NANS 2023 -- Evolving Situation

[lobelsteve]

DRG-S is not for everyone. I mean both patients and docs. But it absolutely is indicated for the crps patient in the right hands. Follow the evidence…

So right hand only? Pretty sure it is only groin to foot.

The Proclaim™ DRG Neurostimulator System treats chronic pain in the foot, knee, or groin in patients with Complex Regional Pain Syndrome (CRPS).1 Best evidence from Deer and Levy (Tim and Bob). Tainted.

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[Espn123]

So right hand only? Pretty sure it is only groin to foot.

The Proclaim™ DRG Neurostimulator System treats chronic pain in the foot, knee, or groin in patients with Complex Regional Pain Syndrome (CRPS).1 Best evidence from Deer and Levy (Tim and Bob). Tainted.

I’m pretty sure you were joking on the first part. But there are docs reading this who bash drg who didn’t know you were joking….

There are industry biased studies yes, but there are also dozens of smaller studies done by independent physicians that continue to show it works for knees, groins, feet.

I can tell you that it’s 5% of all my neuromod, but those 5% in general do better than the other 95%. N=1, take it with several grains of salt.

 

[lobelsteve]

I’m pretty sure you were joking on the first part. But there are docs reading this who bash drg who didn’t know you were joking….

There are industry biased studies yes, but there are also dozens of smaller studies done by independent physicians that continue to show it works for knees, groins, feet.

I can tell you that it’s 5% of all my neuromod, but those 5% in general do better than the other 95%. N=1, take it with several grains of salt.

Unless you do DRG, you do not know how much harder it is to do the trial and implant as compared to conventional SCS. Going to a course then trying it on your own is not as simple as switching from MDT to Abbott to Nevro. Entirely different skill set. Different anchoring, different entry position and angles. That ligament preventing exit out of epidural space and into foramen. I have only done a handful. Working for those folks. But easily 2x as long as a Nevro implant.

 

[Espn123]

Unless you do DRG, you do not know how much harder it is to do the trial and implant as compared to conventional SCS. Going to a course then trying it on your own is not as simple as switching from MDT to Abbott to Nevro. Entirely different skill set. Different anchoring, different entry position and angles. That ligament preventing exit out of epidural space and into foramen. I have only done a handful. Working for those folks. But easily 2x as long as a Nevro implant.

All of these are excellent points. And valid. For the drg implanter who has done over 50 cases it takes about the same as SCS.

BUT this takes time and a learning curve.

May I ask what was the reason you chose DRG for those handful of patients over SCS?

 

[lobelsteve]

All of these are excellent points. And valid. For the drg implanter who has done over 50 cases it takes about the same as SCS.

BUT this takes time and a learning curve.

May I ask what was the reason you chose DRG for those handful of patients over SCS?

Sent to me for these cases. One trial, one de novo implant, 3 revisions.

 

[BobBarker]

But what if the patient has crps in the left hands?

 

[MitchLevi]

You'll revise a lot of these cases. They migrate frequently despite the BS Abbott reps will tell you. I've had a few legitimately insane conversations regarding DRG. I'm trained to do it (2018) and I've done 1 case. Unlikely I'm going to keep doing them.

 

[Ducttape]

DRG-S is not for everyone. I mean both patients and docs. But it absolutely is indicated for the crps patient in the right hands. Follow the evidence…

um.... can you post the evidence?

I’m pretty sure you were joking on the first part. But there are docs reading this who bash drg who didn’t know you were joking….

There are industry biased studies yes, but there are also dozens of smaller studies done by independent physicians that continue to show it works for knees, groins, feet.

I can tell you that it’s 5% of all my neuromod, but those 5% in general do better than the other 95%. N=1, take it with several grains of salt.

please post.

fyi i did look in pubmed but the only real study i see is Deer's ACCURATE study.

 

[Agast]

I haven’t had any DRG migrations yet *knock on wood*

 

[drusso]

...design me a DRG lead you place transforaminally and you will own the world...

