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Chronic Pain Therapies > CPT > Flashcards

CPT Flashcards

1
Q

What is FDA approval for SCS?***

A

Approved for treatment of chronic intractable pain of trunk and limbs

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2
Q

Motor Neurons***

A

Transmit impulses from the central nervous system to muscles & glands

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3
Q

Sensory Neurons***

A

Run from various type of stimulus receptors to the CNS and carry information such as touch, odor, taste, or vision

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4
Q

Nociceptive Pain***

A

Pain that develops in response to a specific situation and damages tissue

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5
Q

Neuropathic Pain***

A

Pain that develops when the nervous system is damaged or not working correctly due to disease

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6
Q

Patient complains of burning, stinging pain in low back that shoots down both extremities…. What kind of pain? Would they be a candidate for neurostimulation?

A

Patient has Neuropathic Pain therefore is a good candidate for Neurostimulation

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7
Q

Patient has intermittent, aching pain that is alleviated when patient sits down and hunches over…. good candidate? why or why not?

A

No not a good candidate because neurostimulation is used to treat intractable pain which is pain that is constant & not curable

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8
Q

5 Characteristics of Chronic Pain

A
  1. Constant / Persistant
  2. Last longer than 6 months
  3. Serves no protective function
  4. May spread or increase in intensity
  5. Has no obvious cause
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9
Q

3 Conditions Treated with Neurostimuation

A
  1. CRPS
  2. FBSS
  3. Phantom limb or Residual limb
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10
Q

Define Hyperalgesia

A

is increased sensitivity to painful stimuli

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11
Q

Define Allodynia

A

pain caused by stimulus that doesn’t normally caused pain.

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12
Q

5 Parts of Neuron***

A
  1. Dendrites
  2. Soma
  3. Axon Hillock
  4. Axon
  5. Axon Terminal
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13
Q

Dendrite Function***

A

Receives signal from other nerve cells

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14
Q

Soma Function***

A

Generates & Processes Signals

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15
Q

Axon Hillock Function***

A

Controls the firing of neuron

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16
Q

Axon Function***

A

Transmit the signal

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17
Q

Axon Terminal Function***

A

Releases transmitted signal (exit)

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18
Q

Action Potiental

A

occurs when a stimulus reaches a certain thershold

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19
Q

You are mapping patient with low back pain in tonic, and you are unable to get paraesthesia in low back. After multiple changes in polarity the patient say he only feels tingling in legs. List reason why this may be occuring

A

Low back is more lateral and less myelinated

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20
Q

What two structures comprise the CNS

A

Brain and Spinal Cord

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21
Q

How can CSF produce challenges to Neurostimulators?

A

Disperses electrically field because CSF is highly conductive

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22
Q

Where is dorsal CSF thickest due to the kyphotic curve?

A

Mid to Upper Thoracic region

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23
Q

3 Layers on the Meninges & Function***

A
  1. Pia Mater - inner most layer
  2. Arachnold Mater - middle layer that contains CSF
  3. Dura Mater - outer layer
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24
Q

In order from top to bottom, list the 5 bone groups of the Spinal Column and how many bones in each

A
  1. Cervical - 7 segments
  2. Thoracic - 12 segments
  3. Lumbar - 5 segments
  4. Sacrum - 4 - 5 segments
  5. Coccyx - 4-5 bones
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25
Q

5 parts of vertebral body

A
  1. Spinous process
  2. Pedicles
  3. Lamina
  4. Transverse Process
  5. Vertebral body
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26
Q

Oblique C- Arm

A

Moved right or left to align the spinous process

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27
Q

Cephalad

A

move C - Arm toward head

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28
Q

Caudal

A

move C - Arm toward trunk/tail

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29
Q

Why is lateral image always necessary

A

to ensure leads are placed in posterior space

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30
Q

C - Arm tilted cephald to align what

A

endplates

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31
Q

Pulse width of SCS IPG***

A

20-1000ms

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32
Q

Max recommended implant depth for proclaim IPG & why

A

4cm for comfort & to be able to communicate with bluetooth

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33
Q

Primary differences for proclaim 5 & 7

A

Size, longevity & warranty

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34
Q

Surgery Mode

A

reduces possibility of negative device interactions during surgical procedure

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35
Q

Rep responsibilities to protect IPG

A
  1. put in surgery mode
  2. Confirm IPG is working correctly before closing pocket
  3. Keep IPG far away
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36
Q

