due to scar/fibrosis etc., CRPS and peripheral neuropathic processes

Thanks

 

[Ducttape]

What has been your experience with SCS for patients with neuroclaudicatory pain?

More specifically pain that is radicular and only occurs with ambulation and relieved by flexion/sitting. (intermittent radicular compression)

Patients who have multilevel severe foraminal stenosis that may not benefit or want to consider a multilevel decompression and fusion surgery.

My experiences in fellowship were mostly with patients with persistent non-positional leg pain after surgery either due to scar/fibrosis etc., CRPS and peripheral neuropathic processes

Thanks

From my personal experience, it is very difficult getting insurance approval. The times I have, it is by declaring that the patient requires extreme measures for compassionate use, or something in that live of reasoning.

Insurance is more likely to approve a $80k fusion on a 90 year old than a $40k SCS trial...

 

[clubdeac]

Hard to get approval for claudication due to stenosis?? That's crazy talk! Don't you just submit it for limb pain. That's one of the true indications

 

[SSdoc33]

What has been your experience with SCS for patients with neuroclaudicatory pain?

More specifically pain that is radicular and only occurs with ambulation and relieved by flexion/sitting. (intermittent radicular compression)

Patients who have multilevel severe foraminal stenosis that may not benefit or want to consider a multilevel decompression and fusion surgery.

My experiences in fellowship were mostly with patients with persistent non-positional leg pain after surgery either due to scar/fibrosis etc., CRPS and peripheral neuropathic processes

Thanks

why does it have to be a multi-level fusion? laminectomy/laminotomy should be all the patient will need.

if there is a clear operative solution (like there usually is with stenosis) then you should not be putting in an SCS.

dont try to find indications for SCS when there are better treatment options out there. post surgical claudication? epidural scarring? CRPS? fine.

dont be THAT guy

 

[lobelsteve]

why does it have to be a multi-level fusion? laminectomy/laminotomy should be all the patient will need.

if there is a clear operative solution (like there usually is with stenosis) then you should not be putting in an SCS.

dont try to find indications for SCS when there are better treatment options out there. post surgical claudication? epidural scarring? CRPS? fine.

dont be THAT guy

What if they are in too poor health for spine surgery?
There is a slippery slope, but it is only partially effective for claudication pain and a PITA to run wires up an old degenerative spine.

 

[Ducttape]

why does it have to be a multi-level fusion? laminectomy/laminotomy should be all the patient will need.

if there is a clear operative solution (like there usually is with stenosis) then you should not be putting in an SCS.

dont try to find indications for SCS when there are better treatment options out there. post surgical claudication? epidural scarring? CRPS? fine.

dont be THAT guy

SCS has been used in Europe for spinal stenosis. http://www.ncbi.nlm.nih.gov/pubmed/16012421

similar to how it is used in Europe for intractable angina.

trust me, i did submit them for limb pain, for radicular pain, for spinal stenosis. two separate insurance companies have deemed it "experimental" for those conditions. i appealed, talked to an insurance company physician, who stated that if it were worded as palliative therapy, compassionate use, it might get approved.

 

[lobelsteve]

SCS has been used in Europe for spinal stenosis. http://www.ncbi.nlm.nih.gov/pubmed/16012421

similar to how it is used in Europe for intractable angina.

trust me, i did submit them for limb pain, for radicular pain, for spinal stenosis. two separate insurance companies have deemed it "experimental" for those conditions. i appealed, talked to an insurance company physician, who stated that if it were worded as palliative therapy, compassionate use, it might get approved.

If you used 338.4 and 724.4 then you would not get denied.

 

[painstop]

If you used 338.4 and 724.4 then you would not get denied.

-nerve root inflammation (radiculitis - 724.4) can cause radicular symptoms

-nerve root injury (radiculopathy - 724.4) can cause radicular symptoms.

-Since both use the same ICD-9 (per my weak billing knowledge) it appears that using 724.4 would be appropriate with spinal stenosis causing nerve root imingement (radiculopathy) even without disk disruption and resultant inflammation (radiculitis) .

-However, I did think that 724.4 wasn't covered by insurers for stim (but throw in the DDD diagnosis and you are good to go...whatever).

 

[SIIMS]

insulting if you think I'm that guy....I am very conservative

But I like to help people so that is why I asked the question

I hope you don't think a laminectoy will work for foraminal stenosis....how many people do you see in your practice that have had no change in their symptoms which are neuroclaudicatory after a multilevel laminectomy......these are the people that also have multilevel foraminal stenosis......

