When to offer SCS trial?

[thecentral09]

Young attending here. I have quite a few young (er?) patient between the age of 30-55 who have had the standard hemilam/discectomy/ foramenotomy with temporary improvement in pain with recurrence within a few years. Most of these patients follow up with surgery and are told they require a 2-3 level fusion, and return to me for second opinion ,and in MOST cases, the MRI is suggestive of moderate to severe spinal or neuroforaminal stenosis. Due to the severity of the nerve compression, the patient is sure they require surgery, but don't want a fusion at such a young age. I believe its fair to offer these patients an SCS trial, but with severe stenosis on MRI, its a a difficult discussion to have as they know surgery may be indicated. Any help/guidance/ long term data would be appreciated

---

Members don't see this ad.

 

[BobBarker]

I wouldn’t offer scs for a young patient with severe canal stenosis.

 

[lobelsteve]

Young attending here. I have quite a few young (er?) patient between the age of 30-55 who have had the standard hemilam/discectomy/ foramenotomy with temporary improvement in pain with recurrence within a few years. Most of these patients follow up with surgery and are told they require a 2-3 level fusion, and return to me for second opinion ,and in MOST cases, the MRI is suggestive of moderate to severe spinal or neuroforaminal stenosis. Due to the severity of the nerve compression, the patient is sure they require surgery, but don't want a fusion at such a young age. I believe its fair to offer these patients an SCS trial, but with severe stenosis on MRI, its a a difficult discussion to have as they know surgery may be indicated. Any help/guidance/ long term data would be appreciated

Who is reading the MRI?
Post pictures, as this sounds highly unlikely and may be an overreading of the imaging by a Radiologist for the surgeon to allow further surgery.

I would offer SCS over repeat surgery because it is supported in the literature. Age is not a barrier. Progressive neurological deficits are.
See Norths work: Here is the prelim study, but can pubmed for the later stuff.
A Prospective, Randomized Study of Spinal Cord Stimulation versus Reoperation for Failed Back Surgery Syndrome: Initial Results

 

[Ferrismonk]

You didn't mention, but I assume you're indicating that the disc/stenosis at the same level as the prior surgery? I'm also assuming you've discussed caudals/transforaminals, PT, and medical management first before more surgery. That being said, if a patient doesn't want surgery and has failed more conservative treatments, I feel a SCS trial at least is indicated.

 

[hyperalgesia]

Young attending here. I have quite a few young (er?) patient between the age of 30-55 who have had the standard hemilam/discectomy/ foramenotomy with temporary improvement in pain with recurrence within a few years. Most of these patients follow up with surgery and are told they require a 2-3 level fusion, and return to me for second opinion ,and in MOST cases, the MRI is suggestive of moderate to severe spinal or neuroforaminal stenosis. Due to the severity of the nerve compression, the patient is sure they require surgery, but don't want a fusion at such a young age. I believe its fair to offer these patients an SCS trial, but with severe stenosis on MRI, its a a difficult discussion to have as they know surgery may be indicated. Any help/guidance/ long term data would be appreciated

I offer scs for radicular pain in setting of post lami and no progressive neuro sxs. I describe fusion as primarily an irreversible hail mary for axial pain, not generally for radicular pain.

In my discussion with pts, I talk about how scar tissue stuck to nerves cannot be fixed surgically. And I talk about the pts who have profound image findings with no sxs. Fixing the image does not mean fixing the pain, etc. Also I like to point out how the natural axial chain is completely disrupted by fusion.

There are plenty of determined pts who get fusion and revisions. I just want to give them a fighting chance against their gut instinct which is telling them the human body is like a car engine and can be "fixed".

 

[painfree23]

Along similar lines, I sometimes have a patient who needs 2-3 norco per day and doesn’t need anything else. No abberent behaviors, functional. Do u offer them scs instead of the meds?

 

[lobelsteve]

Along similar lines, I sometimes have a patient who needs 2-3 norco per day and doesn’t need anything else. No abberent behaviors, functional. Do u offer them scs instead of the meds?

Not typically. If patient functional with FT work or raising family, why change? If patient wants off due to societal pressures and feels SCS could get them there, then they will do well with implant with or without battery turned on. Better usually with battery on.