Upgradeability

A

means we are able to offer patients technology and features upon FDA approval without surgery or replacement

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37
Q

First Upgradeable System

A

Proclaim XR in 2019

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38
Q

Protege and Prodigy IPG warranty time & unmet medical expense amount***

A

7 years and $1250

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39
Q

How long are the EonMini, Protege, Protege MRI and Prodigy IPGs FDA approved to last

A

up to 10 years

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40
Q

How deep can prodigy be implanted & why

A

2.25cm to ensure able to connect to charger

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41
Q

Tonic Programming ranges for Eon, Protege and Prodigy Family

A

Freq - 20-1200 hz
Pulse width - 50-500ms
Amplitude - 0-25.5ma

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42
Q

Which rechargeable IPG is first to come with BurstDR enabled out of box

A

Prodigy MRI

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43
Q

What gauge of epidural needles do we use for SCS leads? what length can you order? what is the curved tip needle called

A
  1. 14 gauge
  2. 4 and 6 inch
  3. Curved is the Coude
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44
Q

5 Key Features of Swiftlock

A
  1. Distal strain relief
  2. Depth indicator (1cm)
  3. Eyelets
  4. Locking area
  5. Suture grooves
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45
Q

What are the electrodes made of on Abbotts percutaneous leads and paddle leads

A

Platinum - Iridium

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46
Q

Why are the contacts on the penta lead micro textured?***

A

to maintain current density despite smaller footprint (increase surface area) and to help overcome impedences

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47
Q

Dr Holsheimers findings on difference between the anatomical and physiological midlines

A

40% of patient’s spinal cords are 1-2mm off midline

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48
Q

How many columns & rows of penta lead?

A

5 Columns
4 Rows

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49
Q

On penta lead how many contacts and how many independent contacts?

A

20 total and 12 independent

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50
Q

Electrode array width and overall width on penta

A

electrode array width is 9mm and overall width is 11mm

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51
Q

What is RF power restriction for Proclaim XR and 60cm octrode leads

A

30 mins active scan, 30 min waittime

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52
Q

No more MRI restriction on lead for Proclaim XR means leads can be placed where for octrode & penta

A

Octrode- C1 - S2
Penta - T7-T12

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53
Q

MRI expansion was for what IPG and lead?

A

Proclaim XR
60Cm octrode lead

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54
Q

Where can IPG be place to meet MRI conditional parameteres

A

Upper buttock, low back, flank, abdomen or midline

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55
Q

Abbotts competitive advantage with MRI expansion

A

30 min active scan, 30 min waitime

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56
Q

Abbotts competitive advantage with MRI expansion

A

30 min active scan, 30 min wait time

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57
Q

Boston Scientific & Medtronic scan vs wait time

A

30 min scan, 60 mins wait time

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58
Q

How should a patient be positioned for an SCS procedure?

A

Prone position
Cervical - pillow under chest, arms neutral, chin to chest
Thoracic - pillow under abdomen, neutral spine, arms out of fluoroscopy

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59
Q

4 things to avoid during SCS trial period to prevent lead migration

A
  1. Bending
  2. Lifting
  3. Twisting
  4. Do not get wet
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60
Q

What needle angle should the physician take to access the epidural space at T12 - L1?

