SCS vs PFS for lbp

[clubdeac]

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So for you guys doing peripheral field stim, are you seeing better results with that or old school SCS for axial lbp? I've recently seen a slew of patients that have reached the end of my treatment algorithm that I am offering stim trials to but was wondering if I should start trying PFS for these folks instead. Any thoughts?

 

[Jcm800]

So for you guys doing peripheral field stim, are you seeing better results with that or old school SCS for axial lbp? I've recently seen a slew of patients that have reached the end of my treatment algorithm that I am offering stim trials to but was wondering if I should start trying PFS for these folks instead. Any thoughts?

i think field stim is silly. i did some, and it didnt really work. you can only really cover a small true area. works for like inguinal/post hernia stuff and for occipital, but other than that, in my hands its kinda useless.

there was that trend of the 1 epidural and 2 field leads, but i never saw much success, and i only tried it 1 or 2 times...

for low back pain that is axial, i guess the question is what is the etiology of the pain...if its muscular as it is in many cased post fusion, with those essnetially dead and de-vascularized para spinals, i dont think that stim works that well, at least in my opinion...

 

[SSdoc33]

So for you guys doing peripheral field stim, are you seeing better results with that or old school SCS for axial lbp? I've recently seen a slew of patients that have reached the end of my treatment algorithm that I am offering stim trials to but was wondering if I should start trying PFS for these folks instead. Any thoughts?

ahh, i see. tried everything in your toolbox, therefore might as well throw in a stim as well?

sorry if im being a bit offensive, but c'mon. we both know you are going to have awful results with axial LBP/failed backs and stim. is it so awful to tell a patient that you can't help them?

 

[Pain_doc]

I have had decent results with epidural placement. Of course, not every patient that fail treatments receives a stim. I don't think that was what clubdeac intended.

 

[hyperalgesia]

What's the difference between peripheral field stim and a TENS unit? We also use the RS-4i interferential stimulator from RS Medical which is a glorified TENS unit. Only the VA will cover such a thing. But I've had refractory axial pain pts respond. Forget the SCS.

 

[SleepIsGood]

As a fellow, I have seen patients that have been in the practice >3 years who have peripheral stim in conjuntion with epidural leads with good results. These patients seem to swear by it. They have stated the epidural leads did not cover everything completely, but with the addition of the peripheral leads have now achieved better coverage. So my experience with follow ups of these patients are different from above.

To the OP. Although my personal experience for transverse tripole has been limited (and I think it's fallen out of favor ), there are obviously people that advocate it for the condition you are referring to.

At the juncture you are at with this patient, what else are you going to do aside from a ITP? Check out the Deer algorithm in his editorial to the Coffey article in Pain Medicine (I'm sure there will be multiple naysers on this forum to it). But seriously, what else can you feasibly do and if the patient gets better function and pain control....

 

[clubdeac]

No I don't do stim in all my back pain pts that fail everything else. Thanks for havin my back pain_doc. In the VA there's not a lot of incentive to do things that don't work. And I used the 4i unit a little when they had a hot rep but she left and so did my interest 😉 Just wish I had something to offer these patients... Only been at this a little over a yr and I guess saying, "there's nothing I can offer you" is something I need to learn how to say more often

 

[lobelsteve]

As a fellow, I have seen patients that have been in the practice >3 years who have peripheral stim in conjuntion with epidural leads with good results. These patients seem to swear by it. They have stated the epidural leads did not cover everything completely, but with the addition of the peripheral leads have now achieved better coverage. So my experience with follow ups of these patients are different from above.

To the OP. Although my personal experience for transverse tripole has been limited (and I think it's fallen out of favor ), there are obviously people that advocate it for the condition you are referring to.

At the juncture you are at with this patient, what else are you going to do aside from a ITP? Check out the Deer algorithm in his editorial to the Coffey article in Pain Medicine (I'm sure there will be multiple naysers on this forum to it). But seriously, what else can you feasibly do and if the patient gets better function and pain control....

