SCS Trial?

[Algiatrist]

Any input appreciated:

27 year-old Hispanic male underwent right median nerve transposition for CTS about 5 years ago. Nerve got dinged and developed textbook CRPS about 2 months after the surgery. He then goes to prison for drugs and gets zero help with his extremely obvious CRPS of his right arm. He doesn't know what to do, so he starts keeping his very painful swollen arm in a sling around the clock. After spending FOUR years in prison, he got out this August and now is seeing me.

Because he keeps his arm in a sling full-time, he has right rotator cuff issues-likely secondary to atrophy/deconditioning of his girdle musculature. The ortho he went to keeps pushing for rehab of his shoulder, but he can't move his arm at the elbow or wrist, or open his hand due to the CRPS.

He seems genuinely honest about cleaning his life up-has 2 kids, a full-time job now, and wants NOTHING to do with opiate medications. He is a Medicaid patient, therefore I may have to beg a surgeon to implant him, and I'll have to essentially get reimbursed peanuts for the trial, but do you all think that an SCS trial would be helpful in a chronic CRPS patient who already has atrophy/contractures of the wrist?

Would anyone do anything different? I think neuropathics may offer some degree of relief, but I think his situation may vastly improve with neuromodulation.

Thoughts?

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[PinchandBurn]

Any input appreciated:

27 year-old Hispanic male underwent right median nerve transposition for CTS about 5 years ago. Nerve got dinged and developed textbook CRPS about 2 months after the surgery. He then goes to prison for drugs and gets zero help with his extremely obvious CRPS of his right arm. He doesn't know what to do, so he starts keeping his very painful swollen arm in a sling around the clock. After spending FOUR years in prison, he got out this August and now is seeing me.

Because he keeps his arm in a sling full-time, he has right rotator cuff issues-likely secondary to atrophy/deconditioning of his girdle musculature. The ortho he went to keeps pushing for rehab of his shoulder, but he can't move his arm at the elbow or wrist, or open his hand due to the CRPS.

He seems genuinely honest about cleaning his life up-has 2 kids, a full-time job now, and wants NOTHING to do with opiate medications. He is a Medicaid patient, therefore I may have to beg a surgeon to implant him, and I'll have to essentially get reimbursed peanuts for the trial, but do you all think that an SCS trial would be helpful in a chronic CRPS patient who already has atrophy/contractures of the wrist?

Would anyone do anything different? I think neuropathics may offer some degree of relief, but I think his situation may vastly improve with neuromodulation.

Thoughts?

You are right. You probably wont get too much help from a surgeon.

Try to do it peripherally. Try a brachial plexus stimulator or placing it over the median nerve using ultrasound.

Then if it' successful, you can do the implant yourself.

 

[lobelsteve]

Get a real psych screen and then decide.

Surgeons wont ask and dont care. Bone broke. Me fix.


PNS sounds terrible. And where you gonna wire this up?

 

[Ducttape]

You are right. You probably wont get too much help from a surgeon.

Try to do it peripherally. Try a brachial plexus stimulator or placing it over the median nerve using ultrasound.

Then if it' successful, you can do the implant yourself.

if you think you will get peanuts for a dorsal column stim, you will be forced to pay medicaid for a periph nerve stim.

 

[drf]

Last week I placed an IT catheter for Prialt for cancer pain. Medicaid 44 yo male who was diagnosed in PRISON with cancer, etoh abuse, poly drug abuse. Wuld have thought he was a terrible candidate.

However a low dose of Prialt, morphine from 360 mg to 0 mg, and almost no pain. I was surprised how well he did.

 

[specepic]

I'm confused. What is median nerve transposition for CTS. Or are we talking about ulnar neuropathy or pronator teres syndrome? Transposition for CTS does not make sense. -5 points for SL not already noting this

I would do peri-arterial sympathetic blocks in the UE first and OT the **** out of him first with those. Then trial for SCS if negative.

my 0.02

 

[PinchandBurn]

Get a real psych screen and then decide.

Surgeons wont ask and dont care. Bone broke. Me fix.


PNS sounds terrible. And where you gonna wire this up?

I respectfully disagree.

I've done this in fellowship with fairly good success. You can wire this up to the axilla or even pec wall.

In fellowship we did a moderate amount of occipital and other peripheral stim. Honestly, I saw better results from them than SCS. Additionally, less risk (no manipulation need in the spine).....

 

[lobelsteve]

I respectfully disagree.

I've done this in fellowship with fairly good success. You can wire this up to the axilla or even pec wall.

In fellowship we did a moderate amount of occipital and other peripheral stim. Honestly, I saw better results from them than SCS. Additionally, less risk (no manipulation need in the spine).....

What your fellowship didn't teach you is that the migration rate or lead fracture rate was higher than acceptable. You can't put a wire over the median nerve at the wrist, run it all the way up the arm to the chest or armpit, and not expect it to stay put if the patient is allowed to use their arm in the next 12 months.

You might want to track those folks down and find out what % migrated/fractured and required explant or revision, as well as who eroded the skin.

Occipital stim works, ilioinguinal stim works, intercostal stim works. All other areas that I've seen/done/reviewed/explanted/revised for others were miserable failures at 6-12 months. N=20

 

[PinchandBurn]

What your fellowship didn't teach you is that the migration rate or lead fracture rate was higher than acceptable. You can't put a wire over the median nerve at the wrist, run it all the way up the arm to the chest or armpit, and not expect it to stay put if the patient is allowed to use their arm in the next 12 months.

You might want to track those folks down and find out what % migrated/fractured and required explant or revision, as well as who eroded the skin.

Occipital stim works, ilioinguinal stim works, intercostal stim works. All other areas that I've seen/done/reviewed/explanted/revised for others were miserable failures at 6-12 months. N=20

I will definitely ask them, try to track them.

I know when I was in fellowship, we had atleast 3 people that had saphenous nerve peripheral stims in for 2+ years w/o problems.

I honestly dont know about the median stimulator.

I did see a handful of brachial plexus stims that were in for more than 2-3 years.