Axillary Nerve v Suprascapular Nerve for Shoulder Pain

[Timeoutofmind]

Question:

Suprascapular nerve block is commonly done for failed total shoulder/non-operable shoulder.

However, in reviewing the anatomy of the shoulder in trying to understand how to help these patients, the glenohumeral joint receives significant innervation from the axillary nerve as well.

Makes me wonder two things:

1. I am going to be starting to use the Bioness peripheral nerve stim soon. The rep is telling me the axillary nerve is an easy/reliable target (actually the original FDA approval was for post stroke pain in the limb with axillary nerve being the target). So that got me thinking which nerve would it be better to stim?

2. Do you think some of the people we are treating with suprascapular pRF, RF, stim, whatever have incomplete pain relief because of the axillary nerve component. Obviously burning the axillary nerve is a no-go, and its not really possible to stim both nerves so that complicates things...

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[lobelsteve]

Hope you can post some proof that you get paid for doing these experimental procedures. Until then good luck

 

[Timeoutofmind]

Hope you can post some proof that you get paid for doing these experimental procedures. Until then good luck

My understanding is if u r using a legit peripheral nerve stim and coding correctly (rather than just using an SCS system off label), getting peripheral stims covered is not an issue...is this not the case?

 

[lobelsteve]

One way to find out is after your first case.
SML

 

[epidural man]

Where will you target it?

Because where I have blocked the Axillary nerve before (with ultrasound), I think the articular branches have left the building.

 

[Orin]

I've done a post-stroke shoulder with Bioness so far and am scheduling another. They and some of their paid faculty do tell me that getting the axillary as it wraps around the humerus at the level of the posterior circumflex humeral artery does help shoulder pain, and for some folks more so than a suprascapular nerve intervention.

I think the diagnostic pathway I would set is suprascapular nerve and axillary nerve block, and then intervention on the one that provides the most relief/function.

The thing costs like $5k and is easy to put in/take out, so I do think it's a better option before RFing or neurolysing, even if it fails.

The insurance approval thing wasn't hard as it is FDA approved for peripheral nerve stimulation and it's not 20-30K like a conventional SCS.

 

[epidural man]

I've done a post-stroke shoulder with Bioness so far and am scheduling another. They and some of their paid faculty do tell me that getting the axillary as it wraps around the humerus at the level of the posterior circumflex humeral artery does help shoulder pain, and for some folks more so than a suprascapular nerve intervention.

I think the diagnostic pathway I would set is suprascapular nerve and axillary nerve block, and then intervention on the one that provides the most relief/function.

The thing costs like $5k and is easy to put in/take out, so I do think it's a better option before RFing or neurolysing, even if it fails.

The insurance approval thing wasn't hard as it is FDA approved for peripheral nerve stimulation and it's not 20-30K like a conventional SCS.

why not do both?

 

[epidural man]

Also, I have never heard of Bioness until right now. What is the advantage of this over Stimwave?

We had the Stimwave inventor/engineer come speak to us and she was very impressive. We haven't used her technology yet either.

The only peripheral nerve stim I have done is with conventional systems.

 

[Orin]

Stimwave's basically a stim lead with an external antenna/generator setup which is worked into clothing and costs like $15 - 20k. They have a spinal cord system and a true peripheral nerve lead with barbs to hold it in place. Stimwave is FDA approved to do any nerve you want. It has a lot more flexibility in the size of the lead, and the external part isn't attached directly to the patient per se. It's approved for active duty military I think. I'm envisiong it for

Bioness' Stimrouter is more like a short stim lead with barbs that is only approved for peripheral nerves that are not craniofacial and it costs like $5K. The lead is also a bit stretchier, kinda like Nuvectra's lead or a spring reinforced epidural catheter if you've ever used those. It requires an adhesive patch over where the lead is. The lead is a fixed length but has no anchoring device needed. It's probably best for limbs, maybe for ilioinguinal issues, maybe for intercostals, basically places where someone could place a patch on them. You get a small amount of surface stim/TENS like stuff with the adhesive patch as well. It's probably ideal for post-stroke shoulder issues as they can program it to cause muscle contraction and help the shoulder subluxation greatly. They seem to recommend staying away from CRPS like stuff.

Regarding the shoulder nerve blocks, you could probably block or stim both nerves. I prefer to figure out the least invasive option to get relief and minimize iatrogenic injury.

With both, I'd worry about spanning a joint as although they're better than conventional SCS systems, they're still a wire made of metal. I haven't handled Stimwave's peripheral lead, but Stimrouter's seems less likely to break/is more flexible.

Stimrouter recommends specifically against joint spanning due to migration issues as it really isn't anchored per se but rather scars in it seems. You also have to plan that patch positioning if you're going to use multiples, though supposedly you can sometimes run a few leads off one patch/unit.

Either way, they're both better options though for peripheral than the old stuff which is basically just guaranteeing you a lead revision due to fracture/migration.

