Transcript Do Spinal Cord Stimulators Work?

Spinal Cord Stimulator
Does It Work?
Steve Storick, M.D.
Palmetto Health
Pain Management and Rehabilitation Center
October 15, 2012
Disclaimer
• I do not receive any direct compensation from
the makers of Spinal Cord Stimulators
(Medtronic, St. Jude or Boston Scientific)
• I may have stock in all three companies
through an investment banker
Approved Uses
• Chronic Pain of the Trunk or Limbs
• Neuropathic Pain
– Radiculopathy
– Peripheral Neuropathy
– Failed Back Surgery Syndrome
– Arachnoiditis
– Phantom Limb / Stump Pain
– Complex Regional Pain Syndrome (RSD)
Other Uses
• Peripheral Vascular Disease / Ischemic Limbs
• Angina Pectoris (not approved in US)
Maybe / Maybe Not
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Knee Pain
Shoulder Pain
Groin / Testicular Pain
Mechanical Back Pain
Abdominal Pain
Post Surgical Pain (Orthopedic)
Primarily Back or Neck Pain
Many abstracts, but not studies
Due Diligence
• Extremity Pain
• Symptoms c/w neuropathic pain
• Test supporting diagnosis
– MRI, EMG, Myelogram/CT Scan
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Appropriate conservative treatments
Surgical remedy?
Psychological evaluation
SCS Trial
Back / Neck Pain
• When SCS does not work well
• Back or Neck Pain greater than extremity pain
• Short term relief during trial and maybe up to
6 months with permanent device
• Peripheral Field Electrodes are experimental
– Very expensive TENS unit
– Placed under skin; not epidural
COMPLEX REGIONAL PAIN SYNDROME
(CRPS)
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Old term is Reflex Sympathetic Dystrophy (RSD)
Usually post traumatic
Fracture most common injury
Usually affects upper > lower extremity
Based on specific subjective and objective
criteria (IASP)
– 2 0f 4 signs
– 3 of 4 symptoms
CRPS (RSD)
• Patients knowledgeable of symptoms (Internet)
but entire clinical picture not c/w CRPS
• Chronic pain maybe secondary to surgical
trauma
• One Physician says so, everyone else does too
• No specific test
• Incidence 5.5-16.8 per 100,000
Back to SCS Trials
• Should have appropriate Psychological
Evaluation including testing
– Not just a mental status exam
• Clear understanding of purpose of SCS and
goals (Reduce pain >50-60% and Functional
Improvement)
• Should last several days
• Complications should be unusual
• Rarely need repeating
Manufacturer
• Three Companies (Boston Scientific, Medtronic,
St. Jude)
• All three equal
• Few different bells and whistles
• No reason to repeat trial with different system
• No reason to replace functioning implanted
system w/ different manufacturer
CMS proposes 2013 changes
• Bundle cost of the lead into 63650 for office
• Suggest that L8680 not appropriate code for
office setting
• Establish values for physician practice expense
in the office setting
Palmetto GBA Draft (DL32549)
• Patients must have undergone careful
screening, evaluation and diagnosis by a
multidisciplinary team prior to implantation
• Must not have active substance abuse issues
• Proper patient education about SCS
• Appropriate Psychological screening
– No major issues including severe depression
– May be a candidate if patient receives treatment
Palmetto GBA Draft (DL32549)
• Can perform SCS trial in office if appropriately
supplied and staffed. Must have like privileges in
local hospital / ASC or board certified in Pain
Management
• Preferable that trial physician also implant
permanent
• Successful trial should be associated w/ at least
50% reduction of target pain or analgesic
medication and show some element of functional
improvement
Palmetto GBA Draft (DL32549)
• Physicians w/ low trial to permanent implant
ratio (<50%) will be subject to post payment
review
– May lead to overimplanting of permanent devices
• Reimburse for a maximum of 2 leads or 16
contacts for 1 trial per anatomic spinal region
per patient per lifetime
• Repeat trial only w/ extenuating circumstances
L8680
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CMS pays per contact to maximum of 16
+/- $428 x 16 = $6828
Cost: Free(?) to $1200 per electrode (8 contacts)
Procedural codes CPT 63650 and 63650-59 are
separate fees
• BCBS of SC pays invoice for L8680
Decisions
• ASC or Hospital costs $6,000-12,000 or more
for trial
• In office has led to over utilization
• Repeat trials w/ different device companies
• No proof one is better than other; different
whistles and bells
• Wrong reason (diagnosis) or patient
Advantages/Disadvantages
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Less medication
More control of pain
Functional improvement
Limited MRI use
Potential interaction with Pacemakers/AICDs
Electrocautery/Surgery
Outcomes
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Over 60 studies of varying quality
Lumbar fusions 1 or 2 level or even more?
Back to work
Private Insurance Patients
– When can I go back to work?
• WC Patients
– I cant work!
No, the SCS does not make patient worse
– Unless major complication such as infection
or nerve damage with implantation
THANK YOU