A

30 degrees or less

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61
Q

What would you suggest if physician hit resistance

A

To use guidewire when hitting obstruction in epidural space

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62
Q

Where would you place leads for back pain***

A

T7 - T8 or T8 - T9

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63
Q

Where would you place leads for back and leg pain***

A

T8 - T9

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64
Q

Where would you place leads for leg pain***

A

T9 - T10 or T10 - T11

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65
Q

Where would you place leads for foot pain?***

A

T10-T11 or T11-T12

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66
Q

When intraop testing which lead should be place on left side of IPG?***

A

Match left lead with port 1-8

67
Q

7 products to take into OR

A
  1. IPG
  2. Leads
  3. Anchors
  4. patient remote
  5. Clinician controller
  6. Anticipated accessories
  7. charger as surgeon may ask to charge
68
Q

Describe prep for Proclain IPG with scrub tech / physician before inserting leads

A

On Proclaim headers come tight so you will need to loosen in quarter turn increments with torque wrench (2 full rotations)

69
Q

What do you do with excess lead prior to placing IPG in pocket?

A

excess leads or extensions should be coiled in large loops and placed behind battery

70
Q

Laminectomy

A

complete removal of lamina

71
Q

Laminotomy

A

enlarging interlaminar space or removing partially removing lamina

72
Q

Hemilaminotomy

A

removing one side on lamina

73
Q

What level should laminectomy be performed if leads are being placed at T8?

A

1-2 vertebral levels below so T9-T10

74
Q

What direction should tunnel be created

A

midline to pocket

75
Q

Explain tunneling process

A

subcutaneous tunnel is created between anchor site and IPG. Avoid tunnel through muscle. Withdrawn plastic sleeve from tunnel & avoid removing strain relief loop

76
Q

Is swiftlock used on Penta Leads? why? ***

A

No, anchors are not used for penta leads because the indicator marks

77
Q

Describe good X Ray for Penta

A
  1. Spinous process midline
  2. Endplates squared
  3. Pedicles clear
  4. Shiney side of penta down
78
Q

For proclaim implant, should the electrosurgical device be in monopolar or bipolar mode

A

Always Bipolar Mode

79
Q

Characteristics of BurstDr waveform

A
  1. Proprietary to abbott
  2. eliminates parathesis
  3. low programming burden
  4. modulates both lateral and medial pathways
  5. superior to tonic
80
Q

How many pulses are in a burstDR pulse train

A

5 pulses

81
Q

***Medial pathway

A

is your emotional response, suffering component and your attention to pain

82
Q

Lateral pathway***

A

is your physical response, perception of pain and the sensory effect

83
Q

Primary endpoint of the sunburst study

A

was to prove non-inferiority of burst stimulation to tonic stimulation in overall VAS scores at 24 weeks for FDA approval

84
Q

How many patients ENROLLED in sunburst study

A

173

85
Q

How many patients were randomized in sunburst study

A

100

86
Q

what was design of Sunburst study

A

randomized with crossover design for 1 year

87
Q

In sunburst, what percent of patients preferred Burst over Tonic SCS

A

70.8 %

88
Q

Why do we use BoldXR dosing protocol to program patients

A

Dosing results in patients receiving minimal stimulation while maintain therapeutic effect and increase battery life

89
Q

List the BoldXR programs given to patients

A
  1. 30 seconds on, 6 min off
  2. 30 seconds on, 3 mins off
  3. 30 seconds on, 90 seconds off
90
Q

Results of Bold Clinical Study

A

100% of patients remained on dosed settings and 50% remained on lowest dose

91
Q

Key Takeaways from the BOLDER study

A
  1. 81% remained on lowest energy setting
  2. 68% and 69% no longer catastrophizing at follow up
  3. 80% and 77% improved across multidimensional responder rate
  4. No difference found in pain relief, function & pain catastrophizing between groups
92
Q

BOLD Guarantee

A

5 year warranty on battery life when patients use burst with BOLD XR dosing protocol

93
Q

7 Features & Benefits of Proclaim XR SCS system

A
  1. up to 10 year battery life at low dose settings
  2. don’t have to recharge
  3. superior BurstDr therapy
  4. familiar apple devices
  5. upgradeable
  6. Full Body MRI conditional labeling
  7. back by industry leading 5 year battery life warranty
94
Q

