SPRINT PNS for low back pain

[cameroncarter]

Who does it? What pathology? What are the results?

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[au bon pain]

Facet loading pain on exam in younger patient and + response to LMBBs. Have only done 5 for LBP, so take that for what it's worth. 4/5 have had sustained >70% relief and 2 at 100 (furthest is only ~9 months out). 5th patient only had ~20% relief after removal 1 month ago. Of these folks, the best responders also had +ttp overlying facets and also hadn't had multiple prior RFAs. There is limited sprint literature on delayed response w/some patients not getting relief until sometimes a few months after removal...which I didn't believe until a patient told me this happened to him for one place in his shoulder (not by me).

 

[MitchLevi]

There is limited sprint literature on delayed response w/some patients not getting relief until sometimes a few months after removal...which I didn't believe until a patient told me this happened to him for one place in his shoulder (not by me).

 

[au bon pain]

Lol I know. Discussed during their course by one of their more famous (and paid) talking heads—put up a slide showing a subset of these patients from one of their studies. Doesn’t seem to pass the face validity test, but changes what I do in that I won’t immediately RFA a pt who failed sprint (like the one I’ve had) without first waiting a few months.

 

[MitchLevi]

I won’t immediately RFA a pt who failed sprint (like the one I’ve had) without first waiting a few months.

Why?

 

[lobelsteve]

Why?

Suffering build character.

 

[au bon pain]

Why?

Off chance they end up getting enough relief after removal and may not need it. Already have my failed patient (only 20% reduction by time she was explanted) boarded for RF, but will cancel if she happens to have improved relief in the interim.

 

[Taus]

I turned down an offer by their rep to bring lunch to my office. Showed up at my surgery center while I was doing cases the following week…

 

[MitchLevi]

Personally, I wouldn't let the prior use of Sprint impact my decision to ablate or not ablate.

Pain = Ablate IMO.

A well-performed RFA usually works. Problem is, it appears most doctors suck at that procedure. They haphazardly throw needles down in the vicinity of the MBN and they're done. If the RFA fails it doesn't matter bc the PA will see the clinic follow up.

 

[nynydoc]

Personally, I wouldn't let the prior use of Sprint impact my decision to ablate or not ablate.

Pain = Ablate IMO.

A well-performed RFA usually works. Problem is, it appears most doctors suck at that procedure. They haphazardly throw needles down in the vicinity of the MBN and they're done. If the RFA fails it doesn't matter bc the PA will see the clinic follow up.

This is sadly occurring more often than not

 

[SC Tian]

possible nerve regenerates in different path, RFA has technical difficulties

 

[Ducttape]

how are nerves regenerating in a different path?

all the nerves we are ablating for spine are inside a myelin sheath.

the nerve will regenerate in that myelin sheath...

unless you destroy the myelin sheath by injecting phenol or absolute alcohol

 

[PinchandBurn]

how are nerves regenerating in a different path?

all the nerves we are ablating for spine are inside a myelin sheath.

the nerve will regenerate in that myelin sheath...

unless you destroy the myelin sheath by injecting phenol or absolute alcohol

How do you describe rearborization of the MBBs after RFA then?

 

[Ducttape]

the nerve root "growing" back to their end point via the myelin sheath... the sheath remains intact with RFA. not so with phenol. at least that is how i was taught...

the thought with phenol and why you get such severe deafferentation pain is that one is forming a scar neuroma at the site of destruction of the sheath.

 

[Taus]

Personally, I wouldn't let the prior use of Sprint impact my decision to ablate or not ablate.

Pain = Ablate IMO.

A well-performed RFA usually works. Problem is, it appears most doctors suck at that procedure. They haphazardly throw needles down in the vicinity of the MBN and they're done. If the RFA fails it doesn't matter bc the PA will see the clinic follow up.

This. Most people do a ****ty job at RF. I’m so glad to hear they can do it in five minutes under AP only….

 

[SC Tian]

the nerve root "growing" back to their end point via the myelin sheath... the sheath remains intact with RFA. not so with phenol. at least that is how i was taught...

the thought with phenol and why you get such severe deafferentation pain is that one is forming a scar neuroma at the site of destruction of the sheath.

thanks, the concept of RFA coagulation of nerves is interesting, so that we can coagulate the nerves in the same location many many times, 80 degree with90 second will destroy the nerve entirely, protein denature of Schwann cells at site will happen for sure. I just cannot attribute recurrent rf failure due to ***ty techniques, why the first one successful? I encounter more genicular rf failure.

 

[bedrock]

thanks, the concept of RFA coagulation of nerves is interesting, so that we can coagulate the nerves in the same location many many times, 80 degree with90 second will destroy the nerve entirely, protein denature of Schwann cells at site will happen for sure. I just cannot attribute recurrent rf failure due to ***ty techniques, why the first one successful? I encounter more genicular rf failure.

