suprascapular neurlagia

[sweetalkr]

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i have a patient with suprascapular neuralgia , idiopathic, with suprascapular and infrascap muscle weakness for 5 years, documented on EMG, etc etc. essentially seeing for pain relief

so i do a cervical stim and a peripheral nerve stim directly on the suprascap nerve.

the results rocked, and he got different relief with each stim as well as synergistic relief. anyone know of any papers writing about this. i was thinking about writing it up if it would be cool, or if peripheral stim to suprascap is not something that interesting.

don't want to waste my time if no one is impressed

 

[PinchandBurn]

i have a patient with suprascapular neuralgia , idiopathic, with suprascapular and infrascap muscle weakness for 5 years, documented on EMG, etc etc. essentially seeing for pain relief

so i do a cervical stim and a peripheral nerve stim directly on the suprascap nerve.

the results rocked, and he got different relief with each stim as well as synergistic relief. anyone know of any papers writing about this. i was thinking about writing it up if it would be cool, or if peripheral stim to suprascap is not something that interesting.

don't want to waste my time if no one is impressed

do it man

I think it owuld be great. Did you also put a lead over the infrascap to get the infrascap pain? or just one lead in teh epidural space and one over the suprascap nerve

 

[upright]

.

 

[lobelsteve]

What is idiopathic suprascapular neuralgia?

How about some history, imaging, and what was done on EMG and by whom?

On the face of it it sounds like posterior shoulder pain. How long has stim been in? If it were a partial brachial plexopathy (Parsonage-Turner) I would think stim would work well long term, but if it were just weird posterior shoulder pain- I'd think it quits working in 6 months. If he gets to 18 months and still happy- publish.

 

[SSdoc33]

exactly. why just suprascap-"opathy?" this is usually from a cyst in the notch, and responds best to decompression. i trust you looked hard for a cause?

 

[101N]

this is usually from a cyst in the notch

1+, what do the T2 coronals show.

 

[joshmir]

I have heard there are folks in private practice in AZ who trained at Texas Tech that do this

It is impressive, but wait to publish to document however many months of relief

where did you put the peripheral lead? through the notch?

 

[PMR 4 MSK]

exactly. why just suprascap-"opathy?" this is usually from a cyst in the notch, and responds best to decompression. i trust you looked hard for a cause?

The scapular notch cyst is typically from a torn labrum, and represents pseudocyst. It can impinge on the branch of the suprascapular nerve to the infraspinatus, but spares the supraspinatus as the branch to that comes off far more superiorly. Classic EMG finding is a normal NCS from ERB's to the SS, normal needle exam of the SS, but denervated IS.

In this case, if EMG of the SS and IS are abnormal, it cannot be from a notch cyst.

Alternatively, entrapment of the suprascapular nerve at the suprascapular notch has been described and can potentially respond to decompression (no outcome studies that I know of), but should not be due to a labral pseudocyst.

 

[clubdeac]

The scapular notch cyst is typically from a torn labrum, and represents pseudocyst. It can impinge on the branch of the suprascapular nerve to the infraspinatus, but spares the supraspinatus as the branch to that comes off far more superiorly. Classic EMG finding is a normal NCS from ERB's to the SS, normal needle exam of the SS, but denervated IS.

In this case, if EMG of the SS and IS are abnormal, it cannot be from a notch cyst.

Alternatively, entrapment of the suprascapular nerve at the suprascapular notch has been described and can potentially respond to decompression (no outcome studies that I know of), but should not be due to a labral pseudocyst.

HAHA this iys why I love this forum! I hadn't thought about this since boards, thanks for the review PMR! And nice work sweets, I,ll get back to u regarding ur other question...

 

[sweetalkr]

sorry to keep this brief, don't hav ea chance for elaborate breakdown

Neurosurgery saw him. This is the Army, so from complaint and symptoms until he was air evac'd out of Afghanistan, it was 3 years of symptoms. they didn't think a decompression would help his symptoms at this point. EMG/PE show suprascap distribution weakness and pain. he was sent to me by neurosurg for any pain relief before trying a decompressiion as last resort. pt did not want surgery

after block and pulsing suprascap, I placed the trial lead at suprascap notch in horizontal direction to minimize migration changes and cervical lead. it worked great, even better when both leads were together. we are going to the OR next month to implant, and ortho shoulder specialist is going to dissect, decompress, and place it for me so we have accurate placement. I will place cervical. and I'll have him close 🙂 I am guessing he is faster haha

 

[sweetalkr]

sorry, yes I placed it through the notch I think. it was perc. did cephalad 15 degrees with oblique ipsilateral 20 degree and saw notch decently. i had accessed notch for block and pulsing before and felt comfortable where I would get good stim. but i want surgery there for much more accurate implant. he had massaging feeling with peripheral, and the tingling/soothing with the cervical. thoguht it was cool!