And hence the original post

 

[lobelsteve]

insulting if you think I'm that guy....I am very conservative

But I like to help people so that is why I asked the question

I hope you don't think a laminectoy will work for foraminal stenosis....how many people do you see in your practice that have had no change in their symptoms which are neuroclaudicatory after a multilevel laminectomy......these are the people that also have multilevel foraminal stenosis......

And hence the original post

I do not believe claudication occurs from foraminal stenosis.

 

[SSdoc33]

insulting if you think I'm that guy....I am very conservative

But I like to help people so that is why I asked the question

I hope you don't think a laminectoy will work for foraminal stenosis....how many people do you see in your practice that have had no change in their symptoms which are neuroclaudicatory after a multilevel laminectomy......these are the people that also have multilevel foraminal stenosis......

And hence the original post

sigh

add a foraminotomy, then.

im not a big fan of surgery, but for stenosis? if they are healthy enough for it? thats a no-brainer. im not including the 85 y/o LOL that gets great relief x 3-4 months with an ESI

if you want to help people, get them to a good surgeon when they need surgery, rather than futz around with something that you know how to do, even if its not the best treatement option

 

[101N]

sigh

add a foraminotomy, then.

im not a big fan of surgery, but for stenosis? if they are healthy enough for it? thats a no-brainer. im not including the 85 y/o LOL that gets great relief x 3-4 months with an ESI

if you want to help people, get them to a good surgeon when they need surgery, rather than futz around with something that you know how to do, even if its not the best treatement option

1+

But sometimes you will see them back after even a technically successful decompression.

 

[SIIMS]

sigh

add a foraminotomy, then.

im not a big fan of surgery, but for stenosis? if they are healthy enough for it? thats a no-brainer. im not including the 85 y/o LOL that gets great relief x 3-4 months with an ESI

if you want to help people, get them to a good surgeon when they need surgery, rather than futz around with something that you know how to do, even if its not the best treatement option

what are you sighing about? If I bother you that much don't reply like a soapbox diva...keep your perfect fingers off your keyboard and don't presume to think my post was profit driven

I am an equal partner in a spine practice with three surgeons, trust me if there is something surgical it is going to them, it only benefits my standing with my patients and my practice to afford somebody the best outcome

If someone has central canal stenosis or a degen. spondy with neuroclaudicatory pain and has failed conservative cares I don't trial SCS to make a buck, they go for a surgical consultation period

In fact, before I trial anybody in my practice they get a spine surgical consultation with a surgeon in my practice

Foraminotomy's done by themselves are a crap procedure.....neurosurgeons did this all the time where I trained.....they never seem to work...patients usually end up having a recommendation for a fusion

Hence my original post.....

 

[SIIMS]

I do not believe claudication occurs from foraminal stenosis.

Then you believe wrong...

 

[lobelsteve]

Then you believe wrong...

Educate me.

 

[SIIMS]

Educate me.

I hope you are messing with me or something.....you treat spine pain for a living

Neuroforamen change in size (especially up-down) with changes in flexion (say sitting) and extension (say walking) This is especially true in spines that have quite a few years on them, facets don't do the job quite as well and allow more movement and less stability between various spinal movements especially with flexion and extension.

When your patient with already tight neuroforamen stand and or walk (decreased size) and develop pain in their back and legs that improves with sitting (increased size) and have no central canal stenosis or have already been widely decompressed with laminectomy then this represents neuroclaudication from neuroforaminal-stenosis. With all the standard rules applying to differentiate between neurogenic and vascular claudication

 

[lobelsteve]

I hope you are messing with me or something.....you treat spine pain for a living

Neuroforamen change in size (especially up-down) with changes in flexion (say sitting) and extension (say walking) This is especially true in spines that have quite a few years on them, facets don't do the job quite as well and allow more movement and less stability between various spinal movements especially with flexion and extension.

When your patient with already tight neuroforamen stand and or walk (decreased size) and develop pain in their back and legs that improves with sitting (increased size) and have no central canal stenosis or have already been widely decompressed with laminectomy then this represents neuroclaudication from neuroforaminal-stenosis. With all the standard rules applying to differentiate between neurogenic and vascular claudication

Nice you say that, but I've never seen it in a textbook, journal article, or other spine doc mention this. Radiculopathy is common with severe foraminal compromise, but I've never seen or heard of claudicatory pain from foraminal stenosis.

