SCS query for Gorback and PAZ

[drrinoo]

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I colleague asked me about your posts on the ISIS website.

Dr. Gorback,

Your polarity configuration is very interesting....you seem to have found a way to obtain one of the benefits of a laminotomy lead, even though you are using perc leads....

North and others have stated that lami leads use less power and obtain better stimulation since all their current flows anterior....

With your configuration and assuming you have a separate program that reverses the polarity...the contact is initially neg....inducing depolarization...then the lead suddenly changes configuration to pos...inducing hyperpolarization...in effect, creating a hybrid guarded cathode in the axial plane. Subsequent, return of the contact to neg....may not be able to overcome the area temporarilty hyperpolarized.

The old MDT synergy oscillated between channel 1 and 2....the current systems oscillate between separate programs, if all are used at the same time.

As far as your preference for 8 contacts, I share a similar experience. I have had great success with revisions using 8 contact electrodes, particularly of previously implanted Quad plus leads.

PAZ,

are you trialing with 3 4-contact electrodes or 1 8-contact/2 4-contact....and for your permanent tripole arrays, I am assuming, you are using a rechargeable system with one bifurcated connector and one in-line connector....or are you just putting in laminotomy leads....

Have most of the areas you have gotten coverage for axial back been at T7 or T8 or T9....

I bet Jan Holsheimer must be having an epiphany, since he predicted that this configuration would be ideal for SCS.


If we become routinely successful in treating axial back pain with SCS, it would induce an interesting paradigm shift, from a structural/anatomic model of spine pain to one that is neuropathic...

Maybe one day, SCS will act as a bridge to spinal fusion/intradiscal therapies or alternatively replace these.....you are not violating the anatomy of the spine (perc leads), you give the patient a voice in their therapy (trial), and you have engaged in a rigorous screening process (multidisciplinary tx), and if the patient becomes dissatisfied, you pull it out (minimal harm, if any)....if we can buy our patients time, until intradiscal gene therapy or other promising intradiscal therapies (on the horizon) bear fruition, we may do some good.

Hence, SCS may preempt or presage spine surgery in the future....as opposed to the reverse...spine surgery and then stim....

 

[Mister Mxyzptlk]

Rinoo, always a pleasure to "see" you.

I don't know. I am just a monkey on a typewriter doggedly trying to write Shakespeare. The configuration I describe does not rely upon flipping the polarities. I was trying to get current across the cord's axis instead of up and down like we usually do - just to see what would happen.

In the last case I did like this I ran two separate programs at once. Initially each side was independent (one program covered the left side, one covered the right), but when she came back for lead removal she was able to get low back stim with only one program.

For those of you who are late to the party, the configuration we are discussing is:

1 2
+ -
+ -
+ -
+ -

I had this lady running the above as program #1 and the opposite as program #2:

1 2
- +
- +
- +
- +

I have also noticed that sometimes you can get lower back by pulling the leads more caudally. I had that yesterday. High voltages and poor low back stim at T8/9, ribs at T7/8, legs at T9, but excellent back coverage at T10.

I would recommend that people try other variations on this theme as well.

There's a lot we still don't know (most of it, would be my guess).

 

[Spine Specialist]

Maybe one day, SCS will act as a bridge to spinal fusion/intradiscal therapies or alternatively replace these.....you are not violating the anatomy of the spine (perc leads), you give the patient a voice in their therapy (trial), and you have engaged in a rigorous screening process (multidisciplinary tx), and if the patient becomes dissatisfied, you pull it out (minimal harm, if any)....if we can buy our patients time, until intradiscal gene therapy or other promising intradiscal therapies (on the horizon) bear fruition, we may do some good.

Hence, SCS may preempt or presage spine surgery in the future....as opposed to the reverse...spine surgery and then stim....

Agreed.
SCS is the future of non-operative spine pain management. Period.

 

[Aether2000]

Unless the cost comes down (not happening) then it is highly doubtful insurers will start to ante up 40 grand each in a population of low back pain patients. Hopefully we will be able to reduce cost and stratify patients to appropriate therapy. Overuse of the technique in my area has provoked the insurers to severely curtail their coverage of SCS.

 

[lobelsteve]

Unless the cost comes down (not happening) then it is highly doubtful insurers will start to ante up 40 grand each in a population of low back pain patients. Hopefully we will be able to reduce cost and stratify patients to appropriate therapy. Overuse of the technique in my area has provoked the insurers to severely curtail their coverage of SCS.

I think $40k is overstated. Granted, the cost is still exorbitant, but for the money you are talking you can get 2 EON's, 3 octrodes, 2 quads, an extension, and an hour of quality programming.

I didn't scrub in, but PAZ may shed more light on his array/montage.

If anyone has the cost analysis for LBP and can prove better than current consrvative care we have a chance.

Kumar K, Malik S, Demeria D 2002 Treatment of chronic pain with spinal cord stimulation versus alternative therapies: Cost-effectiveness analysis. Neurosurgery 51(1):106-116

Bell G K, Kidd D, North R B 1997 Cost-effectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. Journal of Pain and Symptom Management 13(5):286-295 (2 years to break even cost)


The issue will become how can we expand the use of these devices, allow the cost to decrease, and improve selection criteria.
Tripole configuration is interesting and may prove useful for axial pain by steering the current anteriorly without root spread. The real mystery for SCS is when we get amazing results from subQ insertion of leads for discogenic, sacroiliac, or post herpetic neuropathic type pains.

 

[Aether2000]

One of my patients now is appealing the lack of her insurance coverage of a single lead trial plus permanent dual lead implant plus Eon RIPG. The insurance company precerted the SCS system in writing but failed to tell the patient they only cover the first $300 of any pain management procedures. She is stuck with a bill of $42,365. Unfortunately this is a real person that owes real dollars.
SCS systems have simply not fallen in price. They have steadily escalated ostensibly due to improvements in technology, however we are now priced in the range of spinal fusion surgeries. Of course, we could find a dusty Matrix or Renew system in a warehouse somewhere to implant, or perhaps I should start checking ebay for used SCS systems....
The cost of medicine is out of control. When an operation costs double what the average person brings home in a year, and yet the majority of patients having this operation will continue to require pain medicines for a lifetime, not to mention the revisions and explantations that will be needed, all for about 46% pain reduction of low back pain (after increasing use of medications after implantation), it does make one wonder about what a true cost analysis that takes into account all these factors would demonstrate
I am not antitechnology, and have used dorsal sacroiliac ligament stim lead implantation with good success, and have implanted stim leads on the suprascapular nerves, gr occipital, supraorbital, etc with reasonable success rates. But it is heartbreaking to see people mortgaging their houses to pay for the technology we offer. I believe it is important to be brutally honest with patients concerning the long term prospects of treatment, success, failures, and financial ramifications of chronic pain so they can make informed choices regarding astronomically expensive therapies. Therefore, my bar is set quite high before I will implant anything into a patient...

 

[lobelsteve]

Ouch!

I am unsure of the system in place at my practice, but I hope somebody is discussing the costs to the patient before we get into that situation. I have not heard of insurance like that. Most of what I see is either WC, Medicare, or BCBS. Worst case scenario I've heard is paying deductible of $2500 plus 30% of the bill not exceeding $7500 (another $1500).