The below article is by guest author Dr. Samir Sheth, board-certified anesthesiologist and interventional pain specialist. Dr. Sheth is also a board member of the Pacific Spine and Pain Society and former Clinical Associate Professor at the University of California – Davis. He is currently with Sutter Health in Roseville, CA.
In the field of pain medicine, we’re faced with a myriad of treatment options to offer our patients. This is especially so with back pain. And for a long time, I — along with many of my colleagues — opted for the more traditional methods like radiofrequency ablation (RFA) and spinal cord stimulation (SCS). Earlier in my career, I spent a lot of time developing and working with spinal cord stimulation, and only began dabbling with short-term peripheral nerve stimulation (PNS) in the past several years. But after a difficult back pain case where I used the SPRINT PNS System, peripheral nerve stimulation became a keen interest of mine and a treatment option I leveraged more and more. In fact, in the last few years, I’ve come to see that the treatments I instinctively went to and that I used to view with a sense of utility, just don’t work for tough-to-treat patients, and in truth, are no longer the right first-step in my pain treatment algorithm.
But before diving into why I believe short-term PNS should be leveraged early on, I want to touch on how I came to this approach.
A Difficult Chronic Back Pain Case Transforms Pain Treatment Approach
Initially SPRINT PNS wasn’t on the list of therapeutic modalities I went to first, but then I had a 35-year-old back pain patient with multiple sclerosis. She was concerned that medial branch RFA denervated the multifidus and its potential consequences. Based on her preferences and on the intensity of her pain, I didn’t feel RFA was a good option.
I had been exploring SPRINT PNS, and after describing the treatment to her, she was interested in trying it. It was my first case using the SPRINT PNS System, and to be honest, I was somewhat skeptical because she had such a high level of pain. After treatment, however, she reported a significantly marked improvement in pain and a decrease in her medication usage. She ended up getting pain relief that endured long after 60-day treatment, for about as long as is typical for many RFA patients.
I continued to use SPRINT PNS for more back pain cases and also for patients that I would have turned away in the past, including older patients (age 80–85) with non-surgical shoulder pain and patients with non-surgical knee pain. Like my first SPRINT PNS patient with chronic back pain, the SPRINT PNS System provided an option for those patients for whom I previously felt I had no treatment options.
Primary Benefits of Choosing SPRINT PNS First and Early
That first case and those that followed highlight the value SPRINT PNS brings to my patients:
- It’s a temporary, non-permanent, non-destructive implant
- It has a good risk/benefit ratio: low risk and high benefit potential
- It has the potential to treat pain for patients who aren’t a good fit for more invasive options like ablation or spinal cord stimulation
- It’s opioid-free and multiple clinical trials have shown it may help patients reduce or eliminate their use of opioids
The Temporary Nature of SPRINT PNS Enables Physician Confidence and Patient Safety
That first patient was a difficult-to-treat case, and SPRINT PNS offered a viable treatment option that was almost non-invasive by interventional pain management standards. And if it didn’t work for that patient, I wasn’t worried because it wasn’t a permanent implant, and it wasn’t going to denervate the nerve.
For those patients in whom SPRINT PNS works, it has helped them avoid or delay invasive, costly procedures such as DRG and SCS implants, or surgery. And even when it doesn’t work for a patient as well as I’d hoped, it has still: (1) allowed me to know I’ve exhausted a nearly non-invasive option for the patient; and (2) given me a clearer idea of what treatments to explore next.
The same cannot be said for RFA. Once a nerve is burned, that is it. And if I implanted a permanent stimulator and it didn’t work, it becomes a more complex situation. But with SPRINT, there isn’t that patient hesitation to consider a permanently implanted device, just a potential for benefits. So, I believe it’s a smart choice for the patient, because even on a small level – providing temporary pain relief, indicating next-steps for further treatment, it is very helpful.
When I look at back at treatments I’ve done over the years, even when I’ve felt the risk is necessitated, I now wonder whether short-term PNS could have been an option for those cases. Could I have avoided some complications by trying SPRINT PNS sooner?
Focusing on Chronic Back Pain: Using SPRINT PNS Before RFA
The results of my first case, and the promise short-term PNS shows for patients who are difficult to treat, encouraged me to continue using it earlier in the care continuum with other chronic back pain patients simply because it is so minimally invasive. I felt very comforted by the fact that I didn’t have to make any incisions. As I mentioned earlier, with RFA you can’t undo the effects of the treatment, but with SPRINT PNS you can.
I also used SPRINT PNS on a patient with neuralgia. They had tried multiple therapies including dorsal root ganglion stimulation and spinal cord stimulation, but those therapies were not effective. So, after performing a few nerve blocks for her, we tried SPRINT PNS. The patient found profound and durable pain relief and saw significant improvements in her quality of life.
