SCS trial, splenectomy

[MitchLevi]

78 yo M with FBSS and he's s/p splenectomy on acyclovir, fluconazol and PRN levofloxacin. He's got chronic leukopenia. Scheduled for trial next week and WBC 1.0 today. PLT normal.

What does everyone do in this situation? He's miserable.

Thinking move forward with the trial and be meticulous with sterile technique. Hibiclens BID x 3d prior. Keflex PO TID during the trial, which would be shortened to 3 days.

Reasonable?

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[Ronin1]

Yep

 

[lobelsteve]

Better you than me.
If trial was done, I'd help with the implant.
I would not trial. Too much risk vs benefit IMO.
And I am the idiot who does the terrible implants.
Just did a 2 hour implant with 2 leads. Prior surgery T7-8, T11-L1, L2-S1.
Trial done by local pain doc, insurance said no to his ASC (happens a lot in GA).
Got it done, but barely.

 

[paindoc007]

Yep. Reasonable.

 

[soccrwz]

78 yo M with FBSS and he's s/p splenectomy on acyclovir, fluconazol and PRN levofloxacin. He's got chronic leukopenia. Scheduled for trial next week and WBC 1.0 today. PLT normal.

What does everyone do in this situation? He's miserable.

Thinking move forward with the trial and be meticulous with sterile technique. Hibiclens BID x 3d prior. Keflex PO TID during the trial, which would be shortened to 3 days.

Reasonable?

View attachment 378752

May be worth it to use the abx envelope for the perm in this one

 

[MitchLevi]

Better you than me.
If trial was done, I'd help with the implant.
I would not trial. Too much risk vs benefit IMO.
And I am the idiot who does the terrible implants.
Just did a 2 hour implant with 2 leads. Prior surgery T7-8, T11-L1, L2-S1.
Trial done by local pain doc, insurance said no to his ASC (happens a lot in GA).
Got it done, but barely.

Out of curiosity Steve, why an implant but no trial?

 

[Agast]

Would Clindamycin be better than Keflex for benefit of MRSA coverage?

 

[RoloTomassi]

Would Clindamycin be better than Keflex for benefit of MRSA coverage?

I do pre-op IV Ancef then PO clinda for duration of trial, for wide coverage

 

[Orin]

78 yo M with FBSS and he's s/p splenectomy on acyclovir, fluconazol and PRN levofloxacin. He's got chronic leukopenia. Scheduled for trial next week and WBC 1.0 today. PLT normal.

What does everyone do in this situation? He's miserable.

Thinking move forward with the trial and be meticulous with sterile technique. Hibiclens BID x 3d prior. Keflex PO TID during the trial, which would be shortened to 3 days.

Reasonable?

Good academic case and would consider referring to academic person that does high risk cases

Would use IV Abx for the trial with Vanc or Ancef
Wouldn't do the oral antibiotics during the trial as you will want to use those later if things look crappy and that's c/w the trial guidelines. Would consider talking to an ID person about the right abx prophylaxis for them with their lack of a spleen.
I would think about dropping a Biopatch or using CHG impregnated tegaderms for the dressing during the trial.
I would do 3 - 5 days for the trial to give them a change to succeed or fail.

 

[lobelsteve]

Out of curiosity Steve, why an implant but no trial?

Trial proves it works and not my patient selection. Implant is just cut and paste.

 

[nvrsumr]

Cowboy up fellas. Wouldn’t touch this

 

[MitchLevi]

Trial proves it works and not my patient selection. Implant is just cut and paste.

The risk is certainly higher with an implant.

Edit - I always give Ancef or clinda preop.

 

[Espn123]

I’d certainly have a plan for the implant before the trial. If I was receiving this after a trial for implant from another doc I would want to see that due diligence before it was sent to me. Maybe an ID consult for recs

 

[lobelsteve]

The risk is certainly higher with an implant.

Edit - I always give Ancef or clinda preop.

Meh, Part of his clearance will be ID to tell us how to manage peri-operatively.

 

[paindoc007]

The risk is certainly higher with an implant.

Edit - I always give Ancef or clinda preop.

Risk is WAY higher with the implant. Trial is the easier part

 

[TheLoneWolf]

78 yo M with FBSS and he's s/p splenectomy on acyclovir, fluconazol and PRN levofloxacin. He's got chronic leukopenia. Scheduled for trial next week and WBC 1.0 today. PLT normal.

What does everyone do in this situation? He's miserable.

Thinking move forward with the trial and be meticulous with sterile technique. Hibiclens BID x 3d prior. Keflex PO TID during the trial, which would be shortened to 3 days.

Reasonable?

View attachment 378752

I wouldn't knock you for doing this...but if patient was mine in a PP setting, I would send to the university where they could do an interdisciplinary conference with ID involvement

 

[MitchLevi]

My real concern is 8 months post implant. Perioperative I'm not too worried if I take significant precautions.

 

[Ronin1]

I would say that 90% of my aggravation over my career has to do with implants. In part why I stopped doing them almost completely. In this case I would trial the patient if my implanting neurosurgeon was ok with proceeding with implant.

 

[Agast]

Quick question - why is he leukopenic? My lazy Google search tells me they’re typically elevated in WBC after splenectomy. Does he have some bone marrow issue?

 

[painfree23]

Better you than me.
If trial was done, I'd help with the implant.
I would not trial. Too much risk vs benefit IMO.
And I am the idiot who does the terrible implants.
Just did a 2 hour implant with 2 leads. Prior surgery T7-8, T11-L1, L2-S1.
Trial done by local pain doc, insurance said no to his ASC (happens a lot in GA).
Got it done, but barely.

Percs or paddles?

 

[lobelsteve]

Percs or paddles?

Paddle is for NS or Ortho only.

 

[CleanUp]

I would say that 90% of my aggravation over my career has to do with implants. In part why I stopped doing them almost completely. In this case I would trial the patient if my implanting neurosurgeon was ok with proceeding with implant.

Ronin mind if I ask you more specifically causes you aggravation with the implants? Looking to learn. Was it patient not understanding it? Bugging your office and not the rep? Not understanding it cannot cure all areas of pain? Complications? Calls from hospital? Thx

 

[painfree23]

Paddle is for NS or Ortho only.

How did u get the perc leads thru all that scar tissue at T11-L1?

 

[lobelsteve]

How did u get the perc leads thru all that scar tissue at T11-L1?

Didn’t. After 30 min of trying, I entered at T10-11. Tail electrode in ligament.

 

[Ronin1]

Ronin mind if I ask you more specifically causes you aggravation with the implants? Looking to learn. Was it patient not understanding it? Bugging your office and not the rep? Not understanding it cannot cure all areas of pain? Complications? Calls from hospital? Thx

Aggravation meaning mostly issues with complications such as infections, migrations, etc. over the past 25 years I never had to go to the OR at night for an injection. I’ve done a few septic explants on Friday nights. Do enough and you will see some issues.
Now I just really don’t want to go to the hospital and deal with scheduling issues/ anesthesia delays etc. just trying to keep life simple. I’m already regretting doing Intracept at the hospital. Last week 4 cases. Total procedure time 2 1/2 hours. Total time at the hospital mostly waiting for turnover 8 hours