Perspective on How to Build a Neuromodulation Practice

Introduction by Elliot Krames, Editor, Neuromodulation, 2nd Edition

Creating a medical practice around the field of neuromodulation, whether you are a neurosurgeon, an anesthesia pain doctor, a urologist, or some other specialist of medicine interested in the field of neuromodulation is not easy in today’s medical world of increasing economic scrutiny and report burden. However, if you do want to create a neuromodulation practice around your specialty, the rewards are great, not only from an economic perspective, but from the satisfaction derived from helping your patients deal with their disorder in a way that not many of your colleagues do can be its greatest reward. This chapter brings the perspective of three specialists in neuromodulation, one anesthesiologist and two neurosurgeons, on how to develop your practice around neuromodulation. It is hoped that these perspectives will give you some practical ideas on how to best accomplish this while reinforcing your passion for the field of neuromodulation.

Perspective of Giancarlo Barolat, MD, Neurosurgeon, Denver, Colorado

I have been involved with neuromodulation since 1976. I really did not start building a true “neuromodulation” practice until I started working at Thomas Jefferson University in the department of neurosurgery in 1985. Until then, my experience with neuromodulation was mostly with neurostimulation for movement disorders and spasticity. Since the chairman of the department of neurology, Dr. Robert Schwartzman, at the time, had the largest practice in the United States of patients suffering from reflex sympathetic dystrophy, now called complex regional pain syndrome (CRPS), my practice around neuromodulation grew immediately. Dr. Schwartzman was very interested in spinal cord stimulation (SCS) and implantable drug delivery systems (IDDS) for his CRPS patients and started referring a very large number of patients to me because I was the only neurosurgeon in Philadelphia at that time who had in interest in neurostimulation. Also, at that time, there was minimal knowledge of CRPS, let alone SCS for that condition, so I had a very accelerated (and painfully steep) learning curve. Even though some of the patients were beyond help, some of the results in others were anything short of spectacular. That gave me a renewed energy to continue down that path of focusing on neuromodulation for my practice.

In 1986–87, I teamed up with Dr. Evan Frank and Dr. Lorraine Aries, both anesthesiologists at Thomas Jefferson, and formally started a Pain Program with me as the implanter of neuromodulation devices for patients in pain. Within a few years, my involvement with neuromodulation encompassed SCS for chronic pain and spasticity, peripheral nerve stimulation (PNS) for pain, vagus nerve stimulation (VNS) for epilepsy, and IDDS for pain and spasticity. Deep brain stimulation (DBS) for pain was not commonly utilized and DBS for Parkinson’s disease had not been popularized yet, so I did not develop the DBS modality.

I was lucky enough to train several residents in anesthesia who then went on to embrace pain management. Many of them stayed in the Philadelphia area. I developed a very good relationship with the great majority of them and they started utilizing me as a resource, both to give them advice on how to perform neurostimulation procedures for pain and to send me their challenging cases. Since I was not directly involved with pain management, I would refer all the patients back to the pain management doctor after providing the requested services. This established me as “resource” and not as a “competitor.” Several pain management doctors, who might have not considered performing neurostimulation procedures, started doing them after consulting with me and knowing that they could readily rely on my expertise in case of issues or complications.

Another important factor for the success of my neuromodulation practice has been the fact that, being a neurosurgeon, I have extensive experience with spine conditions and spine surgery. This advanced knowledge of the spine has placed me in the enviable position of being able to provide expert advice in the many situations encountered in a neurosurgical or pain practice, where the algorithms for spine surgery versus neuromodulation are not clear. As a result, I did (and still do) receive consultations from established spine surgeons who request my opinion on whether the patient is a candidate for spine surgery or neuromodulation.

Since moving from Philadelphia to Colorado in 2005, I have limited my practice solely to neurostimulation. This has allowed me to focus on multiple neurostimulation approaches that include SCS revisions, PNS, the placement of electrodes subcutaneously, so-called peripheral nerve “field” stimulation (PNfS), sacral nerve stimulation (SNS), and facial-cranial stimulation for headaches and facial pain.

I have learned that there are several ways or scenarios to handle a neuromodulation practice from a neurosurgeon’s perspective.

• Scenario 1. The simplest one, and the one that most spine surgeons across the United States choose, is to be purely the “technician” who implants the stimulation system where he is told by the pain management specialist who has performed the neurostimulation trial. In this scenario, the implanter does not participate in the follow-up care other than to assure surgical healing and treatment of complications. The same can apply to VNS for epilepsy, where the surgeon purely implants the device, but all the device/seizures management is done by the neurologist. The same scenario may apply to IDDS.

• Scenario 2. The surgeon is actually involved in the decision making of where the leads should be placed in the case of SCS for pain, and also manages the patient as far as the long-term management of the implanted device. That is my position in my current practice. I not only perform the neuromodulation trial and permanent implant, but am responsible for the follow-up care of the patient.

An implanting physician might actually serve different roles according to the various modalities of neurostimulation. For instance, an implanter might be involved in managing the neurostimulation systems placed for pain, but might defer to the neurologist for the management of an implanted VNS for seizures or a baclofen pump for spasticity.

As neuromodulation moves in many different branches of medicine, it might be impossible for an implanter to have a full detailed grasp of all the pathologies being addressed. Advantages, for a neurosurgeon, in being involved with neuromodulation include the following:

• Opens up new indications/procedures.

• Referrals from a wider pool of medical providers.

• Ability to treat patients already present in the practice who would otherwise have to be referred out (for instance, for a spine surgeon, patients who failed previous surgical interventions and still have severe pain).

• Intellectually stimulating modalities.

• Ability to make a substantial positive difference in people’s lives.

Disadvantages, for a neurosurgeon, in being involved with neuromodulation might include:

• Reimbursement less than most neurosurgical procedures.

• Difficult patient population.

• Buy the patient “forever.”

• Can be frustrating.

• No “curative” operation.

• Difficult, for most neurosurgeons, to visualize electrical fields and stimulation patterns, which are necessary in most instances for successful SCS implants.

Perspectives of Alon Mogilner, MD, PhD, Neurosurgeon, Great Neck, NY

A “neuromodulation practice” may have different meanings to different neurosurgeons. While some neurosurgeons may simply want to add neuromodulation techniques to an already busy practice, others, specifically those recently out of residency and fellowship training, may want to create ex nihilo a new practice. Less commonly, a surgeon may wish to convert his or her practice to one specializing in neuromodulation. In each of these cases, however, a more specific definition of “neuromodulation practice” is essential. Some surgeons may want to perform all aspects of neuromodulation, including DBS, SCS, and PNS, as well as IDDS, while others may want to perform only a subset of these interventions along with other nonneuromodulation surgeries. For example, common combinations seen include: DBS for movement disorders and epilepsy surgery, or spinal surgery with the inclusion of SCS placement. For practical reasons, most surgeons recently out of training will need to supplement their neuromodulation practice with a general neurosurgery caseload, both to meet the requirements of their department, the licensing board, and to generate sufficient revenue. This, of course, is no different than any junior faculty member who wishes to specialize in neurooncology, neurovascular surgery, or spinal surgery. Here are some general thoughts/recommendations for you to follow from my perspective: