SCS

IPSIS: Formerly the Spine Intervention Society
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
B

Bsb2015

Full Member
2+ Year Member
Joined
Mar 21, 2019
Messages
68
Reaction score
9
Been getting a lot of orthopedic referrals for CRPS. What are your outcomes/success rates trialing with Medtronic vs Nevro vs BS?
Members don't see this ad.
 
Members don't see this ad :)
Just make sure it's actually CRPS. Many orthopods think that CRPS means "I did the surgery, imaging looks good, but the patient is still in pain."

Also, don't jump to SCS. Trial sympathetic blocks, meds, PT, etc long before you consider SCS.

Device used is more about the individual nuances of each manufacturer/device and your relationships. I don't think one brand is necessarily the best choice in all circumstances.
 
My favorite is post-block neuritis. Pt with classic CRPS of the foot at postop month 12, but this must be popliteal nerve catheter perioperatively and definitely not my surgery...

Edit - To the OP...Get comfortable with trials and after you've done enough that you're not anxious in OR start implanting. I like Abbott for the sole reason the rep is always available and he will return my texts immediately. That and the battery doesn't have to be recharged.
 
Ok great, thanks! Yes I use Budapest criteria and I usually have an algorithm of PT/OT desensitization therapy, AEDs, TCA, etc, LSB/SGBz I have also done some ketamine infusions and have considered starting low dose naltrexone in some of these patients. A lot of these patients are hesitant to proceed with SCS, but was thinking ahead and wondering what others thought bc I’ve solely only used Nevro in fellowship.
 
BobBarker said:
I think you need to refer them out to someone with more experience.
Click to expand...

By the way -not sure how far along you are in your career but once upon a time you also lacked experience too out of fellowship. It’s a continuous learning process. If you don’t want to contribute to my learning please by all means, don’t respond to my posts
 

Attachments

  • 4O2Qgj3.jpg
    4O2Qgj3.jpg
    38.6 KB · Views: 142
Bsb2015 said:
I’m sure you’ve had the same questions too starting out. No such thing as a stupid question. Why are you even on SDN if you’re not here to foster a no judgement learning environment?
Click to expand...

Sorry, but you admitted yourself that your fellowship was poor and your questions reflect that.
 
BobBarker said:
Sorry, but you admitted yourself that your fellowship was poor and your questions reflect that.
Click to expand...

Then why not foster/enhance my learning as an experienced colleague instead of making rude remarks?
 
BobBarker said:
I think you need to refer them out to someone with more experience.
Click to expand...

I’m sure others in the same boat as me are thinking the same thing but might be too afraid to ask. Well, I’m not. And yes, I’ll continue to ask those “ stupid questions” Look forward to your continued rude remarks
 
Talk to your Abbott and Nevro rep to try and setup a site visit with a physician. This will help your post fellowship questions on Neuromodulation.

Yes this forum isn’t very helpful sometimes.
 
Members don't see this ad :)
BobBarker said:
I think you need to refer them out to someone with more experience.
Click to expand...

Everyone needs to stop this bullying toward OP. We're grown adults, professionals, and supposed to foster friendly, educational atmosphere here. Doctors should help each other, not tear each other down. No wonder why we're in the weak position we're in, with hospital administration, lawyers, NPs, chiros, insurance, and govt running over us. We do it to ourselves. OP had something completely wrong yesterday, he at least had the guts to come on here and ask and clearly didn't feel comfortable with what he was doing - there are doctors right now doing wrong things and could care less to even second guess themselves.
 
Bsb2015, agree with the recommendation of a site visit. I did two when I was just coming out of fellowship and they were very helpful. We are a preceptorship location at my practice and focus on fresh graduates. We’re passionate about helping the new guys establish good decision making skills on how and why to choose what you use based on clinical evidence. Our practice does about 10 trials and 7 perms a week, happy to have you out.

With your original question being “in everyone’s experience with each company...” it lets me know the industry marketing has probably gotten in your head, as it did me and most everyone else as well. The company name is just that, a name. Need to understand the technology ie, current vs voltage based, density and charge delivered, waveform, neural target, etc, and then understand the pathology you’re trying to treat and what has been shown to work the best for that pathology.
 