Relief Simplified | Neuronoff

The Injectrode® Platform aims to provide chronic pain patients with an easy way to get relief without drugs or invasive surgeries.

www.neuronoff.com

 

[Espn123]

You'll revise a lot of these cases. They migrate frequently despite the BS Abbott reps will tell you. I've had a few legitimately insane conversations regarding DRG. I'm trained to do it (2018) and I've done 1 case. Unlikely I'm going to keep um.... can you post the evidence?

please post.

fyi i did look in pubmed but the only real study i see is Deer's ACCURATE study.

this is a 2022 review of the literature on drg. There is one RCT and 39 observational studies, of course varying in power and quality. There are also more basic science publications about drg stimulation when compared to some other new things in our field. Opinion only.

D'Souza RS, Kubrova E, Her YF, Barman RA, Smith BJ, Alvarez GM, West TE, Abd-Elsayed A. Dorsal Root Ganglion Stimulation for Lower Extremity Neuropathic Pain Syndromes: An Evidence-Based Literature Review. Adv Ther. 2022 Oct;39(10):4440-4473. doi: 10.1007/s12325-022-02244-9. Epub 2022 Aug 22. PMID: 35994195; PMCID: PMC9464732.

 

[Baron Samedi]

this is a 2022 review of the literature on drg. There is one RCT and 39 observational studies, of course varying in power and quality. There are also more basic science publications about drg stimulation when compared to some other new things in our field. Opinion only.

Okay but PRP is about $500 and DRG is about $150000.

 

[Espn123]

Okay but PRP is about $500 and DRG is about $150000.

I’m lost

 

[Ducttape]

All of these are excellent points. And valid. For the drg implanter who has done over 50 cases it takes about the same as SCS.

BUT this takes time and a learning curve.

May I ask what was the reason you chose DRG for those handful of patients over SCS?

i do not do DRG.

fwiw, however, the biggest implanter in the area, that i would send CRPS referrals specifically for DRG, has flatly refused to do any more, for the aforementioned reason - too many side effects, and too little additional benefit over traditional stim. has told me to just do traditional stim myself.

this is a 2022 review of the literature on drg. There is one RCT and 39 observational studies, of course varying in power and quality. There are also more basic science publications about drg stimulation when compared to some other new things in our field. Opinion only.

D'Souza RS, Kubrova E, Her YF, Barman RA, Smith BJ, Alvarez GM, West TE, Abd-Elsayed A. Dorsal Root Ganglion Stimulation for Lower Extremity Neuropathic Pain Syndromes: An Evidence-Based Literature Review. Adv Ther. 2022 Oct;39(10):4440-4473. doi: 10.1007/s12325-022-02244-9. Epub 2022 Aug 22. PMID: 35994195; PMCID: PMC9464732.

um.... thats a review article - and the one study was one done by interventional spine doctors comparing DRG to traditional stim.

you did not list or comment about any of the observational studies, just made a poitn that was direct from the article.


really not adequate....


fyi link to the one RCT that this is all based on:

Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial - PubMed

Animal and human studies indicate that electrical stimulation of dorsal root ganglion (DRG) neurons may modulate neuropathic pain signals. ACCURATE, a pivotal, prospective, multicenter, randomized comparative effectiveness trial, was conducted in 152 subjects diagnosed with complex regional pain...

pubmed.ncbi.nlm.nih.gov

for completeness, they provided this statement:

