SCS in cirrhosis?

[Timeoutofmind]

PT with EOTH cirrhosis

Sober for a couple of years, not on opioids, etc

DM neuropathy + EOTH neuropathy + mild (non surgical) spinal stenosis causing severe neuropathic leg pains

Failed much antineuropathic pain meds.

Was thinking of stim.

I am concerned about potential coagulopathy.

1. PLT and INR levels OK and pt has no CKD

2. Not on ASA or NSAIDs or any other anticoagulants

3. Disease is well controlled but has been complicated by portal hypertension, fluid overload, esophageal varices.

4. History of GI bleed back in 2016. At that time pan endoscopic evaluation. Bleeding secondary to portal hypertensive gastropathy, no definitive lesion found. No further evidence of overt GI bleeing at that time.


Would you do it? Any other labs you would want?

I was thinking about a TEG/ROTEM, and go ahead if it is OK. (Not sure how feasible these are going to be outpt).

Thanks in advance.

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[Ducttape]

What is her MELD?

No offense but she has multiple sequels of end stage liver disease. She should be on transplant list and treatment should probably be more palliative...

Also, doesn’t seem like a great candidate from the standpoint that I don’t think these specific peripheral neuropathies responds well to stim.

But then again I’m not recommending stim for run of the mill thoracic spinal stenosis so what do I know.

 

[Timeoutofmind]

Good evidence for DM neuropathy

MELD is 6

 

[SSdoc33]

liver patients are train wrecks. this seems like a really bad idea. million things could go wrong, and the upside as far as function probably isnt that great

 

[Orin]

If it works, what will you do if she gets coagulopathic sometime after the implant and presents to you with signs of an epidural hematoma?

If it works, if she gets transplanted, are you up for revising the battery or leads?

If it works, if she gets transplanted and seeds your hardware, can she tolerate a removal/I&D around her spine?

If it doesn't work, what are the other options? She's not a great candidate for medications.

Is it the spinal issue or the peripheral neuropathy? Is she a candidate for peripheral stimulation?

 

[painfree23]

How r u gonna get this approved by her insurance? Its always a struggle for diabetic neuropathy.

 

[PainMD23]

I would say no to SCS here. Too much risk, not enough benefit. Agree with prior comments.

 

[lobelsteve]

Not indicated.
Pt with multiple psychological risk factors, would not pass legit screening.
Neuropathy data is weak for scs.

Orin: risk of hematoma is only present when moving leads, not once implanted.

 

[Orin]

Orin: risk of hematoma is only present when moving leads, not once implanted.

I'd believe that if the perc or paddle leads never migrated. We're taught to be afraid whenever you move something in the space, and if that hardware moves/ripping a vein, that will be unnecessary trouble.

Levy's from 2011 data showed a < 0.2% percent rate of hematoma with paddles, but I'm not sure how early/late they were measuring as I can't get the primary paper up right now.

 

[Blitz2006]

I'd believe that if the perc or paddle leads never migrated. We're taught to be afraid whenever you move something in the space, and if that hardware moves/ripping a vein, that will be unnecessary trouble.

Levy's from 2011 data showed a < 0.2% percent rate of hematoma with paddles, but I'm not sure how early/late they were measuring as I can't get the primary paper up right now.

Whats the migration rate of paddle leads? Isn't it close to 0?

 

[Orin]

Whats the migration rate of paddle leads? Isn't it close to 0?

About 5% is what is reported in the literature

 

[Blitz2006]

About 5% is what is reported in the literature

Thanks. And 15 to 20% for perc right?

Sent from my SM-G955U using Tapatalk

 

[Orin]

Thanks. And 15 to 20% for perc right?

Sent from my SM-G955U using Tapatalk

If you read the older papers, there are some that say 60-70% for perc leads. The 15-20% number is probably more reasonable with the newer anchors and attention to anchoring techniques.

There most recent report, covering ~2011 - ~2017, I saw was Jason Pope's article which didn't differentiate between lead types but reported an overall ~4% rate of fracture/migration.
Multicenter Retrospective Study of Neurostimulation With Exit of Therapy by Explant. - PubMed - NCBI

The 5% paddle number comes from a small old Belgian series of 20 some patients.
Long-term outcomes of spinal cord stimulation with percutaneously introduced paddle leads in the treatment of failed back surgery syndrome and lumb... - PubMed - NCBI

If you look at the folks that mine insurance data, they say you are looking at 22% percutaneous vs 9% paddle 5-year reoperation rate in the 2000-2010, although early on there are about twice as many complications with paddles.
Outcomes of percutaneous and paddle lead implantation for spinal cord stimulation: a comparative analysis of complications, reoperation rates, and ... - PubMed - NCBI

 

[lobelsteve]

Migration rate related to experience. Angle of approach mitigates against most migration. Anchor and suture technique takes care of most of the rest.

Paddle migration rate is taught to be 1% or less. Perc rate is 10-15% for 1-5 yrs experience, then drops to under 5%.
More than that needs outside eval of technique to overcome this complication. Because it is easy to fix in watching 1 trial or implant.

 

[244913]

Migration rate related to experience. Angle of approach mitigates against most migration. Anchor and suture technique takes care of most of the rest.

Paddle migration rate is taught to be 1% or less. Perc rate is 10-15% for 1-5 yrs experience, then drops to under 5%.
More than that needs outside eval of technique to overcome this complication. Because it is easy to fix in watching 1 trial or implant.

Would you mind sharing your time honored techniques for limiting lead migration? Thx