Last edited:
fwiw...

do not trust device reps as far as you can see them. they have a financial interest in these matters.

and don't trust interventional spine "experts", because they too have a financial interest in stimming the world over. more stims =/= better care.

and for what its worth, don't trust all the literature you read out there. make sure you parse who is writing the article and see if they have financial interests, and are really out to disprove a "null hypothesis" and not trying to justify what their practice is.


so who do you trust? well, on these forums you will get all different opinions. besides the political ones, almost all of the opinions on a forum such as this is founded on either clinical experience (level IV strength) or literature review (level III strength) or actual well thought of minimally biased prospective studies (level II). read all the opinions and articles, and come to your own conclusions.


that being said, there is some evidence that SCS may be beneficial as salvage therapy but patient selection is most important. many ppl with CRPS will "burn out" of the severe pain over time. the focus on treatment should not be "make my pain go away" but "keep me as functional as possible"... I personally think we are over-stimming and doing way too many stims on dubious cases of ortho-suspected CRPS. (harkens me back to a case last year - ortho sure CRPS... on the infected left carpal scar with WBC 18). when I see a CRPS patient, after history and PE, I focus next on the psychosocial history...

oh and to your opening question - which rep? choose the rep you feel is most able to work effectively with the patient and is most attentive to your needs.
 
CRPS is often thrown around unfortunately by all specialties as the bogey man. With that said, I don't mind a percutaneous stim trial as long as you are objective about calling it a failure. I would try to have some algorithm to walk down before you do that, as the financial incentives for even a failed trial are sometimes hard for people to say no to.

- Agree with a site visit, a training course, or even dinner with more experienced implanters in your area. The device companies want you to feel comfortable with their technology
- Agree that many experts are bull**** and will lie to your face about their volume/experience or tell you to do something they would never do themselves.
- Agree that the device sales reps are often sales motivated
- Consider working with the device clinical specialists that are not as volume motivated, although are still "salesy"
- Consider some of the cadaver courses such as at NANS to get more exposure

The big point some are trying to get across is figuring out if you want to be the person to do this yourself or if you should refer them to someone better. Implantable devices shouldn't be something everyone does. My training sucked for biologics or joint injections, so I don't stress that and kick that out to someone else who can do it better/faster/easier than me. Although you want/need to make money and keep the referral relationships copacetic, at the end of the day figure out the best thing for the patient so you sleep better and with less stress. While I appreciate your curiosity and willingness to talk about mistakes, we need to remember that we've also got a field filled with charlatans and hacks. A paralyzed patient after an RF or a horrible complication with SCS can poison the support for a therapy, as well as have a severe effect on a patient, your mental health, and your financial well being and that of other docs that provide the therapy. It is critical people know their limits, even though we all want to be the best, but the fact that you're asking and trying suggests you may get there eventually.
 
What’s everyone’s opinion about Nevro SCS in the neck specifically? I’m getting frustrated w tonic stim in the neck. Pt get annoyed about the shocks with c spine movement and rotation which is understandable. Anyone have good luck with hf10 up there?
 
Nevro had some posters and a webinar about this a while ago showing amazing results for upper extremity pain. I have just been using paresthesia free settings with the other companies and seem to get similar results on the handful of cervical cases I have. I would offer the ones you have that hate tonic a buried trial with another company or ask the rep to program them to paresthesia free/sub-paresthesia modes if possible on the IPG they have.
 
Nevro has excellent evidence in the neck. Use it regardless of the opinions you get here, or anywhere else for that matter.

I’ll go ahead and give my opinion now. In my experience it has been very successful, similar to the study results.
 
post evidence, if it is so excellent.

fwiw, industry paid data is invariably tainted. after all, industry data also showed that cigarettes never caused cancer...
 
www.acsh.org

Andrew Kolodny Says Chronic Pain Patients Are PR Pawns for Big Pharma

Dr. Kolodny (1) has a long history of spreading misinformation about the opioid crisis; (2) insults chronic pain patients; (3) profits handsomely from doing so; and (4) calls everyone who disagrees with him an industry shill. The good doctor's version of compassion actually comes with poor...
www.acsh.org www.acsh.org

Even this industry?
 
Ducttape said:
post evidence, if it is so excellent.
Click to expand...