Conflict of interest statement​

All authors were paid by Spinal Modulation & St Jude Medical as investigators for the clinical trial. T. R. Deer is a consultant for Axonics, Bioness, Flowonix, Medtronic, Jazz, Nevro, St. Jude, and Saluda and has consulting or equity for Axonics and Bioness. T. R. Deer formerly had equity in Spinal Modulation and Nevro. R. M. Levy has served as a consultant for Bioness, BlueWind Medical, Boston Scientific, Flowonix, Medtronic, Microtransponder, Nevro, Saluda, Spinal Modulation, and St Jude Medical. R. M. Levy is or has been a minority shareholder in Saluda, Spinal Modulation, Bioness, Vertos, and Nevro. N. Mekhail formerly had a consultation agreement with spinal modulation to serve as medical monitor of the ACCURATE study. Currently, he is a consultant for St Jude Medical, Saluda medical, Stimwave, Medtronic neurological, and Flowonix inc. K. Amirdelfan is a consultant for St. Jude Medical, Nevro, Saluda, Nalu, and Biotronik. J. Pope is a consultant for Medtronic, NEVRO, St Jude, Flowonix, Jazz Pharmaceuticals, and Suture Concepts. T. Yearwood is a consultant for St Jude Medical, Boston Scientific, Nevro, Flowonix, and Neuronano; he serves as an officer for Meghan Medical. W. P. McRoberts serves or has served as a consultant for St Jude Medical, Medtronic, Nevro, Boston Scientific, Bioness, Vertiflex, and SPR. T. Davis has conducted research for Spinal Modulation, Vertiflex, Medtronic, Axsome, Nature Cell, and Halyard Health; has received fees for consulting, education, or speaking from St Jude Medical, Medtronic Restorative Therapies, Stryker, Vertiflex, DrChrono, and Tenex Health; and has ownership interests in Paradigm Spine <1%, LDR Holdings <1%, Alpha Diagnostics Neuromonitoring, and Broadway Surgical Institute. J. Scowcroft has served as a consultant for Boston Scientific. L. Kapural is a consultant for St Jude Medical, Nevro, Neuros, SPR Therapeutics, and Saluda. R. Paicius is a consultant for St Jude Medical, Nevro, and Boston Scientific. J. Kramer, Burton, Johnson, and Kristina Davis are employees of St. Jude Medical. The remaining authors have no conflicts of interest to declare.

This study was sponsored by Spinal Modulation, LLC, a wholly owned company of St. Jude Medical.

and 2016, the year before the study came out, was the year Deer made $275k x 4 times, as his highest grossing year listed on propublica... Levy got $127k x4 in 2016...

St Jude "contributed" a lot of money to get this study published...

 

[bedrock]

i do not do DRG.

fwiw, however, the biggest implanter in the area, that i would send CRPS referrals specifically for DRG, has flatly refused to do any more, for the aforementioned reason - too many side effects, and too little additional benefit over traditional stim. has told me to just do traditional stim myself.

um.... thats a review article - and the one study was one done by interventional spine doctors comparing DRG to traditional stim.

you did not list or comment about any of the observational studies, just made a poitn that was direct from the article.


really not adequate....


fyi link to the one RCT that this is all based on:

Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial - PubMed

Animal and human studies indicate that electrical stimulation of dorsal root ganglion (DRG) neurons may modulate neuropathic pain signals. ACCURATE, a pivotal, prospective, multicenter, randomized comparative effectiveness trial, was conducted in 152 subjects diagnosed with complex regional pain...

pubmed.ncbi.nlm.nih.gov

for completeness, they provided this statement:



and 2016, the year before the study came out, was the year Deer made $275k x 4 times, as his highest grossing year listed on propublica... Levy got $127k x4 in 2016...

St Jude "contributed" a lot of money to get this study published...

Interesting that your experienced implanter refuses further DRG

 

[Espn123]

i do not do DRG.

fwiw, however, the biggest implanter in the area, that i would send CRPS referrals specifically for DRG, has flatly refused to do any more, for the aforementioned reason - too many side effects, and too little additional benefit over traditional stim. has told me to just do traditional stim myself.

um.... thats a review article - and the one study was one done by interventional spine doctors comparing DRG to traditional stim.

you did not list or comment about any of the observational studies, just made a poitn that was direct from the article.


really not adequate....


fyi link to the one RCT that this is all based on:

Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial - PubMed

Animal and human studies indicate that electrical stimulation of dorsal root ganglion (DRG) neurons may modulate neuropathic pain signals. ACCURATE, a pivotal, prospective, multicenter, randomized comparative effectiveness trial, was conducted in 152 subjects diagnosed with complex regional pain...

pubmed.ncbi.nlm.nih.gov

for completeness, they provided this statement:



and 2016, the year before the study came out, was the year Deer made $275k x 4 times, as his highest grossing year listed on propublica... Levy got $127k x4 in 2016...

