epidural space in the spinal column and sends the patient home for a
week to see if they get relief from the intervention, says Dr. Shaparin.
When the week is over, the implant comes out regardless of the out-
come. The trial period is key because the patient can adjust the stimu-
lation in real time.
"Let's say the patient is home, and the SCS is not stimulating the exact
right area enough," says Dr. Shaparin. "A lot of times, the device rep can
change the stimulation over the phone or over the internet." If there's
adequate relief, a permanent SCS is implanted in the epidural space,
and the battery goes around the buttocks area, below the beltline, with
a remote control for the patient to adjust as needed.
As you can imagine, between the trial and the implantable device, this
intervention is costly. The stimulator implant alone costs upwards of
$25,000. Plus, from a staffing standpoint, at a minimum you're talking
about needing a physician, at least 2 OR techs, and an X-ray tech or at
least someone who's well-versed in fluoroscopy. The good news is CMS
just began reimbursing for this procedure in 2018, and commercial
insurers tend to pay around the Medicare rate for SCSs.
But the reimbursement process itself is more involved for SCSs.
"Implantable devices require the use of a psychologist, because this
intervention can lead to significant long-term implications," says Dr.
Kramskiy. Due to those implications, insurers' response is to require
some degree of additional screening, besides just relying on the physi-
cian's recommendation, before approving this treatment, he adds.
Still, there's some compelling reasons to consider this option. For
one, it can be very effective. "There's quite a bit of evidence for the
value of spinal cord stimulation in patients who have back pain and
shooting leg pain after surgery," says Paul Christo, MD, the director of
the multidisciplinary pain fellowship program at Johns Hopkins
Medicine in Baltimore, Md. Plus, the upfront costs can be misleading.
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