SCS for refractory neuroclaudication

[manowar rules]

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Hi all,

I have a few patients with severe symptomatic lumbar stenosis, who are not surgical candidates. They are all in their 80s, some with mild dementia (but not assisted-living level), and they have seen surgeons who felt the patient's risk of decline with surgery was too high. Stenosis is severe, like pinhole, no-CSF visible, and they have the classic LBP->posterior thigh pain worse with activity. No cauda equina, or even much leg weakness, but considerable pain and activity limitation. I am pro-Vertiflex, but these patients are not candidates due to either significant lithesis, or in one case, paradoxical worsening of symptoms in flexion and improvement with extension.

I have maxed out neuroleptics and opiates as side effects can tolerate, which isn't much in a 89 y/o. ESI from several approaches, RFA, facet steroids, have provided little or very short term relief.

Is SCS a reasonable option to trial here, or am I wasting everybody's time? I figure we don't have much to lose, although I know that traditionally SCS isn't considered helpful for neuroclaudication. If you think it's worth a shot, do you have any recommendations for one stim brand over the other to treat these symptoms?

Thanks for your help

 

[SommeRiver]

You can try it but it won't work.

Particulate in the canal and Norco.

 

[manowar rules]

You can try it but it won't work.

Particulate in the canal and Norco.

Yeah I feel you, but I'm on particulate in the canal and Norco/Percocet, and in both cases the patient is still miserable and the families are begging me for anything else to help.

 

[SommeRiver]

Yeah I feel you, but I'm on particulate in the canal and Norco/Percocet, and in both cases the patient is still miserable and the families are begging me for anything else to help.

MILD may help if you have huge LF hypertrophy (if you even do MILD).

Trying SCS isn't wrong but it most likely will not help.

If that's my mom I am giving opiates. In my little corner of the world I find Norco does much better than Percocet. Maybe I'm wrong, but I do believe in pharmacogenetics and it seems Norco does better.

 

[manowar rules]

MILD may help if you have huge LF hypertrophy (if you even do MILD).

Trying SCS isn't wrong but it most likely will not help.

If that's my mom I am giving opiates. In my little corner of the world I find Norco does much better than Percocet. Maybe I'm wrong, but I do believe in pharmacogenetics and it seems Norco does better.

Yes, ILESI and Norco are my mainstays for non-surgical LSS as well. One patient I had bumped up from Norco to Percocet and it didn’t seem to make a difference.

MILD is a good thought, although I think that the LF is a lesser contributor to these particular patients’ stenosis. But if it has a higher likelihood than stim of helping, I may refer to someone who does them, thanks.

 

[Gnarvin]

A study showed that MILD worked just as well for patients that had concurrent neural foraminal and/or lateral recess stenosis in conjunction with central stenosis with ligamentum flavum hypertrophy. If that patient has central canal stenosis, they probably also have ligamentum flavum over 2.5mm. If so, I think MILD is your best next step rather than stim.

 

[lobelsteve]

Im ok with scs trial in these folks. Depends on are they participating in activities or just taking Norco and laying around.

 

[manowar rules]

A study showed that MILD worked just as well for patients that had concurrent neural foraminal and/or lateral recess stenosis in conjunction with central stenosis with ligamentum flavum hypertrophy. If that patient has central canal stenosis, they probably also have ligamentum flavum over 2.5mm. If so, I think MILD is your best next step rather than stim.

Thank you. I actually got trained in MILD a few years back, but at the time, the surgery center I went to felt MILD wasn't financially worth their while, so that kind of nipped it in the bud for me. I've gotten a few emails recently from Vertos asking me to reconsider now that the technique is streamlined, doing multiple levels bilaterally through one incision. Are people generally using this new technique?

 

[manowar rules]

Im ok with scs trial in these folks. Depends on are they participating in activities or just taking Norco and laying around.

Thanks. These are otherwise fairly fit, active ladies, previously gardening, pickleball, etc.
Do you think any of the SCS devices would have benefit over the others here, eg conventional vs high frequency vs burst? I have an n of 1 previously trying Nevro for this, and it didn't help.

 

[SommeRiver]

I need to start doing it. I've spoken with Vertos a few times but training right now is nonexistent. Rep told me I'd practice on my first pt more or less.

 

[SommeRiver]

Thanks. These are otherwise fairly fit, active ladies, previously gardening, pickleball, etc.
Do you think any of the SCS devices would have benefit over the others here, eg conventional vs high frequency vs burst? I have an n of 1 previously trying Nevro for this, and it didn't help.

Abbott is nonrechargeable and you no longer have to test intraop. Use that so they don't have to fool with charging it.

 

[Gnarvin]

Thank you. I actually got trained in MILD a few years back, but at the time, the surgery center I went to felt MILD wasn't financially worth their while, so that kind of nipped it in the bud for me. I've gotten a few emails recently from Vertos asking me to reconsider now that the technique is streamlined, doing multiple levels bilaterally through one incision. Are people generally using this new technique?

I can't speak for anyone else, but I have been using the "streamlined technique." One midline stab incision and I have done up to two levels bilaterally. I have heard of some people doing 3 levels from the single midline incision, but I would be worried that the angle would be so flat when going up to the third level that it would make it less than ideal.