St Jude "contributed" a lot of money to get this study published...

This was a review article, which “reviews” the published evidence.

If you are looking for multiple prospective RCTs about anything we do, you are looking in the wrong field…

i do not do DRG.

fwiw, however, the biggest implanter in the area, that i would send CRPS referrals specifically for DRG, has flatly refused to do any more, for the aforementioned reason - too many side effects, and too little additional benefit over traditional stim. has told me to just do traditional stim myself.

um.... thats a review article - and the one study was one done by interventional spine doctors comparing DRG to traditional stim.

you did not list or comment about any of the observational studies, just made a poitn that was direct from the article.


really not adequate....


fyi link to the one RCT that this is all based on:

Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial - PubMed

Animal and human studies indicate that electrical stimulation of dorsal root ganglion (DRG) neurons may modulate neuropathic pain signals. ACCURATE, a pivotal, prospective, multicenter, randomized comparative effectiveness trial, was conducted in 152 subjects diagnosed with complex regional pain...

pubmed.ncbi.nlm.nih.gov

for completeness, they provided this statement:



and 2016, the year before the study came out, was the year Deer made $275k x 4 times, as his highest grossing year listed on propublica... Levy got $127k x4 in 2016...

St Jude "contributed" a lot of money to get this study published...

An RCT and 39 small peer reviewed studies is nearly as good as it gets in this field of neuromodulation.

What is your impression of the published evidence for your most common scs system and specific indications?

 

[epidural man]

...design me a DRG lead you place transforaminally and you will own the world...

Relief Simplified | Neuronoff

The Injectrode® Platform aims to provide chronic pain patients with an easy way to get relief without drugs or invasive surgeries.

www.neuronoff.com

View attachment 364935

Stimwave has always taught that you can place their lead transforaminally.

I never tried it however.

 

[GoBeers]

Stimwave has always taught that you can place their lead transforaminally.

I never tried it however.

i've always thought the stimwave approach made equal sense. when i brought this technique up to abbot, the reps just shrug their shoulders and say "that approach wasn't studied and therefore not indicated"

 

[Ducttape]

This was a review article, which “reviews” the published evidence.

If you are looking for multiple prospective RCTs about anything we do, you are looking in the wrong field…


An RCT and 39 small peer reviewed studies is nearly as good as it gets in this field of neuromodulation.

What is your impression of the published evidence for your most common scs system and specific indications?

first, that amount of "evidence" really means there is insufficient evidence.

What is your impression of the published evidence for your most common scs system and specific indications?

logical fallacy. diversionary at best. discussion has nothing to do with what evidence i use, but whether DRG has evidence to justify its use.

we need to do better.

 

[Espn123]

first, that amount of "evidence" really means there is insufficient evidence.




logical fallacy. diversionary at best. discussion has nothing to do with what evidence i use, but whether DRG has evidence to justify its use.

we need to do better.

first, that amount of "evidence" really means there is insufficient evidence.




logical fallacy. diversionary at best. discussion has nothing to do with what evidence i use, but whether DRG has evidence to justify its use.

we need to do better.

In a perfect world there would be multiple RCTs about everything we do. There’s not.

So my diversionary question remains. If you feel there isn’t enough evidence for this, do you think there’s enough for your system of choice?

 

[Ducttape]

my impression is that there is fair evidence for neuromodulation for failed back syndrome.

i alternate between St Jude and Medtronic for radicular pain, and Nevro for HF10 more for axial symptoms.

not a big fan of Boston Scientific marketing practices so i have chosen not to use.

