Transforaminal PNS Leads

[gaspasser127]

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Has anyone put PNS leads (Nalu or Curonix) into the foramen to stimulate the nerve root?

I saw a patient in clinic who has left foot CRPS. She told me she has a DRG stimulator in place and it’s not helping. I said oh ok… no battery in site. It’s a Curonix lead in the L4 and L5 foramen. I realized on the x ray.

 

[lobelsteve]

Bad idea. Bad doctor. Bad insurance approval. If conventional scs in canal does not work, drg from abbott could be considered. This is just bad.

 

[SpineandWine]

Medial to DRG is no longer peripheral nerve stimulation

 

[gaspasser127]

Is traditional DRG-S actually PNS, then?

 

[au bon pain]

Has anyone put PNS leads (Nalu or Curonix) into the foramen to stimulate the nerve root?

I saw a patient in clinic who has left foot CRPS. She told me she has a DRG stimulator in place and it’s not helping. I said oh ok… no battery in site. It’s a Curonix lead in the L4 and L5 foramen. I realized on the x ray.

I very occasionally feel like I'm missing out on opportunities to help my patients by not offering some of these fancy implantables.
Then I see bat-**** crazy stuff like this.
And I feel pretty good about my decisions.

Thanks for posting this

 

[soxman]

Pretty sure that's creating some severe foramina stenosis with that lead in there

 

[SpineandWine]

Random Q- have a patient with 4 DRGs in back from outside physicians. Got MRI, shows worsening foraminal narrowing.
Okay to do TFESI?
Does battery need to be off for DRG?

The diameter of leads look small on MRI for Abbott placed system

 

[lobelsteve]

Random Q- have a patient with 4 DRGs in back from outside physicians. Got MRI, shows worsening foraminal narrowing.
Okay to do TFESI?
Does battery need to be off for DRG?

The diameter of leads look small on MRI for Abbott placed system

Just say no. Why do you think an ESI will have any effect given the care they have already been through?

 

[SpineandWine]

Just say no. Why do you think an ESI will have any effect given the care they have already been through?

This patient is a pastor.
Had 4 lead DRG placed by outside doc for “CRPS” of hip and knee. His joints have heterotopic ossification and not real CRPS

Has this nerve pain in leg, MRI shows foraminal stenosis at L4-5.
He states DRG doesn’t help but charges it. I want to determine if he’ll get better relief with removal of DRG and decompression of spine for nerve pain in leg.

 

[BobBarker]

the probability of a lead breaking and leaving a remnant that no one can remove is fairly high. Either leave it and use it, or leave it and don’t use it.

 

[lobelsteve]

This patient is a pastor.
Had 4 lead DRG placed by outside doc for “CRPS” of hip and knee. His joints have heterotopic ossification and not real CRPS

Has this nerve pain in leg, MRI shows foraminal stenosis at L4-5.
He states DRG doesn’t help but charges it. I want to determine if he’ll get better relief with removal of DRG and decompression of spine for nerve pain in leg.

Are epidurals diagnostic?
Are SNRB diagnostic?
Was he swindled?

No/No/Yes.

 

[SpineandWine]

the probability of a lead breaking and leaving a remnant that no one can remove is fairly high. Either leave it and use it, or leave it and don’t use it.

What about foraminal stenosis?
Just have him go talk to spine surgeon without trying an ESI? And sign him up for back surgery?

 

[Baron Samedi]

The idea of a tined lead in the epidural space makes my skin crawl

 

[BobBarker]

I would do whatever esi I thought was best and leave the lead in there.

 

[SpineandWine]

I would do whatever esi I thought was best and leave the lead in there.

That’s my plan

 

[MitchLevi]

ILESI if able to do so.

 

[Orin]

Has anyone put PNS leads (Nalu or Curonix) into the foramen to stimulate the nerve root?

I saw a patient in clinic who has left foot CRPS. She told me she has a DRG stimulator in place and it’s not helping. I said oh ok… no battery in site. It’s a Curonix lead in the L4 and L5 foramen. I realized on the x ray.