Pulse width is measured in

A

Microseconds

95
Q

Frequency is measured in

A

Hertz

96
Q

Amplitude is measured in

A

Milliamps

97
Q

where does depolarization occur

A

at cathode

98
Q

Which programming parameter has greatest impact on battery

A

Frequency

99
Q

which programming parameter has most direct impact on which nerves are stimulated

A

Polarity

100
Q

increasing amplitude will or will not increase area of activation

A

will

101
Q

What technology provides ability to change electrode configurations with active amplitude

A

Multisteering

102
Q

What position should patient be in when programing BurstDR

A

Supine Position

103
Q

What are default settings for BurstDR

A

Frequency - 40 hertz
Intra Burst Rate - 500 Hertz
Pulse Width - 1000ms

104
Q

What is max target amplitude for BurstDR

A

1.5 milliamps

105
Q

When using BurstDR, amplitude should be decreased by what % of required energy for patient perception

A

40%

106
Q

Should you ever change the pre defined burst parameters ?

A

no

107
Q

T junction asks as

A

a. a barrier to AP propagation to DH
b. a low pass filter to AP propagation to DH
c. propagator of AP

108
Q

Following electrical stimulation of the DRG does membrane excitability increase or decrease?

A

Decrease

109
Q

Where is DRG located

A

within the epidural space inferior to the pedicle

110
Q

the DRG sits in what aspect of the neural foraman

A

Superior

111
Q

DRG is largest at which level

A

L5

112
Q

During lead placement where does the lead pass through to access the DRG in the neural foramen

A

Intra Foraminal Ligaments

113
Q

Design of the ACCURATE Study

A

a prospective, randomized, multi-center, controlled clinical trial to access the safety and efficacy of the Axium Stimulator in treatment of CPRS 1 and 2 for lower extremities

114
Q

Did Accurate Stidy include chronic intractable pain of upper and lower extremities

A

NO just lower. T10 and below

115
Q

how many patients were enrolled in the ACCURATE study

A

152

116
Q

In Accurate Study, What percentage of the implant only group reached the primary end point at 3 months

A

93.3%

117
Q

in Accurate Study, What percentage of the implant only group VS control reached the primary end point at 12 months

A

86% of implant
70% of control

118
Q

In accurate study, what percentage of patients were considered high responders

A

70%

119
Q

FDA indication for DRG

A

for SCS via epidural and intraspinal lead access to DRG to aid in the management of moderate to severe chronic intractable pain of the lower limbs in patients with CRPS 1 and 2

120
Q

DRG levels for groin, knee and foot pain

A

Groin - T12 to L1
Knee - L3 to L4
Foot - L4 to S1

121
Q

if patient has sympathetic symptoms would it be CRPS 1 or 2

A

CRPS 1

122
Q

How many electrodes does axium slim tip lead have

A

4 electrodes

123
Q

What does the black marker indicate on needle

A

direction of the bevel

124
Q

what length does axium needles come in for DRG

A

4.5 and 6 inch

125
Q

What are two curve sizes of axium delivery sheath

A

2mm and 8mm

126
Q

What is the purpose of the white marks on sheath?

A

needle exit indicators or when sheath is at end of needle

127
Q

Can a torque wrench with the SCS and DRG systems be used interchangeably?

A

No, torque ratio is different. DRG torque allows for 3x more torque

128
Q

3 products that contain DRG torque wrench

A
  1. DRG IPG Kit
  2. Tunneling tool kit
  3. Lead extension kit
129
Q

Max implant depth for proclaim DRG IPG

A

4cm

130
Q

How many leads can the DRG EPG and IPG accomidate

A

EPG - 2 leads
IPG - 4 leads

131
Q

at what levels is the proclaim IPG DRG system MRI conditional

A

T10 to S2

132
Q

which DRG lead is MRI Conditional

A

50 cm slim tip lead

133
Q

is the proclaim DRG system full body MRI conditional like the SCS proclaim?