 

[Espn123]

In

my impression is that there is fair evidence for neuromodulation for failed back syndrome.

i alternate between St Jude and Medtronic for radicular pain, and Nevro for HF10 more for axial symptoms.

not a big fan of Boston Scientific marketing practices so i have chosen not to use.

my opinion, these are very similar strengths of evidence compared to drg

 

[MitchLevi]

This tiny new Abbott battery that's rarely charged and offers both tonic and burst sounds promising.

Implant times with that little battery will be far shorter.

I simply do not get the same outcomes with Nevro that I read about in Senza.

I have a few pts that are SCS grand slams that have completely and utterly failed Nevro.

Like, post laminectomy one leg isolated L5 dermatome.

Would they have failed Abbott? Who knows...

 

[Taus]

This tiny new Abbott battery that's rarely charged and offers both tonic and burst sounds promising.

Implant times with that little battery will be far shorter.

I simply do not get the same outcomes with Nevro that I read about in Senza.

I have a few pts that are SCS grand slams that have completely and utterly failed Nevro.

Like, post laminectomy one leg isolated L5 dermatome.

Would they have failed Abbott? Who knows...

Did my first Abbott trial in a long time this week. Steers dramatically better compared to Nevro imo. Saw their new battery as well… Impressively tiny.

 

[SpineandWine]

my impression is that there is fair evidence for neuromodulation for failed back syndrome.

i alternate between St Jude and Medtronic for radicular pain, and Nevro for HF10 more for axial symptoms.

not a big fan of Boston Scientific marketing practices so i have chosen not to use.

What’s wrong with Boston scientific marketing practice?

 

[MitchLevi]

What’s wrong with Boston scientific marketing practice?

BSc has been dramatically less intrusive and annoying than all over device reps in my area. Not even close.

They're also far less expensive, so if you're an ASC owner take notice.

 

[Ducttape]

the most glaring example for me is that they are the company that changed the way we used to charge for stims by putting out 32 contact leads.

 

[buddababa]

the most glaring example for me is that they are the company that changed the way we used to charge for stims by putting out 32 contact leads.

there's no difference in how we charge - same cpt code for all.

 

[lobelsteve]

there's no difference in how we charge - same cpt code for all.

L8680 for the ASC/HOPD. Pure money maker.

 

[Ducttape]

there's no difference in how we charge - same cpt code for all.

yes... previously it was by contact. could technically charge more for placing 1 lead.

https://forums.studentdoctor.net/threads/shady-boston-sci-scs-in-wilmington-nc.968347/post-14483169

Fluoro and US billing

I own both my fluoro and US unit. My procedures are done in my office (non-facility) but for some reason I can't get reimbursed for image guidance unless I use modifier 26. However, 26 is only the pro fee and I own these machines so I should be reimbursed the global fee to include both 26 and...

forums.studentdoctor.net

 

[buddababa]

weird, in my hospital facility, if we use their 8 contact lead or 16 contact lead, price is same

• Outpatient hospitals must use C codes when reporting devices to Medicare. In a hospital outpatient setting, a neurostimulator lead is reported using C1778 Lead, neurostimulator (implantable). This HCPCS Level II code is reported and reimbursed per lead (array), rather than per electrode (contact point).

 

[Ducttape]

yes it is now.

it was not back in 2013. and it is a lot less reimbursement than pre 2013 per stim trial.

 

[buddababa]

yes it is now.

it was not back in 2013. and it is a lot less reimbursement than pre 2013 per stim trial.

Ah okay.

 

[Bostonspine]

BSc has been dramatically less intrusive and annoying than all over device reps in my area. Not even close.

They're also far less expensive, so if you're an ASC owner take notice.

That may be specific to your contract and area… we have a better deal with metronics and Abbott. We don’t carry Boston because they price gorge so much it creates a loss(they want to charge Hospital prices with ASC reimbursement)

 

[gaseous_clay]

All vendor contracts are region specific.

 

[gaseous_clay]

L8680 for the ASC/HOPD. Pure money maker.

Sole reason Boston came out with that 16-contact lead.