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This appears to be a recondite topic for the highly select. But it's important for the non-clinicians among us (myself included) to understand the issue to avoid being run over by the chronic care bus.

You know there's a battle going on when a manufacturer of a device used in the procedure lobbies state workers' compensation regulators to disparage treatment guidelines which criticize the procedure.

The manufacturer criticized the then draft guidelines on chronic pain of the American College of Occupational and Environmental Medicine.

Spinal cord stimulators first emerged long ago as a clinical option after researchers began to study how the nervous system itself amplifies pain symptoms. If the nervous system can alter itself to become the effective source of pain, then electrical stimulation might reduce pain.

Hundreds if not thousands of physicians today implant spinal cord stimulators in injured workers and swear by them.

The cost to workers' compensation insurers ranges from $25,000 to $75,000 depending on the locus of care--surgical center vs. a hospital--and the ingenuity of the billers.

But the results may not be gratifying to patients, because of a high complication rate and uncertainty about long-term benefit.

The fight has taken on a sharper focus as the two leading publishers of treatment guidelines issued their tome-sized chapters on chronic pain. ODG issued its in 2007. The ACOEM guidelines came out in final form late this summer.

Both publishers say implants should only be used for patients for whom other treatment has failed. The ODG guidelines are more hopeful about patient outcomes and impose fewer hurdles for the physician.

The ACOEM authors are clearly unimpressed with the prospects of long-term pain relief.They try to make approval of the procedure conditional upon the patient undertaking a serious rehabilitation program.

Those I talk with say that misuse of the procedure typically happens when the physician skips through the steps needed to qualify the patient, and the insurer gives in. The physician must make sure that all other therapies have failed or are clearly ruled out, a year's effort.

Open mindedness has a frail chance when care is controlled by a physician ready to use his or her favorite hammer on every nail.

"We tend to deny almost all of the requests that come through," Douglas Smith, medical director of the insurer RTW, told me. Per Minnesota state treatment guidelines, RTW requires a second medical opinion as well as a psychological profile to be done prior to authorizing the spinal cord stimulator. Most patients are deemed not to be candidates after those consults have been obtained.

RTW also uses a specific psychological/personality profile questionnaire to review with the claimants to see if there are other issues in their life that would indicate that the spinal cord stimulator would not be effective for them.

In other words, don't sit back.

PETER ROUSMANIERE is a Vermont-based columnist for Risk & Insurance®.

October 1, 2008

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