 

[SommeRiver]

I can't speak for anyone else, but I have been using the "streamlined technique." One midline stab incision and I have done up to two levels bilaterally. I have heard of some people doing 3 levels from the single midline incision, but I would be worried that the angle would be so flat when going up to the third level that it would make it less than ideal.

What are your results looking like, and are you getting paid for it reasonably well?

Dural tears?

 

[lobelsteve]

Thanks. These are otherwise fairly fit, active ladies, previously gardening, pickleball, etc.
Do you think any of the SCS devices would have benefit over the others here, eg conventional vs high frequency vs burst? I have an n of 1 previously trying Nevro for this, and it didn't help.

My N is a bit higher. Those are my patients. Over 50% responder rate. Not a home run but worth trying.

 

[Gnarvin]

What are your results looking like, and are you getting paid for it reasonably well?

Dural tears?

Anecdotally, results have been good. I don't believe I have yet to have a patient get less than 50% relief (low n at this time, however). Of course, I think proper patient selection is key. Knock on wood, no dural tears. As far as the compensation goes, for better or for worse, I have been doing the procedure for patients I think will benefit and honestly do not know what the physician fee for the procedure is.

 

[Ronin1]

I have done many patients just like this using Abbott over the last 3 years. Probably 90 percent go to implant. Most are fairly happy afterwards. All non rechargeable generators.

 

[Ferrismonk]

Worth a SCS trial at least. I'd use Boston with Wavewriter Alpha, heard great things.

Also may consider a simple back brace. She's 89.

 

[deleted875186]

Hi all,

I have a few patients with severe symptomatic lumbar stenosis, who are not surgical candidates. They are all in their 80s, some with mild dementia (but not assisted-living level), and they have seen surgeons who felt the patient's risk of decline with surgery was too high. Stenosis is severe, like pinhole, no-CSF visible, and they have the classic LBP->posterior thigh pain worse with activity. No cauda equina, or even much leg weakness, but considerable pain and activity limitation. I am pro-Vertiflex, but these patients are not candidates due to either significant lithesis, or in one case, paradoxical worsening of symptoms in flexion and improvement with extension.

I have maxed out neuroleptics and opiates as side effects can tolerate, which isn't much in a 89 y/o. ESI from several approaches, RFA, facet steroids, have provided little or very short term relief.

Is SCS a reasonable option to trial here, or am I wasting everybody's time? I figure we don't have much to lose, although I know that traditionally SCS isn't considered helpful for neuroclaudication. If you think it's worth a shot, do you have any recommendations for one stim brand over the other to treat these symptoms?

Thanks for your help

Interesting thread. I too think the mainstay for these people ends up being opioids.

I’ve pitched SCS trials to my attendings for some of these people, yet to have a trial on any patient, seems like most think the risk is not worth it in this age group for some reason

 

[BobBarker]

They can do really well. Have a lot of older patients that I have implanted. Oldest was 92.

 

[painfree23]

Interesting thread. I too think the mainstay for these people ends up being opioids.

I’ve pitched SCS trials to my attendings for some of these people, yet to have a trial on any patient, seems like most think the risk is not worth it in this age group for some reason

Be careful of thoracic stenosis, don’t force the leads in .
Also try to keep them awake during the trial at least as the intraop pain meds/sedation meds can linger in this age group

 

[Ronin1]

I get a thoracic MRI preop. Straight local is the best plan for scs especially in this elderly population

 

[lobelsteve]

I get a thoracic MRI preop. Straight local is the best plan for scs especially in this elderly population

Meh. My trials are 99% local.
My implants are 75% general anesthesia

 

[Ronin1]

Meh. My trials are 99% local.
My implants are 75% general anesthesia

Do you use Neuromonitoring for GA implants?

 

[lobelsteve]

Do you use Neuromonitoring for GA implants?

Nope, MRI ahead of time and lateral for entry and first 1" of advancement.

 

[Sparkymd]

I don't feel like I have seen much success with SCS for NC.

Especially if LESI is helpful, but short-lived (like a day or two), I feel like MILD has been very helpful. There needs to be SOME LFH, but it doesn't have to be the only factor driving the pain. If it isn't diffuse, like every level, but severe at a level or two.. vertiflex might be reasonable(?)

 

[Vie221]

Thank you. I actually got trained in MILD a few years back, but at the time, the surgery center I went to felt MILD wasn't financially worth their while, so that kind of nipped it in the bud for me. I've gotten a few emails recently from Vertos asking me to reconsider now that the technique is streamlined, doing multiple levels bilaterally through one incision. Are people generally using this new technique?

I do MILD this way and it is much faster. I still think there is a bit of a learning curve to the procedure.

 

[Darkside_]

I get a thoracic MRI preop. Straight local is the best plan for scs especially in this elderly population

How do you get thoracic MRI approved by insurance before SCS?

 

[RoloTomassi]

How do you get thoracic MRI approved by insurance before SCS?

Just say in your note that you need for pre-op planning. Never had pushback

 

[MitchLevi]

How do you get thoracic MRI approved by insurance before SCS?