This. Most people do a ****ty job at RF. I’m so glad to hear they can do it in five minutes under AP only….

I have many local patients who had a good result with first RFA, then fail the second or third RFA from the same physician(s)

I have repeated RFA in these patients and every single one of them did much better after my RFA….which took more than 15 minutes to perform, because I did it with SIS technique.

 

[cameroncarter]

Facet loading pain on exam in younger patient and + response to LMBBs. Have only done 5 for LBP, so take that for what it's worth. 4/5 have had sustained >70% relief and 2 at 100 (furthest is only ~9 months out). 5th patient only had ~20% relief after removal 1 month ago. Of these folks, the best responders also had +ttp overlying facets and also hadn't had multiple prior RFAs. There is limited sprint literature on delayed response w/some patients not getting relief until sometimes a few months after removal...which I didn't believe until a patient told me this happened to him for one place in his shoulder (not by me).

Very interesting- is your target the L3 medial branch or L4?

Also, I find that facet mediated pain isn’t always so pronounced in this patient and that they have a lot of myofascial pain - I wonder if it works for them.

 

[SC Tian]

I have many local patients who had a good result with first RFA, then fail the second or third RFA from the same physician(s)

I have repeated RFA in these patients and every single one of them did much better after my RFA….which took more than 15 minutes to perform, because I did it with SIS technique.

Nice, i encountered that as well, people failed rfa from other providers, i repeated it worked, however the successful rate of 2nd,3rd and 4th time of repeat decline is observed from my practice.

 

[bedrock]

Nice, i encountered that as well, people failed rfa from other providers, i repeated it worked, however the successful rate of 2nd,3rd and 4th time of repeat decline is observed from my practice.

No offense but I haven’t seen that in my practice.

I trained with Paul Dreyfuss and I’m very particular about my RFA technique, it likely takes longer than many of you here, but I also haven’t seen more than a couple repeat RFA failures in my practice of over a dozen years.

 

[SC Tian]

No offense but I haven’t seen that in my practice.

I trained with Paul Dreyfuss and I’m very particular about my RFA technique, it likely takes longer than many of you here, but I also haven’t seen more than a couple repeat RFA failures in my practice of over a dozen years.

wow, interesting, just curious, do you have many patients treated with around 10 times rfa over 5-10 years? just try to learn more from this important procedure in our specialty, thanks.

 

[clubdeac]

Why?

Did you miss the part where he said some patients will start to experience relief 2 months after the lead is removed. This is what the literature shows as well. Don’t ask me how or why. But that was his reasoning

 

[MitchLevi]

Did you miss the part where he said some patients will start to experience relief 2 months after the lead is removed. This is what the literature shows as well. Don’t ask me how or why. But that was his reasoning

I didn't miss that part.

 

[au bon pain]

Very interesting- is your target the L3 medial branch or L4?

Also, I find that facet mediated pain isn’t always so pronounced in this patient and that they have a lot of myofascial pain - I wonder if it works for them.

Target pedicle at mid-point in territory of worst pain. I know of some folks who place it for "low back pain" (and probably myofascial pain), but that's not a targetable dx to me. I only consider it if I think spondylosis is main cause, but yeah in those who also have a myofascial component of pain (and multifidus atrophy on MR)--in my limited experience, they do well.

 

[au bon pain]

Did you miss the part where he said some patients will start to experience relief 2 months after the lead is removed. This is what the literature shows as well. Don’t ask me how or why. But that was his reasoning

Yup. Company data ain't gospel, and if I hadn't seen a normal/functional patient who reported experiencing this, I probably wouldn't wait since there's no known mechanism to explain why. But I'm willing to accept sometimes we don't know everything (or in fact, much at all wrt neurobiology and pain)...provided that it doesn't expose patient to undo risk. What's the downside of waiting 8 weeks in a patient with years of chronic pain and by doing so could possibly spare the patient another procedure? Sometimes hurry up and wait is the right move. If no/almost none non-responders turn out to have relief in the 2 months following removal, I'm always open to changing my practice.

 

[au bon pain]

Personally, I wouldn't let the prior use of Sprint impact my decision to ablate or not ablate.

Who said they do? If on day of explant patient doesn't have >50% relief I book RFA 2 months out. When I'm offering pt RFA vs PNS in the first place, I let them know I won't do an RFA right away in PNS doesn't work. People who don't like it pick RFA and life goes on.

 

[MitchLevi]

You know, the ebb and flow of back pain is enough to wait 2 months, 4 months or 6 months before you RFA any patient, whether they just had multifidus stim or not.