 

[Ligament]

Great work! can you post pics?

My concern is migration of the shoulder lead. Sounds like a lead fracture and migration sweet spot to me. Any thoughts on how to prevent this?

 

[SSdoc33]

i dont get it.

if you are gonna dissect down and decompress the nerve, just do that and see how it goes. putting in a permanent stim in that location in a young guy sounds like a recipe for failure (and permanent disability, might i add).

 

[jsaul]

i dont get it.

if you are gonna dissect down and decompress the nerve, just do that and see how it goes. putting in a permanent stim in that location in a young guy sounds like a recipe for failure (and permanent disability, might i add).

agree

 

[bedrock]

i dont get it.

if you are gonna dissect down and decompress the nerve, just do that and see how it goes. putting in a permanent stim in that location in a young guy sounds like a recipe for failure (and permanent disability, might i add).

Ditto,

Surgery should be attempted first. Get a second surgical opinion.

Stim is appropriate if that surgery fails, but in a young patient in particular, decompression should be attempted first.

 

[Uncovert]

Sweets, I actually presented on SSN lesions(and how under identified they are) at our annual academy meeting - if you want the info, lemme know and I will email. If you don't recognize me, think Genevieve.

 

[sweetalkr]

this is army based. he was seen initially 3 years AFTER symptoms of weakness developed. ortho and neurosurg both said it was too late for decompression to help. I am having ortho implant this lead so they are going to decompress since we are there anyways, not as a first line treatment. but they all said the pathology has been going on too long for a response to decompression (almost 5 years now without pain relief). he has 100% relief with stim on, so there is no reason to go to decompression before stim implant. Read about axonal injjury with normal imaging and physical exam with chronic pain patients after IED blasts in the Army. lots of young people go to Stim after getting the whole gamut of procedures without relief. not uncommon. when i started here i thought they were too aggressive with stim, but the pathology is so different. I just think the older docs tend to be way too passive. we are the last line for pain relief and he failed all measures. the only thing he didnt have was a decompression and both surgical subspecialties refuse to decompress. i'm having them do it anyways because we are cutting down.

for pics, i will post after permanent.

uncovert, u crack my S up. yes email me

 

[Ligament]

this is army based. he was seen initially 3 years AFTER symptoms of weakness developed. ortho and neurosurg both said it was too late for decompression to help. I am having ortho implant this lead so they are going to decompress since we are there anyways, not as a first line treatment. but they all said the pathology has been going on too long for a response to decompression (almost 5 years now without pain relief). he has 100% relief with stim on, so there is no reason to go to decompression before stim implant. Read about axonal injjury with normal imaging and physical exam with chronic pain patients after IED blasts in the Army. lots of young people go to Stim after getting the whole gamut of procedures without relief. not uncommon. when i started here i thought they were too aggressive with stim, but the pathology is so different. I just think the older docs tend to be way too passive. we are the last line for pain relief and he failed all measures. the only thing he didnt have was a decompression and both surgical subspecialties refuse to decompress. i'm having them do it anyways because we are cutting down.

for pics, i will post after permanent.

uncovert, u crack my S up. yes email me

Please educate us, sounds really interesting:
Read about axonal injjury with normal imaging and physical exam with chronic pain patients after IED blasts in the Army

thanks!

