I see this a lot
Someone has had a back surgery, still has radicular pain
Formaminal stenosis on MRI (moderate or severe lets say), at a different level
Does not want anymore back surgery, period.
No weakness
Has failed injections, antineuropathic meds.
I typically do not offer SCS. It just seems like the indicated procedure is a nerve decompression, so that is what they should get, not an SCS which is just going to mask the pain. And I dont even know how good SCS is at masking pain in the face of an ongoing compressive lesion.
Its one thing if they have seen a surgeon and he says its going to be some big risky revision etc, but a lot of the time they wont even see a surgeon, as they are not interested
What do you think?
This is what I tell people. "That's fine if you don't want to see a surgeon. You don't have to. But if you're asking to get a spinal cord stimulator, you're going to end up seeing a 'surgeon'
(whether that's you, or an outside implanting surgeon, is irrelevant) and we need a surgeon's opinion as to whether we can cure this and have other better options, or not. If not, then fine. We can also see if he thinks the stimulator is a better idea. But either way, you at least need to get that evaluation before we commit to going down the stimulator pathway. You don't have to commit to full blown fusion, or any other open back surgery necessarily, just because you get a consultation. But we at least need to get a spine/neurosurgeon's opinion, so we know what our full range of options are."
Most patient's are okay with that. If they insist on being unreasonable, and won't take the steps you need to determine if the stimulator is the best option or not, then they're not a good candidate for a stimulator.
A Pain MD who implants horrible candidates for stimulators, ends up poisoning the well and ruins the reputation of us all and our treatments. We have a guy like this in my town, and it's tough to get anyone to agree to a stim anymore, because this one guy has inappropriately implanted so damn many over the years that haven't panned out, or required explantation, that the treatment has a reputation in town of being a crappy one. All because of this one guy.
But as to your bigger question, which is, "Will a stimulator help radicular pain if there's an untreated compression or not?"
That all depends on whether they're a surgical candidate or not. If they are, and they have a shot at a legitimate cure (which will only be 50% of the time, of course) and reasonably performed surgery, then it's not the best option. If they truly don't, and they truly are not a candidate for curative surgery, then if it was my back, I'd rather have a stimulator than live with a compressed nerve root and nothing but a bunch of crappy medication options. A stim at least gives you a chance to block that pain signal some, if you can't eliminate it completely. But you need a good surgeon you trust, to give you an honest opinion on the appropriateness of surgery. Not a hack who cuts everything that moves. And not a guy who refuses to operate unless it's a 6 inch putt.