Yes. Stimwave -> Curonix used to teach it. Was used prior to that for off label access. Kaparul would also agree with Lobel about it being malpractice, but it was an effective way to capture a single root. Curonix doesn't push it much anymore. Nalu has never promoted that approach. The lead is larger than the DRG lead, which already comes with some risk of neuroforaminal stenosis, and the outside-in approach risks going ventral more than the inside-out approach.

These days I'll park an SPR or Stimrouter lead near the nerve root for stimulation using ultrasound or fluoro, but rarely if ever consider doing the DRG proper. You can also do this with Abbott DRG leads, but migration is a problem there as you can't really create retention loops in the extra-foraminal space the same way.

 

[Orin]

Random Q- have a patient with 4 DRGs in back from outside physicians. Got MRI, shows worsening foraminal narrowing.
Okay to do TFESI?
Does battery need to be off for DRG?

The diameter of leads look small on MRI for Abbott placed system

Those are DRG leads which are thinner than the usual Abbott dorsal column leads so they should look small. You can do the TFESI, but not sure what you're expecting to get?

If this is for surgical planning, you can ask the rep to individually stimulate the DRGs to verify which nerve root's paresthesia stimulation causes concordant pain.

 

[Status Sciaticus]

the probability of a lead breaking and leaving a remnant that no one can remove is fairly high. Either leave it and use it, or leave it and don’t use it.

not even neurosurgery?

 

[SpineandWine]

Those are DRG leads which are thinner than the usual Abbott dorsal column leads so they should look small. You can do the TFESI, but not sure what you're expecting to get?

If this is for surgical planning, you can ask the rep to individually stimulate the DRGs to verify which nerve root's paresthesia stimulation causes concordant pain.

Therapeutic relief,
If not, then surgery for severe foraminal stenosis L4-5 where leads are in place

 

[BobBarker]

not even neurosurgery?

Some might try. The fellowship trained neuromod neurosurgeon at the university looked my case over and thought best to leave them where they were.

I attempted to explant one placed by another doctor. The leads just fell apart bit by bit and I had to quit the case.

 

[Ready_User_1]

Random Q- have a patient with 4 DRGs in back from outside physicians. Got MRI, shows worsening foraminal narrowing.
Okay to do TFESI?
Does battery need to be off for DRG?

The diameter of leads look small on MRI for Abbott placed system

Why do people implant IPGs so low???

 

[Orin]

Some might try. The fellowship trained neuromod neurosurgeon at the university looked my case over and thought best to leave them where they were.

I attempted to explant one placed by another doctor. The leads just fell apart bit by bit and I had to quit the case.

SCS and DRG leads come out easy for me. Cut down to the anchor and release that if present.

Comparatively for PNS, Nalu/Curonix/Stimrouter leads with barbs have fractured on me almost every time and come out in pieces.

 

[BobBarker]

Yes, scs just come out. This was my only DRG explant experience. There were no anchors. The leads might have been sewed down directly. The lead tips were still in excellent position and loops in place. Fractured multiple places in the IPG pocket and the problem just kept progressing as I went.

 

[gaspasser127]

The difficulty of PNS revision and explant cases makes me hesitant about utilizing the therapy a lot. Tyned leads scar down too much and all the random tips and tricks the rep tells you don’t reliably work like hydrodissection or threading the needle back over the lead.

Also, because the Nalu micro-IPG and the excess leads are so superficial there’s a risk of lead erosion and a documented increased risk of infection requiring explant in Nalu cases as opposed to SCS.

Non-diabetic Nalu patients have a statistically higher risk of infection requiring explant compared to diabetic patients getting SCS. (Look at the 12 month data in the COMFORT trial compared to 24 month SENZA PDN data)

Lead fracture is also a very real issue in PNS which then makes the device MRI incompatible.

DRG is obviously more technically challenging to do but compared to PNS has way better data supporting its efficacy for focal neuropathic pain, less complications requiring revision and those revisions are easier to deal with compared to PNS, and tbh is also easier to get covered by insurance.

SCS still reigns supreme for Neuromodulation.

Obviously all this is contingent on proper patient identification. If you’re handing these out like candy then nothing will work well.

 

[TIVAndy]

the only time i would consider this is when someone has a CRPS and they have had prior laminectomy.
that being said, you can still try regular SCS vs PNS.