 

[SIIMS]

Nice you say that, but I've never seen it in a textbook, journal article, or other spine doc mention this. Radiculopathy is common with severe foraminal compromise, but I've never seen or heard of claudicatory pain from foraminal stenosis.

Well it's probably hard to find a journal article telling you that grass is green and water is blue.

I don't know what to tell you, this is common knowledge, I see it on a weekly basis in my practice and every surgeon I know treating spinal stenosis debates about doing just a laminectomy vs a laminectomy-fusion in patients with both central and neuroforaminal stenosis, most end up getting a laminectomy to start, but sometimes these patients will not have any relief.....I see it all the time hence this attending physician's remark from Oregon

Quote:
Originally Posted by SSdoc33
sigh

add a foraminotomy, then.

im not a big fan of surgery, but for stenosis? if they are healthy enough for it? thats a no-brainer. im not including the 85 y/o LOL that gets great relief x 3-4 months with an ESI

if you want to help people, get them to a good surgeon when they need surgery, rather than futz around with something that you know how to do, even if its not the best treatement option
1+

But sometimes you will see them back after even a technically successful decompression.


What does a "technically successful decompression" even mean....probably means the central canal s/p surgery is widely decompressed but the neuroforamen at multiple levels are still extremely tight....

So it may be time you go sink back in to some textbooks, reach out to some surgeons...educate yourself

 

[lobelsteve]

Well it's probably hard to find a journal article telling you that grass is green and water is blue.

I don't know what to tell you, this is common knowledge, I see it on a weekly basis in my practice and every surgeon I know treating spinal stenosis debates about doing just a laminectomy vs a laminectomy-fusion in patients with both central and neuroforaminal stenosis, most end up getting a laminectomy to start, but sometimes these patients will not have any relief.....I see it all the time hence this attending physician's remark from Oregon

Quote:
Originally Posted by SSdoc33
sigh

add a foraminotomy, then.

im not a big fan of surgery, but for stenosis? if they are healthy enough for it? thats a no-brainer. im not including the 85 y/o LOL that gets great relief x 3-4 months with an ESI

if you want to help people, get them to a good surgeon when they need surgery, rather than futz around with something that you know how to do, even if its not the best treatement option
1+

But sometimes you will see them back after even a technically successful decompression.


What does a "technically successful decompression" even mean....probably means the central canal s/p surgery is widely decompressed but the neuroforamen at multiple levels are still extremely tight....

So it may be time you go sink back in to some textbooks, reach out to some surgeons...educate yourself

Nope. I've been around the block, I've read lots of pain texts, read lots of journals, but I've never heard of anyone else ever mentioning foraminal stenosis and claudication before. Perhaps there is a plausible MOA, or an anatomic pathologic correlate, but I cannot seem to find one. Anyone else out there want to chime in?

My take: canal stenosis can lead to hug the buggy and neurogenic claudication. Recess stenosis and root irritation and impingement leads to radiculopathy one level below disc pathology. Foraminal stenosis and root irritation or impingement leads to radiculopathy at disc level of pathology. Contribution from ligament hypertrophy can cause canal or recess stenosis. Facet hypertrophy can contribute to all 3 stenoses.

 

[DOctorJay]

This is all I could find so far. Interested in the topic so I hope there's more discussion.

"Spinal or foraminal stenosis is characteristically associated with pseudoclaudication-type lower limb radicular symptoms in the lumbar spine and persistent symptoms in the cervical spine."

-Spine Disorders
Bartleson/Deen

 

[oreosandsake]

Interested in the topic so I hope there's more discussion.

me too!

 

[lobelsteve]

http://books.google.com/books?id=0T...ly associated with pseudoclaudication&f=false

http://www.medlink.com/medlinkcontent.asp

 

[ampaphb]

If your hypothesis is that this is a dynamic, unstable forminal stenosis, then the logical solution is an interspinus spacer, not a stim

 

[DOctorJay]

Steve,

Second link is just a homepage for Neurology Medlink.

 

[lobelsteve]

Steve,

Second link is just a homepage for Neurology Medlink.

Ill look at it tomorrow. Another text saying neuroclaudication is canal stenosis.