Here is where Deer is wrong:

You say no. Put away needles and devices. Chronic pain is a central process and until we have tools to deal with the peripheral and central sensitization pathways and end organ changes- we cannot help these folks much. Does anyone read Ben Crue?

 

[Dr. Ice]

ahh, i see. tried everything in your toolbox, therefore might as well throw in a stim as well?

sorry if im being a bit offensive, but c'mon. we both know you are going to have awful results with axial LBP/failed backs and stim. is it so awful to tell a patient that you can't help them?

"I cant help you" has basically become my mantra in a lot of patients. Particularly those with axial pain who have already gone through the whole MBB/IA facet/RFA route with no significant relief. I refuse to narc them up and I feel that "I cant help you" is another way of me saying.. "youre fat..loose weight and help yourself for once."

 

[SleepIsGood]

"I cant help you" has basically become my mantra in a lot of patients. Particularly those with axial pain who have already gone through the whole MBB/IA facet/RFA route with no significant relief. I refuse to narc them up and I feel that "I cant help you" is another way of me saying.. "youre fat..loose weight and help yourself for once."

2 scenarios, and tell us what you would do. The guy as FBSS. and he's not "fat"...say 70kg. Still has axial LBP. What are you going to do then? Are you really going to tell him to loose weight? You realize a surgeon somewhere will attempt to fuse him ...again right?

Not saying you should do a stim because a surgeon will fuse the patient...but what other REAL options are there that are less invasive? I agree there is a component of central sensitization. Patients should certainly do the behavioral modification therapy as well. But in certain cases stims arent a bad idea if done correctly. Again, I've seen and have followed up with patients that have had peripheral stim in place for >3 years. So to make a blanket statement that they dont work, is unjustified.

 

[Jcm800]

No I don't do stim in all my back pain pts that fail everything else. Thanks for havin my back pain_doc. In the VA there's not a lot of incentive to do things that don't work. And I used the 4i unit a little when they had a hot rep but she left and so did my interest 😉 Just wish I had something to offer these patients... Only been at this a little over a yr and I guess saying, "there's nothing I can offer you" is something I need to learn how to say more often

learn how to say it fast, or in 5 years from now, your life will be consumed with "mistakes" "trying to help"...

sometimes just say no...and say it most at the beginning of your career.

 

[Jcm800]

"i cant help you" has basically become my mantra in a lot of patients. Particularly those with axial pain who have already gone through the whole mbb/ia facet/rfa route with no significant relief. I refuse to narc them up and i feel that "i cant help you" is another way of me saying.. "youre fat..loose weight and help yourself for once."

amen

 

[SSdoc33]

2 scenarios, and tell us what you would do. The guy as FBSS. and he's not "fat"...say 70kg. Still has axial LBP. What are you going to do then? Are you really going to tell him to loose weight? You realize a surgeon somewhere will attempt to fuse him ...again right?

Not saying you should do a stim because a surgeon will fuse the patient...but what other REAL options are there that are less invasive? I agree there is a component of central sensitization. Patients should certainly do the behavioral modification therapy as well. But in certain cases stims arent a bad idea if done correctly. Again, I've seen and have followed up with patients that have had peripheral stim in place for >3 years. So to make a blanket statement that they dont work, is unjustified.

you do an exam. you look at imaging. you try to find a pain generator and treat it the best you can. all axial back pain is not created the same, and all axial back pain does not require medial branch blocks.

your REAL options are therapy, therapy, and more therapy. if the patients dont like that option, don't offer them one that they'll accept (trial of stim). especially if its not truly indicated.

if you are at all interested, jim rainville out of boston/baptist has done a ton of work with failed back and functional restoration/rehabilitation. read some of his stuff, and that will always provide patients with an "option".

 

[Dr. Ice]

2 scenarios, and tell us what you would do. The guy as FBSS. and he's not "fat"...say 70kg. Still has axial LBP. What are you going to do then? Are you really going to tell him to loose weight? You realize a surgeon somewhere will attempt to fuse him ...again right?