 

[clubdeac]

Agree with Lobel. How many of these cases truly have severe stenosis. If under 50, why would they have severe stenosis unless they have a large disc or they’ve had a prior fusion and they’ve developed adjacent segment disease. Outside of this, severe stenosis rarely happens in these relatively young spines

 

[swamprat]

It’s interesting how many patients are resistant to injections but will jump under the knife for these big lamis and fusions.

On another note - I have a 19 year old very nice girl - college student headed for med school she says. She has spondylolisis bl l5/s1 with grade 1 listhesis and has both axial back pain and radicular symptoms. Tried a couple transforaminals. First one helped but transient second one made pain worse. Just did SI joint injections on her. May consider MBBs. Started tizanidine and cymbalta on her. She act states tizanidine working well did not start cymbalta. She still has a lot of radic pain. Would u ever consider stim in a patient this young?


Sent from my iPhone using SDN mobile

 

[clubdeac]

It’s interesting how many patients are resistant to injections but will jump under the knife for these big lamis and fusions.

On another note - I have a 19 year old very nice girl - college student headed for med school she says. She has spondylolisis bl l5/s1 with grade 1 listhesis and has both axial back pain and radicular symptoms. Tried a couple transforaminals. First one helped but transient second one made pain worse. Just did SI joint injections on her. May consider MBBs. Started tizanidine and cymbalta on her. She act states tizanidine working well did not start cymbalta. She still has a lot of radic pain. Would u ever consider stim in a patient this young?


Sent from my iPhone using SDN mobile

No way

 

[lobelsteve]

F/E films please.

 

[DODOCSS]

It’s interesting how many patients are resistant to injections but will jump under the knife for these big lamis and fusions.

On another note - I have a 19 year old very nice girl - college student headed for med school she says. She has spondylolisis bl l5/s1 with grade 1 listhesis and has both axial back pain and radicular symptoms. Tried a couple transforaminals. First one helped but transient second one made pain worse. Just did SI joint injections on her. May consider MBBs. Started tizanidine and cymbalta on her. She act states tizanidine working well did not start cymbalta. She still has a lot of radic pain. Would u ever consider stim in a patient this young?


Sent from my iPhone using SDN mobile

you're kidding right?

 

[painfree23]

It’s interesting how many patients are resistant to injections but will jump under the knife for these big lamis and fusions.

On another note - I have a 19 year old very nice girl - college student headed for med school she says. She has spondylolisis bl l5/s1 with grade 1 listhesis and has both axial back pain and radicular symptoms. Tried a couple transforaminals. First one helped but transient second one made pain worse. Just did SI joint injections on her. May consider MBBs. Started tizanidine and cymbalta on her. She act states tizanidine working well did not start cymbalta. She still has a lot of radic pain. Would u ever consider stim in a patient this young?


Sent from my iPhone using SDN mobile

Please don’t ruin her life with a stim

 

[swamprat]

you're kidding right?

Well I’m not. I mean obviously I’m thinking too young hence why I asked but she has a bad back. There’s some other MRI findings I’m forgetting about now. Hypothetically would U prefer opioids for this patient? What is ur age cut off for a stim trial? Im obviously trying everything else first.. non-opioids, PT etc but let’s say u went through all that stuff. No psych pathology. Patient misses school sometimes due to the severe pain.. what do u do at this point? What if she was 21? 25? 30?


Sent from my iPhone using SDN mobile

 

[Hoya11]

Young attending here. I have quite a few young (er?) patient between the age of 30-55 who have had the standard hemilam/discectomy/ foramenotomy with temporary improvement in pain with recurrence within a few years. Most of these patients follow up with surgery and are told they require a 2-3 level fusion, and return to me for second opinion ,and in MOST cases, the MRI is suggestive of moderate to severe spinal or neuroforaminal stenosis. Due to the severity of the nerve compression, the patient is sure they require surgery, but don't want a fusion at such a young age. I believe its fair to offer these patients an SCS trial, but with severe stenosis on MRI, its a a difficult discussion to have as they know surgery may be indicated. Any help/guidance/ long term data would be appreciated

this strikes me as a " no way"

just give them the refill and let them follow up with neurosurgery as needed

the chance the stim is going to make a difference for these people is minimal

maybe if they were 80s, 90s and not surgical candidates you could make a better argument

 

[Hoya11]

Well I’m not. I mean obviously I’m thinking too young hence why I asked but she has a bad back. There’s some other MRI findings I’m forgetting about now. Hypothetically would U prefer opioids for this patient? What is ur age cut off for a stim trial? Im obviously trying everything else first.. non-opioids, PT etc but let’s say u went through all that stuff. No psych pathology. Patient misses school sometimes due to the severe pain.. what do u do at this point? What if she was 21? 25? 30?