 

[SIIMS]

http://books.google.com/books?id=0T...ly associated with pseudoclaudication&f=false

http://www.medlink.com/medlinkcontent.asp

Steve, DoctorJ already posted that this concept indeed "exists" from a "textbook" perspective

Your link (that worked) did not favor your argument that foraminal stenosis does not cause neurogenic claudication whatsoever....

It is simply a chapter titled Spinal stenosis...then goes to explain three categories of stenosis: 1. Central 2. Foraminal then lastly 3. Lateral Recess

Then it clearly states 18.4.1.1 "Unless otherwise indicated this discussion refers primarily to central canal stenosis" So it listed three categories at the begining and is only choosing to cover one of the three variants of spinal stenosis that can cause neurogenic caludication.....

Then it goes on to talk about the clinical manifestation of spinal stenosis, which is just a radiologic finding....that is neurogenic claudication

Then it states under "Relief of symptoms" flexion...."which distracts the facet joints(which enlarge the neuroforamen) Remember when you scoffed at the idea of this in my previous post and you quote "Nice you say that, but I've never seen it in a textbook" Guess what, now you have

Then lastly under surgical treatments they specifically talk about "procedures to increase disc height therefore indirectly decompress the neuroforamen" Why on earth would someone want to decompress the neuroforamen in a chapter of a textbook covering neurogenic claudication if it didn't exist???????

 

[SIIMS]

If your hypothesis is that this is a dynamic, unstable forminal stenosis, then the logical solution is an interspinus spacer, not a stim

I can't leave this one alone...

If a patient has dynamic unstable foraminal steonosis then the treatment is not an interspinous spacer by one hundred thousand million miles....it is a fusion surgery period if not responded to conservative cares (an example of this would be a degenerative spondylolisthesis say at L4-5 causing either central or foraminal stenosis that moves between flexion and extension greater then 3 mm on plain films)

Also my original post referred to a patient that theoretically may have already had a widelaminectomy hence you could not use an interspinous spacer in this patient (they have no spinous process left)

My original post detailed a patient that had pathology at several levels (not just one) who may not want or be in a position to handle a larger spine surgery but still wants relief

So far with this entire post I have only found one mention of someone who has tried SCS in this population and they said they were not impressed....I would still appreciate other physicians experiences

 

[ampaphb]

Also my original post referred to a patient that theoretically may have already had a widelaminectomy hence you could not use an interspinous spacer in this patient (they have no spinous process left)

Patients who have multilevel severe foraminal stenosis that may not benefit or want to consider a multilevel decompression and fusion surgery.

Might want to re-read your original post

 

[lobelsteve]

Steve, DoctorJ already posted that this concept indeed "exists" from a "textbook" perspective

Your link (that worked) did not favor your argument that foraminal stenosis does not cause neurogenic claudication whatsoever....

It is simply a chapter titled Spinal stenosis...then goes to explain three categories of stenosis: 1. Central 2. Foraminal then lastly 3. Lateral Recess

Then it clearly states 18.4.1.1 "Unless otherwise indicated this discussion refers primarily to central canal stenosis" So it listed three categories at the begining and is only choosing to cover one of the three variants of spinal stenosis that can cause neurogenic caludication.....

Then it goes on to talk about the clinical manifestation of spinal stenosis, which is just a radiologic finding....that is neurogenic claudication

Then it states under "Relief of symptoms" flexion...."which distracts the facet joints(which enlarge the neuroforamen) Remember when you scoffed at the idea of this in my previous post and you quote "Nice you say that, but I've never seen it in a textbook" Guess what, now you have

Then lastly under surgical treatments they specifically talk about "procedures to increase disc height therefore indirectly decompress the neuroforamen" Why on earth would someone want to decompress the neuroforamen in a chapter of a textbook covering neurogenic claudication if it didn't exist???????

Now now. I guess the problem is twofold. You cannot read and you cannot recognize when you are wrong. That's sad.

 

[SIIMS]

Now now. I guess the problem is twofold. You cannot read and you cannot recognize when you are wrong. That's sad.

