1. Future Medical Cost Projections
Module 3
Common Treatments, Part 1

2. 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
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Common Treatments
Medical
Injections
Spinal cord stimulator
Pain Pump
Medications
Laboratory
Diagnostics
Surgery
Therapy
Equipment
Physician
Home Care
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Injections
Trigger point
Epidural steroid
Facet
Rhizotomy
Stellate ganglion
Botox
Joint
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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
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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
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Facet
Common area is lumbar spine
Medication either/or both an anesthetic and a corticosteroid
Unless otherwise indicated, allow for 1 injection annually
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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
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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
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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
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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
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12. Spinal Cord Stimulator
Indications
Contraindications
Components
Placement
Complications
Cost
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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
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Contraindications
Spinal cord injuries
Malignancies
Psychological intolerance
Major psychiatric disorders, including somatization
Pacemaker
Incompetency
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Components
Neurostimulator (battery)
Leads
Programmers
Common suppliers
St. Jude
Boston
Medtronic
Note: new type called a pulse generator available now (Dec, 2016)
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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)
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Complications
Breakage
Lead migration
ineffectiveness
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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
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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
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Contact Information
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