Not saying you should do a stim because a surgeon will fuse the patient...but what other REAL options are there that are less invasive? I agree there is a component of central sensitization. Patients should certainly do the behavioral modification therapy as well. But in certain cases stims arent a bad idea if done correctly. Again, I've seen and have followed up with patients that have had peripheral stim in place for >3 years. So to make a blanket statement that they dont work, is unjustified.

Are there secondary gain issues? concomittant psych issues? Behavioral modification/biofeedback can be helpful but its a tough sell. Other than that, I try TENS, recommend myofascial release/OMT...and most importantly, have a serious conversation with them, that this may be an intermittent and chronic problem that they may just have to learn to deal with.

Trust me..you dont want to be "that guy" that does all these interventios with no significant benefit for the patient. You are doing more harm than good in the end...

 

[hyperalgesia]

Again, I've seen and have followed up with patients that have had peripheral stim in place for >3 years. So to make a blanket statement that they dont work, is unjustified.

Why are you still following him after >3 years? Is he on opioids? Sorry to be skeptical here...

When I was a fellow and when I first came out, I was the most enthusiastic supporter of SCS. I am so much more skeptical now after seeing excellent results that turned out to be temporary with many patients. I feel like you can make lots of pain pts happy by "stimulating" them all over the place. Which company now makes a 16 contact lead? So, in a private fluoro suite, one could trial with three 16 contact leads and take home about 17 thousand dollars for a 45 minute procedure. And that's a Medicare pt. The pt feels a pleasant tingling all over and now has a better case to claim disability so he never has to work again. Who cares that 3 months down the road the novelty wears off? That is why many are rightfully skeptical about people's intentions when they do these.

I do enjoy doing them and feel like they work well for certain kinds of neuropathic pain, as in FBSS (the neuropathic component) and some other indications. As long as your intentions are strictly for the pt's benefit and you are open minded when things don't work out the way you expect, it's all good. Tim Deer is a nice and smart guy but he is on the SJM payroll so he deserves all the skepticism you can muster.

I also routinely tell pts that we've done the best we can with interventions and really have nothing more to offer on that front. Then I go with the therapies and couseling and alternative treatments and whatever else conservative. They are welcome to go see a spine surgeon for a revision if they want.

 

[onewithpain]

Does anyone do MBB/RFA after L-spine surgery? I have had enough success with that that the local ortho spine surgeon now paces the pedicle screws a little more medial so that my target is visible. SCS seems to have helped at first, but I see a lot of patients who have them but turned them off.

 

[sweetalkr]

few questions, club_deac

1) What brand are you using for low axial back pain? I have heard from a few friends in private that boston does well for low axial.. not sure if this has a basis

2) have you considered Cluneal neuralgia? This is something that i have found to be very helpful.

3) Post-fusion FBSS - the racz procedure actually does help in this situation. this in my opinion is one of only a few indications for it. if you don't know how, just call me i'll tell you how we do it.

4) i am assuming you have tried QL's and psoas in pt's with muscular pain?

 

[drpainfree]

I remember as a fellow I did a few epidural SCS combined with two field paraspinal PNS with good outcome. Didn't have long term follow-up with these patients. But what's wrong with a trial of stim?

 

[SSdoc33]

I remember as a fellow I did a few epidural SCS combined with two field paraspinal PNS with good outcome. Didn't have long term follow-up with these patients. But what's wrong with a trial of stim?

whats RIGHT with it? for failed back. sure, you CAN try it. not particularly dangerous. the data out there is pretty awful, any way you slice it. failed back + chronic radicular pain is a much better indication IMHO.

 

[clubdeac]

few questions, club_deac

1) What brand are you using for low axial back pain? I have heard from a few friends in private that boston does well for low axial.. not sure if this has a basis

2) have you considered Cluneal neuralgia? This is something that i have found to be very helpful.

3) Post-fusion FBSS - the racz procedure actually does help in this situation. this in my opinion is one of only a few indications for it. if you don't know how, just call me i'll tell you how we do it.

