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10 Articles in this Series
Introduction
An AAPM 2019 Preview
APRNs/PAs in Pain Medicine SIG Gets Underway
Cannabis Has Entered Pain Management and Is Here to Stay: What Clinicians Need to Consider
Managing Pain in Marginalized Populations, including Ethnic Minorities, LGBTQ, and the Obese
Neuromodulation: A Roundtable on Current Best Practice & Key Questions
Pro/Con: CGRP Antibodies and Treatment Choice for Chronic Migraine
Pro/Con: Conservative Care is the Best Route for Chronic Pelvic Pain
Pro/Con: CRPS - Use Everything but Stimulation
Pro/Con: Ketamine for Complex Regional Pain Syndrome, Neuropathic Pain, and More
Pro/Con: Radiofrequency Denervation is Effective (The MINT Studies)

Neuromodulation: A Roundtable on Current Best Practice & Key Questions

The following 2019 AAPM session "Rapid Fire Discussion: Neuromodulation" featured a roundtable-type discussion with experts Timothy R. Deer, MD, Michael S. Leong, MD, and Salim M. Hayek, MD, PhD. The session was moderated by Robert W. Hurley, MD, PhD with additional questions posed by the audience.*

 

What is one thing often forgotten about when discussing spinal cord stimulation (SCS) or intrathecal therapy (IT)?

Drs. Hayek, Leong, and Deer agreed: Often, the procedure is considered too simplistic and it should not be. The key is good patient selection, which needs to be defined by a number of factors including: other diagnoses that could manifest (including reviews of imaging and lab work), behavioral standpoints, opioid or nicotine use, ability to cope/follow-up, the position of the patient when inserting the device, and the selection of devices. You can’t just put in a device and cure the problem.

With regard to follow-up, it is important to discuss expectations with the patient before any device insertion. For instance, Dr. Deer said he always recommends 12 weeks of rehabilitation/physical therapy after insertion.

 

Has the focus on opioid limits and tapering changed your neuromodulation practice?

Dr. Leong:The current model is to get patients’ opioid doses down as low as possible but not totally off. Our group philosophy at Stanford has been to lower opioids as an overall goal, and we mimic that with SCS.

Dr. Hayek:In the same way that it is important for a patient to stop smoking before a surgery, less opioids are better before a neuromodulation procedure.

Dr. Deer:  We have much better outcomes if a SCS or DRG is offered prior to the patient being placed on chronic opioids. This has been shown in Medicare data analyses, therefore we recommend SCS and DRG when appropriate before opioids.

Proper patient selection, device, frequency, and trialing are key to successful stimulation treatment. (123RF)

What new waveforms, frequencies, technologies, etc, are you excited about?

Dr. Leong: DRG stimulation has been profoundly different; the technique is fascinating and the results that even our center has had have been very profound. The patients getting it, even after failing traditional stimulation, has been remarkable even with just 3 to 4 days of trialing. I have not seen as many successes with peripheral nerve stimulation (PNS) in the past (whether temporary or permanent).

Dr. Deer: The large prospective studies on DRG have shown very good results and has the best data at the current time. I am excited to see the one-year data on the feedback loop study in the United States, and the BOLD study on Burst and low electrical delivery may change the field.

Dr. Hayek: To be honest, we need more of these studies and, until then, I am holding my excitement on the technology. For instance, we have yet to see a large placebo-controlled trial on dorsal root ganglion (DRG), high frequency stimulation versus subcutaneous tissue peripheral field stimulation and comparing results at six months.

 

What is your take on implantables in the cervical region? Are myelopathy concerns valid?

Dr. Deer:This region is okay from an anatomical standpoint but it is important to work closely with a radiologist.

Dr. Hayek: Such risks may be higher in older patients, but overall, risk is exceedingly small.

Dr. Leong: This is why we do trials before implantation; if you cannot get a lead-in during a trial, then you know the implant won’t work.

 

Paresthesia-free trialing and implantation is growing as the healthcare community has seen more adverse events during implantation. What is your take on new anesthetic techniques?

Dr. Deer: Patients should be conversing with you during implantation; if a deeper anesthetic is used, you need to use neuromonitoring including SSEP and EMGs. The danger zone lies in the middle where there is no response and no monitoring; it is here that nerve injury risk goes up.

 

How do you judge tolerance, when for instance, a patient comes back after 18 months and an implanted stimulator is no longer working?

Dr. Deer: If there was only one device option or one target from the beginning, then, sometimes you have to expect that it may fail. It could be that a new pathology develops, and down the road, the patient may need more than one target. This is why the community needs to look more at biomarkers and at identifying more targets. We also need devices that use less electricity so that recharge is needed less often.

Dr. Hayek: I agree, tolerance is the number one problem for our patients. We put a lot of hope into stimulation for big problems and, sometimes, appropriate patient selection and identification is not accurate. We have to go back to the basics and always be sure the individual is a perfect candidate. And with low back pain, in particular, where there are many SCS device claims, I have yet to be convinced of long-term efficacy.

 

It is often hard to keep up with the number of available neuromodulation products today, including which one is good for which patient, which frequency is best, etc, especially when these products are often studied and presented by the manufacturers. How do you differentiate the data?

Dr. Deer: Marketing lingo can be confusing. Randomized studies conducted by companies may show efficacy—and these are reviewed by FDA—but it is important to then look at real-world studies and see if they hold up to the original data. Use that information when considering specific therapies for your patients.

Dr. Leong: Your point is excellent, as every choice we make in pain medicine has to be based on the highest evidence available. Unfortunately, we do not have any head-to-head trials. So, every week, my team at Stanford meets to discuss each case in an individual way and we select the highest-level evidence for treating that specific patient.

 

*Quotes and comments are paraphrased for clarity and style. Commenters’ disclosures may be found on the 2019 AAPM meeting speakers’ webpage. 

-Reported by Angie Drakulich

 

Next summary: Pro/Con: CGRP Antibodies and Treatment Choice for Chronic Migraine
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