Opening the Door for More Complicated Pain Cases
Another place where SPRINT PNS has been a very effective treatment option has been in instances of severe shoulder pain in the elderly population. As shoulder replacements and rotator cuff repairs can be very invasive and often associated with a prolonged and painful recovery, many elderly patients are deemed non-operable. SPRINT PNS has given these patients an option, where previously, the only options came with significant surgical risk.
In fact, I had one patient who was referred to me after being turned away by multiple surgeons. She had severe pain that limited her from her favorite activity — knitting. Because surgery wasn’t a viable option for her, we chose to try SPRINT PNS. We placed a lead at the suprascapular nerve and had excellent results, which helped her achieve pain relief and significant improvements in range of motion. Most important to her, she was able to return to her knitting.
We Don’t Need to Eliminate Treatments but Change the Pain Treatment Approach Mindset
To be clear, my thinking isn’t that we need to get rid of these other pain treatments, and completely replace them with PNS. Rather, it’s more of a push to really advocate for non-destructive, non-permanent and non-surgical treatment options earlier in the algorithm. If we can push for this earlier in the care continuum, I think we have a better chance at creating a more patient-centric approach to pain treatment with broader applications that generally fit well within a patient-preferred paradigm.
A Stepwise Approach to Treating Pain with Short-Term PNS First
The biggest draw for me to including SPRINT PNS earlier in the pain treatment algorithm is that it allows for a stepwise approach to treating pain that doesn’t just jump to invasive and sometimes irreversible procedures.
For example, let’s say I use SPRINT PNS for shoulder pain, and the patient sees a 60 percent improvement in range of motion. In this case, by opting for SPRINT PNS first I’ve avoided major shoulder surgery. This allows me to then ask myself, “Okay is there something malfunctioning in the nerve signals that I should investigate? Should we do a second round of treatment?” The point is that with SPRINT PNS, I can avoid larger, more invasive procedures until I identify them as necessary and take a step-by-step approach that’s likely to be safer for the patient. We should think about the rationale for putting a patient through invasive surgery or using a permanent implant when SPRINT PNS offers a temporary treatment that’s capable of providing sustained relief and the opportunity to assess the potential for PNS.
This is the approach I take with all my patients now. I want to ensure I’m trying the least invasive option first. And if it doesn’t work, we go the next step. And if that doesn’t work, we explore another step.
The Ladder of Pain
As pain physicians, we all should look at the whole patient — their pain, their life, what they need long-term. I think if we can create a ladder formula for pain treatment (and honestly, many of us are already using this), we can reinforce the idea of not jumping to something that’s super invasive and permanent. Recently, in reviewing abstracts for a society meeting, I came across the use of spinal cord stimulation (SCS) for patients who have low back pain but did not have any prior surgeries. While this may be helpful in some patients, I could not help but wonder: How many of these patients were exposed to temporary PNS first prior to a permanent implant? Going forward it makes the most sense to me that we should exhaust temporary PNS first, then advance to a permanently implanted system as necessary.
If we can reinforce this idea of thinking stepwise — create that “ladder of pain” mentality with minimally invasive, temporary options first — and work to increase therapy awareness about available treatments, I think we have a great opportunity to improve the overall pain treatment approach, the health economics, and the long-term results for patients.
Conclusion: Choosing Short-Term First is Always a Smart Move
When I look at the overall pain treatment algorithm, short-term PNS is the right first step in my practice. SPRINT PNS is a treatment option that may work incredibly well alone to provide long-term, sustainable relief, or it may only provide some pain relief and be the first step in a longer treatment plan. In both cases, it’s still a logical and worthwhile first choice.
If it works, you will have opted for a motor-sparing, non-destructive path versus an invasive, costly treatment that may result in denervation and sensory and motor consequences that can impact a patient’s quality of life. In addition, this path allows the treatment to be repeated, as appropriate, before more invasive options are considered. Some patients who would have never considered a permanently implanted system may be inclined to do so after they’ve tasted how good neuromodulation can be.
And if it doesn’t work, you’ll have tried a treatment option that you can go back from with little risk, potential benefits, and now can learn from and determine the next best step in treatment.
And especially when it comes to chronic back pain, choosing to leverage short-term PNS early has the potential to shift the pain management paradigm because it may provide patients with a potentially effective, minimally-invasive, nondestructive, non-opioid and motor-sparring treatment. And at the end of the day, if this allows us to find lower-risk solutions to pain, even better.
About Dr. Samir Sheth
Dr. Samir Sheth is board certified in Anesthesiology and Pain Medicine and has been practicing in Northern California for more than 10 years. He is active in the Pacific Spine and Pain Society (PSPS), Spine Intervention Society (SIS), North American Neuromodulation Society (NANS) and International Neuromodulation Society (INS), and he has an active interest in patient-centric approaches to medicine and also to ensuring proper use of therapies via careful patient selection and therapy education. Dr. Sheth believes in the use of a multimodal approach to pain management and hopes to focus outcomes on quality of life, patient satisfaction, and functional improvement. Dr. Sheth is also a proud father of two boys.