When you say things like this realize that it may create doubt among the less experienced and less up to date readers of the forum. The upper limb and neck data from Nevro’s study is very good and the study design is well thought out. It’s not published yet, still waiting on the last few patients to to reach 12 months post implant to aggregate the results. Preliminary results were presented at NANS and Bob and I were able to see it at a local dinner recently.
 
i disagree. it behooves those who is touting an opinion to show evidence. it is correct to be skeptical if there is no evidence. your way of thinking is bass ackwards.

i have heard of tons of studies that are not published that states:
marijuana works for everything - chronic pain, migraines, cure cancer, fix autoimmune disease, cure diabetes, treat autism, cure addiction, cure lung disease and hypertension...

green tea extract cures chronic pain

kratom cures chronic pain, improves diabetes, and fights infections by improving immune system

bloodletting reduces inflammation, helps prevent malaria, decrease heart attack risk, decrease diabetes risk, prevent cancer.

and, more recently, wasnt Burst supposed to be much better than Nevro? at least the prelim data said so, right? it was supposed to be published showing better efficacy... we are still waiting.


if something is not reviewed/not published, then it is just a claim that cannot be backed up, and is being used to push marketing. industry published data is already biased, but to quote a "study" that you cant produce is misleading.

show it, review it in as much of a non-biased manner, and then we can discuss.

that being said, for lower extremity symptoms/back, i use primarily Nevro (because the Anesthesiology study and studies such as High Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Chronic Pain: 6-Month Australian Clinical Experience. - PubMed - NCBI )
 
While the published data for Nevro has been amazing, I have not seen that in my trials or the Nevro implants that transferred in. Based on the market share, I would assume that the other implanters in the country also are not seeing the study results reproduced.

I agree the UE data looked amazing though.
 
I think Nevro’s decision to allow reps to try tonic if HF is not working out was very wise. They can also run tonic and HF simultaneously. My last Nevro was a 50 year old FBSS. He wanted to get better and was an ideal candidate. No relief after 7 days of HF trial, flipped into tonic, excellent coverage with the midline T8 lead, excellent pain relief.

Now implanted, weaning off opioids, and getting CDL/back to work. Still in tonic. Charging once/week.
 
BobBarker said:
I think Nevro’s decision to allow reps to try tonic if HF is not working out was very wise. They can also run tonic and HF simultaneously. My last Nevro was a 50 year old FBSS. He wanted to get better and was an ideal candidate. No relief after 7 days of HF trial, flipped into tonic, excellent coverage with the midline T8 lead, excellent pain relief.

Now implanted, weaning off opioids, and getting CDL/back to work. Still in tonic. Charging once/week.
Click to expand...

So how long did this trial last? 7 days of hf10 plus another 2 for tonic? That’s the only issue I have, how long am I willing to keep a trial lead in to “play” with all the options
 
Ducttape said:
i disagree. it behooves those who is touting an opinion to show evidence. it is correct to be skeptical if there is no evidence. your way of thinking is bass ackwards.

i have heard of tons of studies that are not published that states:
marijuana works for everything - chronic pain, migraines, cure cancer, fix autoimmune disease, cure diabetes, treat autism, cure addiction, cure lung disease and hypertension...

green tea extract cures chronic pain

kratom cures chronic pain, improves diabetes, and fights infections by improving immune system

bloodletting reduces inflammation, helps prevent malaria, decrease heart attack risk, decrease diabetes risk, prevent cancer.

and, more recently, wasnt Burst supposed to be much better than Nevro? at least the prelim data said so, right? it was supposed to be published showing better efficacy... we are still waiting.


if something is not reviewed/not published, then it is just a claim that cannot be backed up, and is being used to push marketing. industry published data is already biased, but to quote a "study" that you cant produce is misleading.

show it, review it in as much of a non-biased manner, and then we can discuss.

that being said, for lower extremity symptoms/back, i use primarily Nevro (because the Anesthesiology study and studies such as High Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Chronic Pain: 6-Month Australian Clinical Experience. - PubMed - NCBI )
Click to expand...

Good points. I guess I was assuming that Nevro running a multicenter, prospective RCT meant it was just a matter of time before the final results are published for us all to review. Until they are published and peer reviewed we must take them with a grain of salt.


