Spinal Cord Stims

[Jordan 1]

I know pain docs do spinal cord stimulator trials. In private practice, after a sucessful trial who does the actual implant? I've heard that pain docs often hand these patients over to the neurosurgeons to do the actual implant because they don't feel comfortable/don't want to deal with potential post op/intra op complications. Any insight?

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[mille125]

I know pain docs do spinal cord stimulator trials. In private practice, after a sucessful trial who does the actual implant? I've heard that pain docs often hand these patients over to the neurosurgeons to do the actual implant because they don't feel comfortable/don't want to deal with potential post op/intra op complications. Any insight?

it varies....many doctors do their own implants and many refer them to neurosurgery....fellowship trained pain managment docs are trained to do permanent implants and it is within our scope....

 

[lobelsteve]

I do both.

I like paddles for some patients, percs for others.
Everyone trials a perc lead. So getting the surgeon to put the paddle in the right spot is the trick. Also getting them to use the right paddle, and not screw up the post-op on a pain patient.

 

[Aether2000]

Trained interventional pain physicians are completely capable of placing both trial and permanent leads without hiring a neurosurgeon to babysit. Pain physicians are doctors with some surgical training and are becoming even more surgically oriented as the surgeons begin doing interventional injections themselves and claim that anyone can be trained to do injections. So our field is changing to a more surgical nature specialty...

 

[Jordan 1]

OK thanks for the info, the reason I originally asked the question is because I am currently a Anesthesiology resident at what most would consider a "top ten program" whatever that means....and I asked some of the pain fellows this exact question. I felt the same way you all do in terms of I thought they would be putting in the permenant leads as well. The response I got from the fellows was that when they practice they will only do trials and will refer the perm leads to neurosurgeons. I found this surprising. I wonder if it is fellowship dependent meaning some programs train the fellows in perm placement more extensively?

 

[Aether2000]

Not wanting to place perm stims by fellowship trained pain physicians can come from lack of self confidence in their abilities, inadequate training in the fellowship program, political issues if the NS are already placing perm paddle leads in a region, decision to not use any surgical interventions in a practice, or malpractice insurance/privileging issues.

 

[mille125]

OK thanks for the info, the reason I originally asked the question is because I am currently a Anesthesiology resident at what most would consider a "top ten program" whatever that means....and I asked some of the pain fellows this exact question. I felt the same way you all do in terms of I thought they would be putting in the permenant leads as well. The response I got from the fellows was that when they practice they will only do trials and will refer the perm leads to neurosurgeons. I found this surprising. I wonder if it is fellowship dependent meaning some programs train the fellows in perm placement more extensively?

I agree with Algos....You should ask each of the fellows why they feel this way if you are curious.

 

[paindefender]

Not wanting to place perm stims by fellowship trained pain physicians can come from lack of self confidence in their abilities, inadequate training in the fellowship program, political issues if the NS are already placing perm paddle leads in a region, decision to not use any surgical interventions in a practice, or malpractice insurance/privileging issues.

I see several advantages

1. Run a more efficient practice.
I don't waste my time traveling to the hospital, waiting for anesthesia,waiting for OR staff, writing orders and dealing with all post op issues. I spend my time seeing patients and doing blocks.

2. Network with spine surgeons.
I do the trial and send the patient to the surgeons for implants. They love do do a lami and place paddle leads. I see a lot of referrals from them.

3. Lower malpractice insurance

 

[Tenesma]

interestingly my premiums wouldn't be any different whether i did trial leads or implants...

i think most do both... especially because implants are money losers for the hospital... so it will be hard to find a hospital/surgeon who will do the implants alone without the trials - unless you guys are at the same hospital...

or you can place the trial lead - bury it - and then have an implanter make the pocket and put everything together at a later date if the lead is successful... that is an option...

i think the real question is: who wants to be married to these patients.

 

[drusso]

Just to take it up a notch further: I'm aware of one busy neurosurgeon who only does the LAMINOTOMY portion of the procedure.

That is, he places the paddle and leaves a general surgeon friend of his to do the pocket and closures. The GS will also manage any post-op infections. So, the patient goes from a trial with a pain doc ---> paddle with a neurosurgeon ---> wound check with general surgeon's PA ---> back to pain doc. Interesting...

 

[ghost dog]

Just to take it up a notch further: I'm aware of one busy neurosurgeon who only does the LAMINOTOMY portion of the procedure.

That is, he places the paddle and leaves a general surgeon friend of his to do the pocket and closures. The GS will also manage any post-op infections. So, the patient goes from a trial with a pain doc ---> paddle with a neurosurgeon ---> wound check with general surgeon's PA ---> back to pain doc. Interesting...