Sent from my iPhone using SDN mobile

how about this mind blowing idea: no opiates AND no injection...

shes missing school for back pain, really? who cares?? find another psych for her.. she very very most likely has either some type of somatoform disorder and/or muscle tension lbp.. the injections that you are doing for her arent helping she is obviously fishing for opiates

 

[hyperalgesia]

Well I’m not. I mean obviously I’m thinking too young hence why I asked but she has a bad back. There’s some other MRI findings I’m forgetting about now. Hypothetically would U prefer opioids for this patient? What is ur age cut off for a stim trial? Im obviously trying everything else first.. non-opioids, PT etc but let’s say u went through all that stuff. No psych pathology. Patient misses school sometimes due to the severe pain.. what do u do at this point? What if she was 21? 25? 30?


Sent from my iPhone using SDN mobile

Age cut off really depends on a lot of variables. If this person has had lami for severe and objective pathology and pain is radicular, severe, and constant, she is considering additional surg, etc, I would consider scs at this age.

But in this example, you have a virgin back with questionable pathology and questionable functional deficits, in the setting of a kid who probably has undeveloped coping skills.

Maybe there's more to the history but I would be very hesitant to try to improve this person's physiology with anything other than therapies and reassurance.

 

[Taus]

It’s interesting how many patients are resistant to injections but will jump under the knife for these big lamis and fusions.

On another note - I have a 19 year old very nice girl - college student headed for med school she says. She has spondylolisis bl l5/s1 with grade 1 listhesis and has both axial back pain and radicular symptoms. Tried a couple transforaminals. First one helped but transient second one made pain worse. Just did SI joint injections on her. May consider MBBs. Started tizanidine and cymbalta on her. She act states tizanidine working well did not start cymbalta. She still has a lot of radic pain. Would u ever consider stim in a patient this young?


Sent from my iPhone using SDN mobile

Absolutely not. Though also don’t understand the rationale for the sij or mbb given the nature of pathology being radicular pain from a spondy. I’d like to see the mri and flex/ex xrays, but if her issue is legit, painful and refractory, she should see a surgeon despite her young age.

 

[swamprat]

Absolutely not. Though also don’t understand the rationale for the sij or mbb given the nature of pathology being radicular pain from a spondy. I’d like to see the mri and flex/ex xrays, but if her issue is legit, painful and refractory, she should see a surgeon despite her young age.

Well I think she has a couple sources of pain. The SI was obviously not to help her radic pain. I’ll post imaging results next time I’m in office. I don’t have access to the actual images themselves unfortunately


Sent from my iPhone using SDN mobile

 

[Taus]

Young attending here. I have quite a few young (er?) patient between the age of 30-55 who have had the standard hemilam/discectomy/ foramenotomy with temporary improvement in pain with recurrence within a few years. Most of these patients follow up with surgery and are told they require a 2-3 level fusion, and return to me for second opinion ,and in MOST cases, the MRI is suggestive of moderate to severe spinal or neuroforaminal stenosis. Due to the severity of the nerve compression, the patient is sure they require surgery, but don't want a fusion at such a young age. I believe its fair to offer these patients an SCS trial, but with severe stenosis on MRI, its a a difficult discussion to have as they know surgery may be indicated. Any help/guidance/ long term data would be appreciated

If they have mainly leg pain and have clear major recurrent or adjacent level nerve compression on mri that corresponds, and I’ve done what I can will pills, shots, rehab, etc.... unless really old or ill they should at least have a surgical consult before stim. They can refuse or be told no surgery, but I do think it’s important to at least strongly consider before Scs especially if it’s just decompression.