A

No only head and extremities

134
Q

What to bring to DRG trial

A
  1. slim tip lead kit
  2. EPG header and cable
  3. EPG base
  4. accessory kit
  5. patient and clinician programmer
135
Q

What to bring to DRG perm

A
  1. slim tip lead kit
  2. EPG header/ base/ cable for intraop testing
  3. IPG
  4. Tunneling tool kit
  5. patient manual / magnet
  6. patient and clinician programer
136
Q

For lead placement at T10-L3 where should skin entry be

A

2-3 pedicles below on contralateral side

137
Q

What are the order and landmarks that a physician will mark on patient for appropriate needle trajectory and entry

A
  1. inferior medial aspect of target pedicle
  2. Superior and midline aspect of the epidural space
  3. use those two marks to draw a line to appropriate skin entry point on contralateral side
138
Q

L4 and L5 needle trajectory tends to be

A

wider and more contralateral

139
Q

Which electrode should be under pedicle

A

2 and 3

140
Q

Removal process for delivery system

A
  1. Sheath
  2. needle
  3. stylet
141
Q

Recommended pulse width and frequency for DRG

A

Pulse width - 200ms
Freq - 20 hz

142
Q

RFA stands for

A

Radio Frequency Ablation

143
Q

2 types or methods of RF we offer are

A
  1. continuous thermal
  2. pulsed RF
144
Q

at what temp does tissue damage begin

A

45 degrees Celsius and above

145
Q

How many channels or ports does the NT2000 and Ionic have?

A

both have 4

146
Q

how many lesions are created using the simplicity

A

5 lesions

147
Q

what are the lesions patterns when using simplicity

A
  1. Bipolar lesion between distal and medial electrodes
  2. Bipolar lesion between proximal and medial electrodes
  3. monopolar lesion at distal
  4. monopolar lesion at medial
  5. monopolar lesion at proximal
148
Q

what gauge RF needles are available

A

16 g - purple
18 g - pink
20 g - yellow
22 g - black

149
Q

What length needles are available for RF?

A

5cm - GREEN
10cm - BLUE
15cm - YELLOW
20cm - ORANGE

150
Q

Does the Venom electrode by Stryker create bigger or smaller lesion than our 16g

A

Smaller

151
Q

RFA is intended to decrease or stop pain originating at what joints

A

Facet Joints

152
Q

Grounding pads should be

A

proximal or close to treatment site and in a well vascularized area

153
Q

RF competitors

A
  1. Medtronic
  2. Stryker
  3. Avanos
  4. Cosman
154
Q

What kind of stimulation is used to determine if the needle and probe are in good location for RF

A

Sensory and motor

155
Q

Pulsed RF creates…

A

an electromagnetic field which may boost the immune response

156
Q

1 rule when troubleshooting RFA issues

A

start with least expensive product to most expensive

157
Q

Purpose of diagnostic nerve blocks before RF procedure

A

to ensure the correct nerve is ablated

158
Q

two types of reusable probes

A
  1. stainless steel
  2. Nitinol
159
Q

Explain bi-pole lesion

A

a bi-pole lesion is when 2 needles are place 2-5mm apart. one needle heats up and the other serves to close the circuit therefore no grounding pad is needed

160
Q

Default settings on RF generator for creating lesions are

A

80 degrees Celsius for 60 seconds

161
Q

RFA is indicated for

A

the destruction of neurolytic tissue

162
Q

Key differences between NT2000 and Ionic

A

Ionic is
1. Overall better performing ( high average power output per channel, reliable and consistent)
2. Enhanced safety Features (auto stop lesion if circuit is broken or if high impedances and new grounding pad)
3. modern looking, smaller, lighter, more portable
4. touch screen like Ipad
5. only generator that can be mounted on IV pole

163
Q

What is the ProCharge Intelligent Power Algorithm

A

Intelligently distributes power between channels to ramp to temperature quicker and ensure maintenance of temperature throughout lesioning process

Chronic Pain Therapies (1 decks)

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