SCS leads for peripheral stim

[drf]

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I've now done a handful of occipital nerve stims with ultrasound guidance. I'm still looking for the appropriate patient to let me do a PNS on some other nerve, ie saphenous.

Anyone else doing peripheral nerve stim? Anyone using US?

What about scar leads or soft tissue leads? Are you getting paid for this?

I'm really falling in love with the US machine. I feel like I can poke anything I want in the body with success, and lead placement seems like a great next step for the ones who don't respond to pRF.

 

[lobelsteve]

Peripheral nerve stim is really two types of stim.

Actual stim over a sensory branch of a named peripheral nerve, but much more commonly it is peripheral field stim over innominate nerves at a tissue plane depth of 7-8mm. I'm sure 90-99% of all PNS is field stim. It is not as well studied, but appears to work llke a $30000 TENS unit. But better. Easy to do and essentially risk free. Would not use US, just some cutaneous pain mapping and slide it in.

 

[PinchandBurn]

I've now done a handful of occipital nerve stims with ultrasound guidance. I'm still looking for the appropriate patient to let me do a PNS on some other nerve, ie saphenous.

Anyone else doing peripheral nerve stim? Anyone using US?

What about scar leads or soft tissue leads? Are you getting paid for this?

I'm really falling in love with the US machine. I feel like I can poke anything I want in the body with success, and lead placement seems like a great next step for the ones who don't respond to pRF.

Hey DRF

I think its variable. I went to a Peripheral stim course at the ASA a few years back. It was taught by Marc Huntoon at Mayo and Allen Burton (MD anderson). Huntoon used Utz to place the leads into a fascial plane. Burton on the other hand did not and just used fluro.

A majority of the PNS I've seen (saphenous, lower back, occipital) were done with no ultrasound and rather just fluro to confirm. So I'm not sure there's a correct answer. I agree, I think it's a great tool nonetheles..

 

[Aether2000]

It is a technique that will soon be restricted or eliminated altogether given its expense and lack of scientific support.

 

[PinchandBurn]

I've seen it done for ilioinguinal/iliohypogastric neuralgia for post-hernia pain. Use the U/S to see the fascial planes and the nerves. A little hydrodissection with local to nub up the tract and then put the needle and probe right where it needs to go. I think using a second lead is probably beneficial to widen the field of the block, much like what lobelsteve was mentioning. I'm not sure where the reimbursement is going to go on this. If you saw Tim Deer's recent editorial in Pain, with all the stuff coming out about the relative dangers of ITP therapy in non-cancer pain, he's advocating changing the treatment algorithms to trying PNS well before considering offering ITP therapy.

Iknow people on here will have probs with Deer's article. But he makes a point. For chronic NON malignant pain...do PNS, then you can augment with SCS...Last resort should be ITP. Cancer pain is a different beast.

 

[drpainfree]

anyone has the deer's article to post here?

also original question, how have you been getting paid for PNS?

 

[DOctorJay]

Eldridge from Mayo has an article documenting ONS with US placement. I'll post it tomorrow if anyone is interested.

 

[lobelsteve]

Eldridge from Mayo has an article documenting ONS with US placement. I'll post it tomorrow if anyone is interested.

Now it's getting ridiculous with US.

The occipital nerve lies superficially in a tissue plane bounded by the skull and the skin. It has readily definable anatomic landmarks and is palpably painful in any stim candidate.

US is a tool looking for extra indications and needs to go back to the regional anesthesia folks. It still is easier, less cumbersome, and uses less than 10 sec of fluoro to get into any joint. I just don't get US in Pain Medicine.

 

[PinchandBurn]

Now it's getting ridiculous with US.

The occipital nerve lies superficially in a tissue plane bounded by the skull and the skin. It has readily definable anatomic landmarks and is palpably painful in any stim candidate.

US is a tool looking for extra indications and needs to go back to the regional anesthesia folks. It still is easier, less cumbersome, and uses less than 10 sec of fluoro to get into any joint. I just don't get US in Pain Medicine.

I agree.

Steve, you would be very surprised as to how many PMR folks are 'trying' to use ultrasound to dx things like Tendonitis. I think that's fraudulent biling. With the current technology it's very difficult to obtain such good resolution to dx these sorts of pathology. We know frm the the Anesthesiology literature that even dxing intraneural injections isn't always that straight forward, even with ultrasound. I dont know how these people are dxing tendonitis definitively..

 

[TX PAIN DOC]

anyone has the deer's article to post here?

also original question, how have you been getting paid for PNS?

I second the above question.

What evidence in the literature or patient selection criteria are used for the different peripheral sites to convince insurers to cover PNS? It is still considered experimental.