 

[daphilster78]

this is army based. he was seen initially 3 years AFTER symptoms of weakness developed. ortho and neurosurg both said it was too late for decompression to help. I am having ortho implant this lead so they are going to decompress since we are there anyways, not as a first line treatment. but they all said the pathology has been going on too long for a response to decompression (almost 5 years now without pain relief). he has 100% relief with stim on, so there is no reason to go to decompression before stim implant. Read about axonal injjury with normal imaging and physical exam with chronic pain patients after IED blasts in the Army. lots of young people go to Stim after getting the whole gamut of procedures without relief. not uncommon. when i started here i thought they were too aggressive with stim, but the pathology is so different. I just think the older docs tend to be way too passive. we are the last line for pain relief and he failed all measures. the only thing he didnt have was a decompression and both surgical subspecialties refuse to decompress. i'm having them do it anyways because we are cutting down.

for pics, i will post after permanent.

uncovert, u crack my S up. yes email me

Now this I definitely don't understand. I really doubt you can say its too late to decompress to improve pain symptoms after xx amount of time. I still think this is first line if you're going to go in and cut anyways. Why not do it simultaneously? Or you can always peripheral stim the nerve later if decompression fails first.

Lets take a similar analogy. I've had patients who had severe CTS(by emg) for many years, kept on wanting to avoid surgery, and finally did carpal release after 5+ years of symptoms. The results? Some have done better pain wise, some did not. There is nothing to suggest a certain time line is too late for decompression, even when there are 'severe' findings on emg.

 

[epidural man]

sorry to keep this brief, don't hav ea chance for elaborate breakdown

Neurosurgery saw him. This is the Army, so from complaint and symptoms until he was air evac'd out of Afghanistan, it was 3 years of symptoms. they didn't think a decompression would help his symptoms at this point. EMG/PE show suprascap distribution weakness and pain. he was sent to me by neurosurg for any pain relief before trying a decompressiion as last resort. pt did not want surgery

after block and pulsing suprascap, I placed the trial lead at suprascap notch in horizontal direction to minimize migration changes and cervical lead. it worked great, even better when both leads were together. we are going to the OR next month to implant, and ortho shoulder specialist is going to dissect, decompress, and place it for me so we have accurate placement. I will place cervical. and I'll have him close 🙂 I am guessing he is faster haha

If you placed them percutaneously, why not implant in that way? It seems a lot less morbid.

 

[sweetalkr]

Daphilster, sorry of I wasn't clear. All surgeons refused to touch him 3 years out for whatever reason I did a cervical lead and a peripheral. H loved them both together more than the cervical alone. When I placed the peripheral lead, I had to place it in dorsal to ventral fashion which to me is a set up for migration. S I spoke with Ortho and asked if they would assist in placing the lead . They said sure and we will put it longitudinally. So I'll place cervical lead they place peripheral. Then I said why don't u just do a decompression while u r down there. They said sure. But they will not do a decompression by itself because they don't want to be primary on a pain patient. When he had his tria he didn't take any opioids or a week and is stoked to get this done. Epidural Man you are right perc is much less morbid but I am really worried about migration in this area. I could probably get away with just the cervical lead however the patient loved them together so m going with what he wanted. This is after suprascapular nerve block and pulsing without much benefit and a once suicidal patient because of his pain now excited about life. I am all about doing what I can for this kid. He served us in Afghanistan and he wants it. We discussed it all with him and he wants both

 

[epidural man]

Daphilster, sorry of I wasn't clear. All surgeons refused to touch him 3 years out for whatever reason I did a cervical lead and a peripheral. H loved them both together more than the cervical alone. When I placed the peripheral lead, I had to place it in dorsal to ventral fashion which to me is a set up for migration. S I spoke with Ortho and asked if they would assist in placing the lead . They said sure and we will put it longitudinally. So I'll place cervical lead they place peripheral. Then I said why don't u just do a decompression while u r down there. They said sure. But they will not do a decompression by itself because they don't want to be primary on a pain patient. When he had his tria he didn't take any opioids or a week and is stoked to get this done. Epidural Man you are right perc is much less morbid but I am really worried about migration in this area. I could probably get away with just the cervical lead however the patient loved them together so m going with what he wanted. This is after suprascapular nerve block and pulsing without much benefit and a once suicidal patient because of his pain now excited about life. I am all about doing what I can for this kid. He served us in Afghanistan and he wants it. We discussed it all with him and he wants both

Well I agree. It will work either way.

We have had very little migration issues so far with our small number of peripheral stims on nerves. I think if planned out right you probably could place the suprascap nerve lead under ultrasound and get it to stay okay with the ancor fairly close to the site.

Either way, I bet ya you give the guy a better life.

Nice job.