Orin said:
While the published data for Nevro has been amazing, I have not seen that in my trials or the Nevro implants that transferred in. Based on the market share, I would assume that the other implanters in the country also are not seeing the study results reproduced.

I agree the UE data looked amazing though.
Click to expand...

If “real world” results aren’t matching what we saw in the studies then are we choosing patients correctly? Or, are we really following them the as objectively as we were in the studies? I’ve implanted a whole bunch of Nevro, most from my own trials and a fair amount from other trialing docs in town. I try to be very diligent about following my own outcomes objectively and not be one of those guys who says “in my experience” followed by my opinion because I found that what I perceived to be reality was often times far from the truth. Example: I felt like roughly 50% of my patients were on opioids. I audited my practice and found it was actually only 28%.

I too felt like Nevro wasn’t working as well because it seemed like I saw these patients a lot more often. Reps calling to ask for lead xrays because they were afraid the leads migrated, patients saying they didn’t think it was working anymore, etc. When I looked more closely I found that I simply saw this patients who weren’t doing as well because there was only one question to ask them: are you feeling better or not? Contrast that to “does the tingling cover the areas of your pain?” Patients on tonic weren’t coming in because the reps would meet with them and “optimize their coverage” but it didnt involve me so I perceived them as doing better. I also saw that the patients who weren’t doing well seemed to make up a small percentage of those implanted but a large portion of the office visits which also made it seem Nevro didn’t work as well. In the end the Nevro population I’ve implanted has had a 73% responder rate and avg pain score of 2.8 which is t too far off from the study and I’ll openly admit I have a lot less stringent selection criteria than the study did so some patients aren’t perfect candidates.

Lastly, at NANS it was presented where 1660 consecutive patients implanted from sites across the US and Europe were followed and the “real world” outcomes were measured. The results were good which I think really helps out to rest the argument that Nevro doesn’t get real world results like the study. I find it interesting Burst has had the opposite story line. Their level 1 study showed terrible results but they spun it to say they get great real world outcomes yet have never published anything to back up these claims and from the market share data above it appears many are following this sales pitch.
 
I use Nevro and Abbott, lately using mostly Abbott. I haven't had much luck flipping on tonic coverage with Nevro. The tonic coverage is hard to map out. I really want to like Nevro- and I've implanted quite a few esp. for neck- but I have seen a few treatment failures now at 2 years out. These were carefully selected candidates who initially responded well. I haven't seen that yet with other systems. Nevro's recharge burden is also high. You really have to choose a motivated, engaged patient to get them to stick with the therapy long term, and if they stop getting results they stop charging and it creates a vicious cycle.

- ex 61N
 
You’re saying you haven’t seen very many failures with other systems but you have with Nevro? So everyone else on the planet over the past 40 years gets roughly 50% success rate with tonic SCS and you’re over there slaying pain with it!?

Please take the above as a light hearted joke and not all all wanting to come across as a jerk, just trying to make you laugh a little. On a serious note, Level 1 studies have pretty consistently shown the same results for tonic SCS yet there are 4 companies out there telling us they get it to work better than HF10. I’m really intrigued at the whole marketing game all these companies do and how they influence us, myself included. In the SUNBURST study St Jude did BURST was studied against tonic stim, both groups did terrible, worse than the Boston arm of SENZA that was published a year prior, yet they gain market share after publishing it? How do we justify using that technology? I had to ask myself that same question because I was using it a lot and had to acknowledge I had been sold on marketing. I sat down with my rep who I respect very much and simply said “I like you and the service you provide but your product isn’t the best thing for my patients”. It was really hard to do.

Anyone else share my thoughts on this stuff? I feel like for once in our specialty we’re getting some good research and advancements in our specialty but we as a group aren’t following it. I’m young and it makes me worry where our specialty (and reimbursement) is going.
 
gdub25 said:
You’re saying you haven’t seen very many failures with other systems but you have with Nevro? So everyone else on the planet over the past 40 years gets roughly 50% success rate with tonic SCS and you’re over there slaying pain with it!?

