Future Medical Cost Projections Module 3 Common Treatments, Part 1

Common Treatment Modalities Overview Discusses common treatment modalities for injections and spinal cord stimulator Objectives Be able to discuss spinal cord stimulator algorithm Be able to list at least 3 categories of injections Copyright InSitu Academy

Copyright InSitu Academy Common Treatments Medical Injections Spinal cord stimulator Pain Pump Medications Laboratory Diagnostics Surgery Therapy Equipment Physician Home Care Copyright InSitu Academy

Copyright InSitu Academy Injections Trigger point Epidural steroid Facet Rhizotomy Stellate ganglion Botox Joint Copyright InSitu Academy

Copyright InSitu Academy Trigger Point Used for acute or chronic pain Trigger points are focal areas of spasm and inflammation in skeletal muscle Common site is rhomboid and trapezius in the back Extremities less common areas Typical allowance: 1 set per year, unless otherwise indicated Copyright InSitu Academy

Copyright InSitu Academy Epidural Steroid Lumbar or cervical spine most common Thoracic less common Usually done in series of 3 Some physicians recommend up to 3 per year lifelong Excessive steroid use may result in ophthalmological issues Consider evaluation by ophthalmologist if excessive ESI recommended Done under fluoroscopy Upcharges frequently added for supplies, additional personnel, equipment Copyright InSitu Academy

Copyright InSitu Academy Facet Common area is lumbar spine Medication either/or both an anesthetic and a corticosteroid Unless otherwise indicated, allow for 1 injection annually Copyright InSitu Academy

Copyright InSitu Academy Rhizotomy Radiofrequency ablation or RFA Burns nerve endings that cause back pain and radicular pain Nerve endings regenerate within 6 months to 2 years, requiring additional ablation treatments Medial branch blocks prior to procedure First set of blocks are diagnostic to determine appropriate placement Second set of blocks are therapeutic to determine (chemically) if disruption of nerve ending will lessen or eliminate pain Allowance for cost projection, 1 per year unless otherwise indicated, may consider 3-4 lifetime due to scar buildup Copyright InSitu Academy

Copyright InSitu Academy Stellate Ganglion Sympathetic nerve block Local anesthetic in neck Useful in RSD/CRPS and phantom limb pain May cause eyelid droopiness Frequency to be determined Not a common procedure Copyright InSitu Academy

Copyright InSitu Academy Botox Used for spasticity, primarily in spinal cord or significant brain injury cases Also used in neuromuscular disorders, such as cerebral palsy Dosage calculated per body weight Cost calculated per dose Can be performed every 3 months Some PMR physicians use a combination of Botox and oral baclofen Limited use of botox due to secondary conditions and complications Copyright InSitu Academy

Copyright InSitu Academy Joint Cortisone injection into any major joint Common locations are shoulders, knees, SI joint, hip Less common are elbows, wrists, ankles Typical allowance is for 2 in lifetime Consider long term steroid use and implications, same as for ESI Joint drainage often performed at same time as injection Usually done under fluoroscopy Copyright InSitu Academy

Spinal Cord Stimulator Indications Contraindications Components Placement Complications Cost Copyright InSitu Academy

Copyright InSitu Academy Indications Failed back syndrome Radicular pain Post-laminectomy pain Multiple back surgery Degenerative disc disease Complex Regional Pain Syndrome Significant chronic pain Controls neuropathic pain only No effect on nociceptive pain Copyright InSitu Academy

Copyright InSitu Academy Contraindications Spinal cord injuries Malignancies Psychological intolerance Major psychiatric disorders, including somatization Pacemaker Incompetency Copyright InSitu Academy

Copyright InSitu Academy Components Neurostimulator (battery) Leads Programmers Common suppliers St. Jude Boston Medtronic Note: new type called a pulse generator available now (Dec, 2016) Copyright InSitu Academy

Copyright InSitu Academy Placement Psychological evaluation required prior to trial placement Trial placement Can patient tolerate device Is device effective Often done in office surgical suite Permanent placement Percutaneous Paddle placement Done in hospital outpatient setting Replacement of unit every 9-10 years (battery) Copyright InSitu Academy

Copyright InSitu Academy Complications Breakage Lead migration ineffectiveness Copyright InSitu Academy

Copyright InSitu Academy Costs Exorbitant expense Medicare capped pricing Trial placement typically $6-10,000 Permanent placement can be over $100,000 Annual maintenance costs Breakage and other complications are added expenses Our cost projections reflect a very conservative estimate, based on lifelong use: countering reality of usual 1-2 replacements only Copyright InSitu Academy

Copyright InSitu Academy Homework Research types/suppliers of spinal cord stimulators, download information, retain in records Establish a relationship with a local pain management specialist, arrange for a conference to discuss various pain management modalities including interventional injection therapy, medications, behavioral modification techniques Copyright InSitu Academy

Copyright InSitu Academy Contact Information info@insitutraining.com Copyright InSitu Academy