4) i am assuming you have tried QL's and psoas in pt's with muscular pain?

sweets,
1) I'm using SJM. I know BS claims they have found the holy grail of lbp coverage but thanks to you I can't use them
Read in b/w the lines
2) I have done cluneal nerve blocks for possible cluneal neuralgia. Just not sure what to do when then block wears off
3) I talked with Tibor last year, he said that after mechanical lysis with the catheter he was using smaller volumes like 7cc's of anesthetic, then 7cc's hypertonic then a squirt of steroid and marcaine. Is that what your doing with Gabor? Frankly, I've done this on 15 pts since being out on my own and I've only seen one positive response. From my own personal experience, I'm losing faith in this procedure, especially for lbp. Then again maybe I'm doing it wrong.
4) QL and psoas? you talkin tpi's? Then yes I have

 

[Tenesma]

could the Deer protocol be biased by his source of support?

 

[Jcm800]

could the Deer protocol be biased by his source of support?

i dont think so, but i thought it was wierd he added MILD after Stim trial failed...heehhehe

 

[Tenesma]

Sleepisgood....

I have had a patient who was "cured" of their cervical myelopathy by undergoing 2 Reiki sessions... i have followed that patient for 3 years... I guess I am going to have recommend Reiki to all my cervical myelopathy patients...

the point is that your n=? is not enough to impart real scientific basis for suggesting that it should be part of an algorithm.

however, i believe there is a role for field stim especially on patient who can't tolerate their hardware in the muscle and do well with hardware blocks but they or surgeon don't want hardware out...

but for the most part, peripheral stim is doomed by the fact that wihtout using "tined" leads you have such a high migration and re-operation rate...

 

[sweetalkr]

Club,
My SJM buddies are smiling.
For Cluneal neuralgia, you cryo that sucker dude! 65/75/85 mm from midline is typically where all 3 nerves lie. it works like a charm really. blocks are temporary. cryo those b****s
3) The godfather does 10mL of Omni (assuming good run off), then 10mL of hyaluronidase (this is honestly the key. we use this with Gabor on his TFESI and I will implement it in my practice personally). then ropi/lido/depo infusion. then he does a hypertonic saline infusion over 30 minutes after confirmation it is not subdural.
4) QL - many ways to do it, but a needle under fluoro lateral to transverse process L4 until it is at or posterior to transverse process on lateral. omni to ensure it is QL, then inject local/steroids, and consider botox in future if great response. Psoas - we go at L3 lateral to TP, advance straight down utnil you are at anterior 1/3 of vertebral body on lateral, omni to show psoas spread, inject L/S and botox in future injections.

sweets,
1) I'm using SJM. I know BS claims they have found the holy grail of lbp coverage but thanks to you I can't use them
Read in b/w the lines
2) I have done cluneal nerve blocks for possible cluneal neuralgia. Just not sure what to do when then block wears off
3) I talked with Tibor last year, he said that after mechanical lysis with the catheter he was using smaller volumes like 7cc's of anesthetic, then 7cc's hypertonic then a squirt of steroid and marcaine. Is that what your doing with Gabor? Frankly, I've done this on 15 pts since being out on my own and I've only seen one positive response. From my own personal experience, I'm losing faith in this procedure, especially for lbp. Then again maybe I'm doing it wrong.
4) QL and psoas? you talkin tpi's? Then yes I have

 

[PMR 4 MSK]

Does anyone do MBB/RFA after L-spine surgery? I have had enough success with that that the local ortho spine surgeon now paces the pedicle screws a little more medial so that my target is visible. SCS seems to have helped at first, but I see a lot of patients who have them but turned them off.

Our local ortho spine guys maintain that after fusion, it is impossible for that level of the spine to cause any pain, therrefore, any therapy targetted at that level, including MBB/RFA is worthless. I disagree. I do try to avoid it in pts with pedicle sscrew and have never done RFA on one.

 

[Tenesma]

futhermore, insurance will not pay for an RF at a previously fused level... so therefore I get a CT scan on patients post fusion with persistent axial back pain, and will find out if there is a fusion, or if it just a pseudoarthrosis... the pseudoarthrosis pts do respond to RF on occasion - difficulty is the amount of bone in the way to the medial branch