You really should get it preoperatively.

I discovered a massive lower thoracic herniation with cord compression and signal change once. Like, T10ish maybe? Pt ended up getting a decompression but still got a stimulator anyways. Hindsight, not sure that cord compression was symptomatic but TBH I can't remember how that case ended up going.

 

[PinchandBurn]

Im ok with scs trial in these folks. Depends on are they participating in activities or just taking Norco and laying around.

How do you get it approved..

It's not crps or fbss. Medicare you can do it. But clawback for not being on indication??.

 

[lobelsteve]

Submit notes and imaging. Chronic intractable pain of the trunk and limb.

 

[PinchandBurn]

Submit notes and imaging. Chronic intractable pain of the trunk and limb.

Thts not a covered diagnosis. They can do clawback. 2 diagnosis are fbss and crps.

 

[lobelsteve]

Thts not a covered diagnosis. They can do clawback. 2 diagnosis are fbss and crps.

I have an entire department dedicated to getting precert done. If dx incorrect it comes back to me. Also, chronic radiculopathy, DPN are covered codes.

 

[MitchLevi]

I once had a denied SCS go to P2P with chronic radic as the Dx. My "peer" said I can only do it if the pt has seen a surgeon and been denied surgery. She had seen a surgeon (no less than 4-5x) who repeatedly said no. Well documented too.

BTW - I still don't believe severe spinal stenosis is a good Dx for stim.

 

[Darkside_]

I have an entire department dedicated to getting precert done. If dx incorrect it comes back to me. Also, chronic radiculopathy, DPN are covered codes.

Thank you for this post.

I once had a denied SCS go to P2P with chronic radic as the Dx. My "peer" said I can only do it if the pt has seen a surgeon and been denied surgery. She had seen a surgeon (no less than 4-5x) who repeatedly said no. Well documented too.

BTW - I still don't believe severe spinal stenosis is a good Dx for stim.

I was going to echo this. If you submit notes from a surgeon indicating that the patient is not a surgical candidate, it can help make your case.

 

[Vie221]

I have had decent success with stim in these cases but my practice pattern has changed with MILD. If they are anesthesia candidates for a stim implant, they are an a anesthesia candidate for an MIS lami. So the trial is not concerning but the implant may be.

MILD can be done under local if necessary. The recovery is less than 24 hours and well selected patients get relief. I think it would be a better first option in this case. It reimburses about 4-5x an ESI on the professional fee side for those that are wondering. However, it is a global per procedure and not per level. I’ve done up to three levels bilateral through the streamlined technique and it unfortunately reimburses the same as a quick one level. It’s the best thing for the patient, though.

The IFU has been updated not to require an epidurogram. I still like them because I like to give a little steroid during the procedure and it allows me to be more aggressive about the decompression but you can be just as safe without them.

 

[Darkside_]

I have had decent success with stim in these cases but my practice pattern has changed with MILD. If they are anesthesia candidates for a stim implant, they are an a anesthesia candidate for an MIS lami. So the trial is not concerning but the implant may be.

MILD can be done under local if necessary. The recovery is less than 24 hours and well selected patients get relief. I think it would be a better first option in this case. It reimburses about 4-5x an ESI on the professional fee side for those that are wondering. However, it is a global per procedure and not per level. I’ve done up to three levels bilateral through the streamlined technique and it unfortunately reimburses the same as a quick one level. It’s the best thing for the patient, though.

The IFU has been updated not to require an epidurogram. I still like them because I like to give a little steroid during the procedure and it allows me to be more aggressive about the decompression but you can be just as safe without them.

Most laminectomies require general anesthesia whereas stim implants can routinely be done under mild to moderate sedation.

 

[deleted875186]

Most laminectomies require general anesthesia whereas stim implants can routinely be done under mild to moderate sedation.

Sedation versus general anesthesia versus neuraxial has never really shown to matter for outcomes such as cognitive impairment.

There are many who believe the surgical insult itself is what does it …. So called neuroinflammatikn. So the main thing is the least inflammation associated with surgery, a minimally invasive procedure, so would depend how much dissection the surgeon has to do.

 

[Darkside_]

Sedation versus general anesthesia versus neuraxial has never really shown to matter for outcomes such as cognitive impairment.

There are many who believe the surgical insult itself is what does it …. So called neuroinflammatikn. So the main thing is the least inflammation associated with surgery, a minimally invasive procedure, so would depend how much dissection the surgeon has to do.

I guess you can then debate the level of inflammation caused by the MILD vs SCS implant.

 

[PinchandBurn]

I have an entire department dedicated to getting precert done. If dx incorrect it comes back to me. Also, chronic radiculopathy, DPN are covered codes.

here's the LCD for SCS

essentially doing it on a "virgin surgical back" isnt an indication.

See attached LCD from medicare

not sure how you guys are getting away with it?

One of the indications is: "nerve root injuries" . Is that what you all are using for a patient let's say is not a surgical patient and is 80yo and has no other options but has a herniated disc? Failed ESI etc

 

[lobelsteve]

To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of postlaminectomy syndrome (failed back syndrome).