I read quite well steve-o....explain yourself...what is twofold?? What have you provided to convince me or any one else reading this thread that you are 100% right in your conviction that neuroforaminal stenosis, under absolutely NO circumstances, can cause neurogenic claudication...write it out in terms that I (who can't read or recognize the error of my ways) will understand

And I am absolutely not wrong on this, not by a long shot.....but what I am is done trying to convince you about this clinical entity

Frankly I don't give a rat's ass wether you believe it or not

 

[SIIMS]

Might want to re-read your original post

Doesn't change the fact that you very incorrectly posted that you should place an "interspinous spacer for dynamic unstable foraminal stenosis, logically that is"


Remember....

the spirt of this thread was not of being conceited or personal attack on my end, it was soliciting to a group of physicians to gauge wether you had any experience with (insert original post) in order to further educate myself and perhaps gauge wether it would help my patients.

Clearly I received not a single useful response on this but was myself accused of illegitimate medical practice and profits over ethics which clearly isn't the case

 

[DOctorJay]

I'd like to break this down anatomically.

With central canal stenosis there is intermittent compression of the roots. With foraminal stenosis there is compression on the DRG or possibly the spinal nerve or maybe even still the root depending on the compressive tissue.

I know the NCS/EMG would look different (pre vs postganglionic) but would this necessarily lead to different symptomatology?

 

[lobelsteve]

http://www.google.com/url?sa=t&sour...Dayw8BE42w1akebEQ&sig2=3tDbZ-5o771ZZf1c8MFlFw

Ive found 10+ texts refuting your foraminal argument.

Back on topic:

Yes. Ive taught SCS FOR ST JUDE. Ive got 20 + implants for nonoperative spinal stenosis with a success rate of 70%. Most recent was a 96 y/o with Afib and surgeons wouldn't touch him. He wanted to continue playing golf and even with a cart he couldnt walk from cart to green without claudication pain. Last trial I did was on 77 y/o for LSS and she did poorly.

 

[tensunit]

some authors are suggesting that SCS can/should be used as an intermediate procedure for LSS - betweeen failure of conservative treatment and decompressive surgery, NOT only patients deemed non-surgical candidates.

thoughts on this?

 

[SSdoc33]

Frankly I don't give a rat's ass wether you believe it or not

Yeah you do

 

[Taus]

Correct me if I'm wrong.... but this is the distinction I've been taught/read...

Central canal stenosis-->venous hypertension and relative neural ischemia-->limb pain that worsens with progressive ambulation with the spine in relative extension, not just positional/extension changes in pain.... the pain takes time to occur and worsen. May or may not have clinical and historical findings of radiculopathy

vs.

foraminal stenosis: pain more positional with extension, as in a radic with neural compression and/or inflammation..... and not truly claudicatory in presentation

Can certainly have both/overlap....

 

[lobelsteve]

Correct me if I'm wrong.... but this is the distinction I've been taught/read...

Central canal stenosis-->venous hypertension and relative neural ischemia-->limb pain that worsens with progressive ambulation with the spine in relative extension, not just positional/extension changes in pain.... the pain takes time to occur and worsen. May or may not have clinical and historical findings of radiculopathy

vs.

foraminal stenosis: pain more positional with extension, as in a radic with neural compression and/or inflammation..... and not truly claudicatory in presentation

Can certainly have both/overlap....

This is correct and c/w texts. Claudication is believed to be a vascular insufficiency to the cauda equina due to deformity in the spinal canal. Other mechanisms may be at play relating to nerve metabolism, vascular tortuosity, but not from root pathology in the foramen.

 

[SSdoc33]

never really thought about it this deeply before.

in general, when patients complain of claudicatory pain, it is the LOL with stenosis. and in GENERAL, this is central stenosis. but, there is typically also concomitant foraminal stenosis.

if you imagine the scenario of the 50 y/o guy with unilateral single-level foraminal stenosis, they do also complain of claudication, but it typically isnt as clear-cut. "does it hurt when you walk? yeah, doc, but it hurts all the time).

i do believe that formainal stenosis can cause neuroclaudication, but the classical case is central stenosis.

SIIMS, i have no idea why you seem to believe that the only way to surgically treat foraminal stenosis is a fusion. that seems to be a bit of surgical propaganda to me.

 

[Ducttape]

getting back to the key question -

yes, i do believe patients with NF stenosis can be helped with SCS.

yes, I have had successful trials with SCS for neuroclaudication symptoms. i have done it the couple of times that i did get approval, in patients that clearly did not want surgery (had already seen a neurosurgeon) or were considered too ill for any major surgical intervention (which of course SCS implant is not considered).

 

[tensunit]

when evaluating a patient with LSS, and considering SCS, is there any data to predict who is going to respond before the trial?