Please take the above as a light hearted joke and not all all wanting to come across as a jerk, just trying to make you laugh a little. On a serious note, Level 1 studies have pretty consistently shown the same results for tonic SCS yet there are 4 companies out there telling us they get it to work better than HF10. I’m really intrigued at the whole marketing game all these companies do and how they influence us, myself included. In the SUNBURST study St Jude did BURST was studied against tonic stim, both groups did terrible, worse than the Boston arm of SENZA that was published a year prior, yet they gain market share after publishing it? How do we justify using that technology? I had to ask myself that same question because I was using it a lot and had to acknowledge I had been sold on marketing. I sat down with my rep who I respect very much and simply said “I like you and the service you provide but your product isn’t the best thing for my patients”. It was really hard to do.

Anyone else share my thoughts on this stuff? I feel like for once in our specialty we’re getting some good research and advancements in our specialty but we as a group aren’t following it. I’m young and it makes me worry where our specialty (and reimbursement) is going.
Click to expand...

I like where the conversation is going.
I agree with the above. The sunburst study has some pretty weak endpoints, yet what is referenced again and again by jude people.
I would love to see a Boston’s waverider study: Countour/HF1 and , combo vs parasthesia alone. My guess is the data would suggest combo therapy does not provide any added statistical benefit to parasthesia alone. That’s what I’ve seen again and again in my practice at least
 
gdub25 said:
You’re saying you haven’t seen very many failures with other systems but you have with Nevro? So everyone else on the planet over the past 40 years gets roughly 50% success rate with tonic SCS and you’re over there slaying pain with it!?

Please take the above as a light hearted joke and not all all wanting to come across as a jerk, just trying to make you laugh a little. On a serious note, Level 1 studies have pretty consistently shown the same results for tonic SCS yet there are 4 companies out there telling us they get it to work better than HF10. I’m really intrigued at the whole marketing game all these companies do and how they influence us, myself included. In the SUNBURST study St Jude did BURST was studied against tonic stim, both groups did terrible, worse than the Boston arm of SENZA that was published a year prior, yet they gain market share after publishing it? How do we justify using that technology? I had to ask myself that same question because I was using it a lot and had to acknowledge I had been sold on marketing. I sat down with my rep who I respect very much and simply said “I like you and the service you provide but your product isn’t the best thing for my patients”. It was really hard to do.

Anyone else share my thoughts on this stuff? I feel like for once in our specialty we’re getting some good research and advancements in our specialty but we as a group aren’t following it. I’m young and it makes me worry where our specialty (and reimbursement) is going.
Click to expand...
Agreed. I don’t care what the reps say in the least. I was in a very Neuromodulation-heavy fellowship so we were wined and dined by all the companies and I heard all their sales pitches. It all sort of cancels out like white noise. If you go read the actual studies, Nevro does seem to have an edge, so that’s what I use most of. If there are mitigating factors like my patients who have a flip phone and no home computer (as one of my residency attendings said, “Don’t put high tech things in low tech people”) If I trial at all I’d use a primary cell. Of course, Boston likes to trot around the PROCO study but it was a 20 patient study that didn’t even use Nevro hardware. The Boston rep has been absolutely relentless in pursuing me - I agreed to a lunch at the end of March and she asked for another meeting a week later! I told her I’d see her again in a few months. Even Nevro with its RCTs, I’m suspicious of the outcomes - I really want them to do a sham controlled study but basically they said it’s a lose-lose to do that so they never will. I’d also like to see more functionality data. The sensors in the new Medtronic system will be great for that but their stimulation is still trying to catch up from when they blew off Nevro.
 
Nevro is doing a sham study in Europe now. Boston needs to do a level 1 study and at a recent focus group I went to with their leadership they have plans to launch one soon. Plan is to enroll 150 patients and follow for 12 months. THey have some pretty good case series put together with large numbers of patients so I’d love to see what they come up with. If they can show good outcomes it just raises the bar for everyone else. PROCO was interesting, and to me at least raised the question “is it really the frequency?” However, it does not negate the fact that Nevro showed the best success we’ve ever seen in a clinical trial and they did so twice; once in Europe and then again in the US. Now they are backing it up with upper limb and axial neck. We as doctors are the end users of these therapies. If we stop biting on these marketing tactics and instead shift our decision making to following the evidence our specialty will almost certainly morph into an evidence based field which would be refreshing.
 
gdub25 said:
Good points. I guess I was assuming that Nevro running a multicenter, prospective RCT meant it was just a matter of time before the final results are published for us all to review. Until they are published and peer reviewed we must take them with a grain of salt.