This treatment modality is EXTREMELY expensive. In Canada, it is very difficult to access this type of treatment for chronic pain; there are very few centres that perform assessments and implantations for stims.

I imagine it's much more commonplace in the U.S. due to insurance companies willingness to foot the bill. Unfortunately the Canadian government hasn't "seen the light" for stimulators to the same extent as the States.

 

[lobelsteve]

This treatment modality is EXTREMELY expensive. In Canada, it is very difficult to access this type of treatment for chronic pain; there are very few centres that perform assessments and implantations for stims.

I imagine it's much more commonplace in the U.S. due to insurance companies willingness to foot the bill. Unfortunately the Canadian government hasn't "seen the light" for stimulators to the same extent as the States.

They will when the angina and vascular stuff cathces on. Right now we only have pain docs doing them on marginal candidates (some). I have seen Fibro and Crazy both with stims.

 

[Mister Mxyzptlk]

If a paddle is needed I get a spine surgeon to do the lead but I do the tunneling and IPG. Why give the procedure to a general surgeon?

 

[Tenesma]

question: why do you give implant to general surgeon

answer: because i love getting chronic abdominal pain patients status post 15 laparotomies with several entero-cutaneous non-healing fistulae...

 

[ampaphb]

The reason pain docs hand off the per implantations is financial, i large part.

If you do perms in the hospital, you only get the professional fee. Given all the issues raised by Paindefender, the #1000-1500 professional component is not worth the 2-3 hours you could better spend in the office or the procedure suite.

Algos is right about our abilities, but the ability to network with referral sources may well be better for your practice in the long run. Take your ego out of the equation, and I believe you will conclude that, while we certainly CAN do perms, in the vast majority of cases, it makes more sense to hand them off.

 

[Mister Mxyzptlk]

2-3 hours to do a stim implant?

 

[lobelsteve]

2-3 hours to do a stim implant?

Whether I do 1 or 3 cases, it takes about 3 hours out of the office. Paperwork, commute, post-op, more paperwork, etc.

I can do the trial while a new patient is filling out the paperwork and getting vitals. (I do have a lot of paperwork and never rush procedures).

 

[Tenesma]

i have a similar experience w/ stim implants - while my times have gradually gotten better - in a straightforward patient i can get it done in under an hour easy...

however, the OR games of waiting, the anesthesia games of a new CRNA stating that they aren't comfortable sedating a prone patient without securing the airway, the recovery room being backed up and not able to take our patient for another 30 minutes, getting bumped a few times, etc... i have had several implants cancelled because of emergent cases bumping them... i have had several implants where i literally sat on my hands for 3 or 4 hours waiting for the stars to line up...

for the amount of paperwork, aggravation, time consumption, is an implant really a financially viable option when i can stay in my office and generate 3-4-5 times the income???

 

[Ligament]

for the amount of paperwork, aggravation, time consumption, is an implant really a financially viable option when i can stay in my office and generate 3-4-5 times the income???

Probably not, assuming that you can find an implanter that understands the nuances of spinal cord stimulation and the importance of location and proper parasthesia overlap. That means, usually, a surgeon that does not do these implants under general, and does a intraoperative programming to confirm the permanent is creating the same parasthesias as the trial.

Such surgeons are few and very far between. Therefore, it makes sense for the pain doc to do the implant in such a situation. In the "old days" nobody would do implants so all pain docs had to do them by themselves or not get it done at all.

If you can find a surgeon that will perform a quality implant as above, I see only benefits for the pain doc and for the patient.

 

[Tenesma]

well the surgeons realize the financial constraints as well --- they don't mind scrubbing in to do a quick pocket or a quick laminotomy, but they don't want to be bothered with the time spent for intra-op programming, positioning etc... heck they can make 5k on an ACDF in 50 minutes, why would they want to spend 1 hour for 0.5-1k...???

 

[Ligament]

well the surgeons realize the financial constraints as well --- they don't mind scrubbing in to do a quick pocket or a quick laminotomy, but they don't want to be bothered with the time spent for intra-op programming, positioning etc... heck they can make 5k on an ACDF in 50 minutes, why would they want to spend 1 hour for 0.5-1k...???

Thats a good point, and I think why good implanter surgeons are so far and few between. I happen to have one here in Seattle that is highly interested in SCS and also does deep brain stim and motor cortex stim, so he likes doing the implants for his own enjoyment....which is great!

 

[ampaphb]

I have a similar guy down here, who moved recently from fla

He does mostly laminotomy paddle leads, and thus I don't think the reimbursement is at the level you referenced