 

[callmeanesthesia]

Well I’m not. I mean obviously I’m thinking too young hence why I asked but she has a bad back. There’s some other MRI findings I’m forgetting about now. Hypothetically would U prefer opioids for this patient? What is ur age cut off for a stim trial? Im obviously trying everything else first.. non-opioids, PT etc but let’s say u went through all that stuff. No psych pathology. Patient misses school sometimes due to the severe pain.. what do u do at this point? What if she was 21? 25? 30?

Sent from my iPhone using SDN mobile

How much physical therapy, and how much psychological therapy has she had respectively? And specifically what exercises did she do it PT? Was it tailored toward stabilizing the spondy or was she just sent for evaluate and treat for “back pain”?
How is her posture? In a student that’s a huge contributor. Any other activities that may be aggravating the pain from the spondy, especially if she has a weak core? What was she doing that caused the spondy and is she still doing it?
For a 19 year old, therapy and lifestyle modification all the way. And please don’t start her on opioids. Btw, if tizanidine helps, don’t forget that’s an alpha-2 adrenenergic receptor agonist and probably has some anxiolytic effects as well. Great choice.

 

[swamprat]

How much physical therapy, and how much psychological therapy has she had respectively? And specifically what exercises did she do it PT? Was it tailored toward stabilizing the spondy or was she just sent for evaluate and treat for “back pain”?
How is her posture? In a student that’s a huge contributor. Any other activities that may be aggravating the pain from the spondy, especially if she has a weak core? What was she doing that caused the spondy and is she still doing it?
For a 19 year old, therapy and lifestyle modification all the way. And please don’t start her on opioids. Btw, if tizanidine helps, don’t forget that’s an alpha-2 adrenenergic receptor agonist and probably has some anxiolytic effects as well. Great choice.

Thanks for the info. Yeah I pulled an evaluation and treat haha so I’m not sure what exercises they did for her. I’m 5 months out of fellowship so obviously still learning a lot. The one contributing factor I think def aggravating her symptoms is she does this show thing wearing high heals for hours on end I told her she may want to slow that down since she seems to come to me after one of these shows always in worse shape. I personally also love cymbalta I feel like a lot of patients get improvement in symptoms on it but it’s always a hard sell due to it being an antidepressant


Sent from my iPhone using SDN mobile

 

[pastafan]

Thanks for the info. Yeah I pulled an evaluation and treat haha so I’m not sure what exercises they did for her. I’m 5 months out of fellowship so obviously still learning a lot. The one contributing factor I think def aggravating her symptoms is she does this show thing wearing high heals for hours on end I told her she may want to slow that down since she seems to come to me after one of these shows always in worse shape. I personally also love cymbalta I feel like a lot of patients get improvement in symptoms on it but it’s always a hard sell due to it being an antidepressant


Sent from my iPhone using SDN mobile

I also like Cymbalta but it does carry a black box warning:
In short-term studies, antidepressants increased the risk of suicidality in children, adolescents, and young adults when compared to placebo. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24.

 

[BobBarker]

Well I’m not. I mean obviously I’m thinking too young hence why I asked but she has a bad back. There’s some other MRI findings I’m forgetting about now. Hypothetically would U prefer opioids for this patient? What is ur age cut off for a stim trial? Im obviously trying everything else first.. non-opioids, PT etc but let’s say u went through all that stuff. No psych pathology. Patient misses school sometimes due to the severe pain.. what do u do at this point? What if she was 21? 25? 30?


Sent from my iPhone using SDN mobile

No, no, no.

And don’t ask her on a date either.

 

[bedrock]

It’s interesting how many patients are resistant to injections but will jump under the knife for these big lamis and fusions.

On another note - I have a 19 year old very nice girl - college student headed for med school she says. She has spondylolisis bl l5/s1 with grade 1 listhesis and has both axial back pain and radicular symptoms. Tried a couple transforaminals. First one helped but transient second one made pain worse. Just did SI joint injections on her. May consider MBBs. Started tizanidine and cymbalta on her. She act states tizanidine working well did not start cymbalta. She still has a lot of radic pain. Would u ever consider stim in a patient this young?


Sent from my iPhone using SDN mobile

Did you use particulate steroid or dex for the epidurals?

And test her core strength yourself. Anything less than excellent core strength needs more PT from a better PT. And flat out tell her no more high heels.