If “real world” results aren’t matching what we saw in the studies then are we choosing patients correctly? Or, are we really following them the as objectively as we were in the studies? I’ve implanted a whole bunch of Nevro, most from my own trials and a fair amount from other trialing docs in town. I try to be very diligent about following my own outcomes objectively and not be one of those guys who says “in my experience” followed by my opinion because I found that what I perceived to be reality was often times far from the truth. Example: I felt like roughly 50% of my patients were on opioids. I audited my practice and found it was actually only 28%.

I too felt like Nevro wasn’t working as well because it seemed like I saw these patients a lot more often. Reps calling to ask for lead xrays because they were afraid the leads migrated, patients saying they didn’t think it was working anymore, etc. When I looked more closely I found that I simply saw this patients who weren’t doing as well because there was only one question to ask them: are you feeling better or not? Contrast that to “does the tingling cover the areas of your pain?” Patients on tonic weren’t coming in because the reps would meet with them and “optimize their coverage” but it didnt involve me so I perceived them as doing better. I also saw that the patients who weren’t doing well seemed to make up a small percentage of those implanted but a large portion of the office visits which also made it seem Nevro didn’t work as well. In the end the Nevro population I’ve implanted has had a 73% responder rate and avg pain score of 2.8 which is t too far off from the study and I’ll openly admit I have a lot less stringent selection criteria than the study did so some patients aren’t perfect candidates.

Lastly, at NANS it was presented where 1660 consecutive patients implanted from sites across the US and Europe were followed and the “real world” outcomes were measured. The results were good which I think really helps out to rest the argument that Nevro doesn’t get real world results like the study. I find it interesting Burst has had the opposite story line. Their level 1 study showed terrible results but they spun it to say they get great real world outcomes yet have never published anything to back up these claims and from the market share data above it appears many are following this sales pitch.
Click to expand...

There's lot of good points there. It sounds a lot like a sales pitch though from the Nevro rep in my region, except it's data, so I guess it's not. I would offer a few less important or maybe less valid points perhaps.

The real world matters. We can all blame patient selection for why some folks have better outcomes, but at the end of the day, I don't think electricity cares who it's working on. My implant technique, lead placement, etc, that might be worse than yours and so maybe that's why I explant Nevro batteries, where your patients do great. There's a lot of things to hide behind, but I don't think any of the devices are that much superior to the other. I do some want objective data on function, sleep, and medication usage. There are well over 20k SCSs implanted a year, so yeah, the 10% of trial patients may do better than the average, but pragmatic, realistic studies and outcomes are important.

While I guess it's easy to say one size fits all or is the best, or that some patients aren't worth trying or able to be fixed because of various factors, I don't think that's realistic or ideal. We need to trial things and fail. If your trial/perm rate is 80-90%, you're wasting time/money and exposing the patient to risk.

I am also worried by the device company follow-up and reporting. They've got a vested interest in reporting good outcomes. While I applaud them for doing it, I don't hold any illusions about what they're doing. Some companies have made patient/therapy optimization programs that give the semblance of a clinical trial, and we know patients do better when enrolled in a "program." I'm glad though we have some data for payors, but a large boulder of salt is needed.

Again, I just don't buy any of it in terms of superiority, but I'm happy if the patient is happy and functional. I'll use whatever works with the patient in a trial with accounting for patient tolerance for charging/MRIs/etc. Regardless of what is best, I'm just glad we have options to try with patients. Kudos to you for looking at your practice objectively.
 
I apologize for an unproductive comment, but I just wanted to say as a fellow graduating soon, I really appreciate the input of everyone who has contributed to this thread so far. So easy to get caught up in the marketing and lose sight of data (or even anecdotal experience).
 
You must log in or register to reply here.

Similar threads

Y
SCS Anchoring
Replies
6
Views
406
Asclepius186
A
M
SCS trial aborted - billing?
Replies
13
Views
698
Drd105
D
P
SCS Removal
Replies
7
Views
864
BobBarker
BobBarker
T
United SCS criteria, InterQual?
Replies
1
Views
422
BobBarker
BobBarker
P
SCS positioning
Replies
4
Views
706
callmeanesthesia
C
Top