This makes zero sense. You put Sprint in for 60 days.

Something doesn't happen for 60 days, but does happen within the 60 days after it's taken out?

This in regards to a device whose MoA makes no sense to begin with...

You do you. I won't judge you for it.

 

[bedrock]

wow, interesting, just curious, do you have many patients treated with around 10 times rfa over 5-10 years? just try to learn more from this important procedure in our specialty, thanks.

Yes,

I have personally repeated RFA up to 6 times on many patients with similar relief. My first job lasted for 6 years.

RFA still worked for all those patients the 6th time. I have also done RFA on an elderly patient from age 95-99 years. Worked every time, and then she died a few months before her 100th birthday.

 

[MitchLevi]

Yes,

I have personally repeated RFA up to 6 times on many patients with similar relief. My first job lasted for 6 years.

RFA still worked for all those patients the 6th time. I have also done RFA on an elderly patient from age 95-99 years. Worked every time, and then she died a few months before her 100th birthday.

I have a few pts who reliably get 8-12 months that I've burned 3-5 times.

Those pts who do well 2 or 3 times and then fail prob have some other reason to hurt.

Back pain is complicated IMO, too many moving parts.

Ever evolving pie chart IMO - The size of each piece varies by the day. Disk, muscle, facet, nerve, etc...Each piece variably hurts depending on a million things.

 

[NeuroGuyIP]

I turned down an offer by their rep to bring lunch to my office. Showed up at my surgery center while I was doing cases the following week…

Now that is persistence!

 

[SC Tian]

Yes,

I have personally repeated RFA up to 6 times on many patients with similar relief. My first job lasted for 6 years.

RFA still worked for all those patients the 6th time. I have also done RFA on an elderly patient from age 95-99 years. Worked every time, and then she died a few months before her 100th birthday.

Thanks, maybe sometimes our criteria for lumbar rfa is too liberal imo, often together with mire or less disk, si joint, more segments facet arthropathy, myofascual pain etc. i very rarely saw complete relief from rfa that was reported from bogduk. Appreciated your input!

 

[cameroncarter]

No offense but I haven’t seen that in my practice.

I trained with Paul Dreyfuss and I’m very particular about my RFA technique, it likely takes longer than many of you here, but I also haven’t seen more than a couple repeat RFA failures in my practice of over a dozen years.

Please share your technique!!

 

[bedrock]

Please share your technique!!

This is the best way to learn my technique post fellowship

https://www.spineintervention.org/events/EventDetails.aspx?id=1665874&group=

 

[epidural man]

I turned down an offer by their rep to bring lunch to my office. Showed up at my surgery center while I was doing cases the following week…

Never turn down free lunch.

 

[epidural man]

Who does it? What pathology? What are the results?

I have done 2 or 3 cases.

Lead fracture or dislodgment in all of them.

Each really liked the therapy while it was on, no benefit after it was gone.

All had significant multifidus marbling on MRI.

 

[cameroncarter]

I have done 2 or 3 cases.

Lead fracture or dislodgment in all of them.

Each really liked the therapy while it was on, no benefit after it was gone.

All had significant multifidus marbling on MRI.

Did you refer to have lead fragment removed or no?

We this before the “new” lead was released?

 

[MitchLevi]

Did you refer to have lead fragment removed or no?

We this before the “new” lead was released?

My n = 1 for LBP and she has lead in her still. My shoulder doesn't.

 

[epidural man]

Did you refer to have lead fragment removed or no?

We this before the “new” lead was released?

No - it's a tiny piece of metal less than a surgical staple. It's that tiny little piece that anchors the lead that usually breaks off.

I don't think I have used the stronger lead yet for back pain. I have for peripheral nerve stuff.

 

[Ducttape]

is that metal a contraindication for future MRI?

 

[MitchLevi]

is that metal a contraindication for future MRI?

"Conditionally approved."

 

[au bon pain]

is that metal a contraindication for future MRI?

Can get up to a 3T of any area. IIRC, sprint gives pt a wallet card with conditional parameters to show when they go to imaging center.

 

[SC Tian]

Yes,

I have personally repeated RFA up to 6 times on many patients with similar relief. My first job lasted for 6 years.

RFA still worked for all those patients the 6th time. I have also done RFA on an elderly patient from age 95-99 years. Worked every time, and then she died a few months before her 100th birthday.

In my limited experiences,yes I do see patient has long and reliable relief from repeat rfa, however clinically I see quite common, more and more degeneration of spineal segments during the course of treatment, this is especially true for adjacent level pathologies, such as facet hypertrophy, separation of joint, the root of SAP, or junction of sap and tp is really difficult to access, what is your experiences about this? Appreciate it.