 

[Timeoutofmind]

Stimwave's basically a stim lead with an external antenna/generator setup which is worked into clothing and costs like $15 - 20k. They have a spinal cord system and a true peripheral nerve lead with barbs to hold it in place. Stimwave is FDA approved to do any nerve you want. It has a lot more flexibility in the size of the lead, and the external part isn't attached directly to the patient per se. It's approved for active duty military I think. I'm envisiong it for

Bioness' Stimrouter is more like a short stim lead with barbs that is only approved for peripheral nerves that are not craniofacial and it costs like $5K. The lead is also a bit stretchier, kinda like Nuvectra's lead or a spring reinforced epidural catheter if you've ever used those. It requires an adhesive patch over where the lead is. The lead is a fixed length but has no anchoring device needed. It's probably best for limbs, maybe for ilioinguinal issues, maybe for intercostals, basically places where someone could place a patch on them. You get a small amount of surface stim/TENS like stuff with the adhesive patch as well. It's probably ideal for post-stroke shoulder issues as they can program it to cause muscle contraction and help the shoulder subluxation greatly. They seem to recommend staying away from CRPS like stuff.

Regarding the shoulder nerve blocks, you could probably block or stim both nerves. I prefer to figure out the least invasive option to get relief and minimize iatrogenic injury.

With both, I'd worry about spanning a joint as although they're better than conventional SCS systems, they're still a wire made of metal. I haven't handled Stimwave's peripheral lead, but Stimrouter's seems less likely to break/is more flexible.

Stimrouter recommends specifically against joint spanning due to migration issues as it really isn't anchored per se but rather scars in it seems. You also have to plan that patch positioning if you're going to use multiples, though supposedly you can sometimes run a few leads off one patch/unit.

Either way, they're both better options though for peripheral than the old stuff which is basically just guaranteeing you a lead revision due to fracture/migration.

Great post.

I am going to go with Bioness as I think my hospital will not like the price tag on Stimwave at all.

Can you comment on how you tunnel the suprascapular lead typically with Bioness in terms of the route you take and where you have them place the adhesive patch? This seems to be the most tricky part.

Also, when you are talking about spanning a joint...what do you mean more specifically? The issue is simply that there is one lead anterior to and one lead posterior to the joint? How is that going to increase risk of lead fracture necessarily?

 

[Timeoutofmind]

I've done a post-stroke shoulder with Bioness so far and am scheduling another. They and some of their paid faculty do tell me that getting the axillary as it wraps around the humerus at the level of the posterior circumflex humeral artery does help shoulder pain, and for some folks more so than a suprascapular nerve intervention.

I think the diagnostic pathway I would set is suprascapular nerve and axillary nerve block, and then intervention on the one that provides the most relief/function.

The thing costs like $5k and is easy to put in/take out, so I do think it's a better option before RFing or neurolysing, even if it fails.

The insurance approval thing wasn't hard as it is FDA approved for peripheral nerve stimulation and it's not 20-30K like a conventional SCS.

I like the idea very much of blocking the two different nerves as a diagnostic pathway.

When you are blocking the axillary nerve at the level of the humerus/posterior circumflex humeral artery are you using ultrasound? This is not how I have blocked the nerve peri-operatively...Do you have any ultrasound pics you could share?

Sounds like with both the suprascapular and the axillary you are taking more of a perpendicular approach (versus parallel) to the nerve...has that been an issue for you with getting good coverage?

 

[epidural man]

Orin,

Do the barbs cause problems when they need to be removed? What if one of those little guys grabs the nerve when you tug on it to pull it out?

 

[Orin]

Ultrasound guidance with stim, though I'm told you could do it with just landmarks or fluoro. I really suck as taking pictures to put up on things, so here's Google results.

Axillary Nerve Stimulation for Post-Stroke Shoulder Pain | 18th Annual Meeting of the North American Neuromodulation Society
The Axillary Nerve

Basically they recommend finding the small circumflex artery and following it medial into that posterior axillary fold, to what's defined as the Quadrangular Space. Throughout the procedure, you can stimulate and see if you're close enough to the nerve.

The tunneling is more or less identical to tunneling an epidural catheter, except your goal is to leave the tip of the catheter inside the patient. Supposedly there was going to be an app or something to help with planning out patch positioning, but they can give you a mockup of the lead and you can use ultrasound to map out where your entry point would be, how far it is to the nerve, and then figure out how you're going to tunnel at the end based on your entry point and expected amount of lead left. You can also get patches for the patient to try on, so they can feel the surface stimulation before they move to the implant. It can be TENS like.

For spanning a joint I mean as in crossing over the joint itself. At the end of the day the leads are still mechanical objects with some degree of bend fatigue that'll lead to fracture. That combined with the lack of real bite to their barbs/anchors means if the lead's two end points move a lot with respect to each other, that lead is probably going to break or move out of place faster than one that doesn't get much flexion/pulling/tugging on it. I will say I've got no data for that but it makes sense in my head, and Bioness' folks seem to agree about trying to minimize that relative motion aspect to the leads

The barbs really have trivial mechanical strength. I'm sure they sure could scar into the perineurium or pull on a nerve just like peripheral nerve block catheters can. I did a few trials of pulling it in out on a cadaver which was rather easy. Regardless, for Stimrouter it's a 10 cm wire that I would consider just leaving in unless it's infected or something crazy.

 

[nvrsumr]

is this paid by medicare?