Dr. Gemayel Lee discusses how he uses the SPRINT® PNS System to help shoulder pain patients get back to enjoying an improved quality of life
Shoulder pain is one of the most common musculoskeletal complaints in the U.S. But effective non-opioid treatment options have been limited for non-surgical patients and patients with persistent post-surgical pain — until now. Board-certified interventional pain specialist at Relive You Center for Advanced Pain Management and SPR consultant, Dr. Gemayel Lee, shares how the SPRINT PNS System has expanded his treatment approach to shoulder pain with a clinically proven, durable and drug-free option.
What makes the SPRINT PNS system appealing for the treatment of shoulder pain?
If a patient has significant shoulder pain and functional limitations, their quality of life is suboptimal — they have difficulty sleeping, brushing their teeth, carrying their grandchildren, etc. With SPRINT PNS, we’re able to improve their neuropathic pain, and, in our experience, are very often seeing significantly improved physical function. These improvements have a significant positive impact on our patients’ lives.
What are the main causes of shoulder pain in your patient population?
Typically, patients arrive in our practice with their pain resulting from the fairly normal degenerative process of the shoulder joint. We see some patients early in this process and others after they’ve tried multiple treatments. We also have a few post-surgical patients who have persistent pain post-arthroscopic or joint replacement procedure despite the success of the surgery, due to the neuropathic nature of their pain.
What treatment options are available to address chronic shoulder pain?
The majority of the shoulder patients we see will have already pursued conservative treatments like activity modification, physical therapy and medications. They may have also had corticosteroid injections from their referring physician. When these treatments fail, our main options are regenerative therapies, neuromodulation or surgery.
At what point do you consider neuromodulation for shoulder pain?
Neuromodulation comes into play for patients who have tried to reduce inflammation or regenerate the pathology of the shoulder and are still having persistent neuropathic pain. The goal with neuromodulation is essentially to find the nerve that’s sending the pain signal — typically with a small volume local anesthetic nerve block — and then turn it down, turn it off, kill it or turn it to a different channel, so to speak.
Which neuromodulation approaches have you utilized to treat shoulder pain?
Historically for our clinic, our first choice for treatment of shoulder pain with neuromodulation was pulsed radiofrequency (PRF) ablation of either the suprascapular nerve or the axillary nerve — the two major nerves that provide the innervation to the shoulder joint. But similar to regenerative therapies, PRF is not always covered by insurance. If that’s the case, we have often turned to thermal radiofrequency ablation (RFA) which is a more commonly covered procedure.
However, in addition to sending pain signals, the axillary nerve and the suprascapular nerve also control muscle function. For the majority of patients, we now try to avoid RFA of a nerve that has motor function to avoid potentially healthy tissue damage— particularly for those of an important joint like the shoulder. This is when we typically start looking at neuromodulation with spinal cord stimulation (SCS) or peripheral nerve stimulation (PNS).
At what point do you recommend your patients consider the use of the SPRINT PNS System?
While PRF was historically one of our early-stage therapies, SPRINT PNS completely changed our treatment algorithm. Now we discuss SPRINT PNS very early in our care continuum and while results may vary, it has an excellent safety profile. It’s non-destructive, non-permanent, non-steroidal and non-opiate and is backed by significant supporting evidence. Fortunately, SPRINT PNS is covered by many of the payers in our market including Medicare, which has a national coverage determination (NCD) in place.
What nerve(s) do you target when using SPRINT PNS to address shoulder pain?
We’ve had great success with the suprascapular nerve. This nerve provides significant conduction of the pain signal from the shoulder joint. If a patient has persistent shoulder pain and, as a result, functional limitations or decreased range of motion, we’ll do a small volume diagnostic suprascapular nerve block, and sometimes will include a small volume diagnostic axillary nerve block if we may potentially include the axillary nerve as a second target for PNS.
Why do you consider targeting both the suprascapular and axillary nerves with SPRINT?
Because SPRINT supports Bimodal PNS® modality, we can use a dual lead approach to target both the suprascapular and axillary nerves at two different stimulation frequencies — delivering both sensory and motor stimulation.
For the suprascapular nerve, I typically use sensory stimulation at 96 Hz. Depending on the pathology of the axillary nerve, if motor function is relatively compromised, I’ll typically use 12 Hz motor stimulation. Alternatively, I may use 96Hz for the axillary nerve for neuropathic pain with normal motor function (range of motion). This dual approach allows us to target the neuropathic condition from multiple different angles, providing more coverage of the shoulder area to send more healthy signals to both motor and sensory nerve fibers. This offers the potential to address multiple etiologies of underlying pain by engaging multiple mechanisms.
What type of imaging are you using to guide the placement of the SPRINT PNS MicroLead?
Fluoroscopy can be a good modality to use for lead placement, especially for physicians who may not have experience or significant comfort with ultrasound. For those new to placing SPRINT, targeting the suprascapular nerve, I often recommend starting by going inferior to the scapular spine, staying above the protection of the scapula, and staying above the periosteum and going just until they can visualize the posterior spinoglenoid notch, which is the exit of the inferior division of the suprascapular nerve. For the axillary nerve, anatomical landmarks can be used when targeting the terminal branches of the axillary nerve at the deltoid. The stimulating probe can be inserted approximately three finger widths or 6cm below the acromion.
Ultrasound guidance is also an excellent option for lead placements targeting the suprascapular and/or axillary nerves because it gives multiple opportunities to see the nerve and finetune placement. After I position the lead, I turn on the device to confirm that the patient can feel comfortable sensations in more than 50% of the painful area.
How are you assessing pain relief and functional improvement with SPRINT PNS?
For our PNS patients, we do multiple different functional assessments, including the Oswestry Disability Index (ODI) and Shoulder Pain and Disability Index (SPADI). Our patients are consistently reporting not just reduced neuropathic pain, but also sustained improved physical function within the first couple of weeks.
After the 60-day SPRINT PNS treatment ends, we continue to track patients’ neuropathic pain and functional scores at regular intervals for two years. We also encourage them to follow up with their surgeon and referral network. And that’s really increased interest in SPRINT PNS with our referral partners.
How are shoulder patients referred to your clinic? What type of referral sources are you experiencing?
At first, patients were typically referred from their primary care physician or a small network of orthopedic surgical colleagues. Now after three years of great results with SPRINT PNS, we’re getting a lot of referrals from orthopedic surgeons who don’t have good surgical options for a patient and are interested in seeing what SPRINT PNS can do to improve their patients’ daily experience and overall quality of life.
Patients are also investigating on their own. They’re interested in neuromodulation, so they do an Internet search, see our Google reviews, and reach out directly to us. We receive a significant number of cold calls specifically for this wonderful therapy. SPRINT PNS really has been a game-changing addition to our shoulder pain treatment toolkit.
For more information, view SPR Therapeutics’ shoulder pain data for SPRINT PNS. Or call SPR at 844.378.9108 to learn how to expand your approach to shoulder pain.
The SPRINT PNS System is indicated for up to 60 days for: (i) Symptomatic relief of chronic, intractable pain, post-surgical and post-traumatic acute pain; (ii) Symptomatic relief of post-traumatic pain; and (iii) Symptomatic relief of post-operative pain. The SPRINT PNS System is not intended to be placed in the region innervated by the cranial and facial nerves.
Physicians should use their best judgment when deciding when to use the SPRINT PNS System. For more information see the SPRINT PNS System IFU. Most common adverse events are skin irritation and erythema. Results may vary. Rx only.
Important safety & risk information: https://bit.ly/2FU92NH