Neuromodulation News: October 2017

President's Message l New Executive Officers l DBS Innovations Expert Panel in November l Cadaver Workshop in Sydney in October l NSUKI ASM Joint Meeting in November l Facial Pain Expert Panel in 2018 l Neuromodulation in Cuba l Abstracts and Video from the 13th World Congress l Public Education Event Template for Local Use l 2018 Interim Meeting in Brazil l 1st European INS Chapters' Congress on Neuromodulation in September 2018 l Ways to Get Involved

A Message from the President

Dear INS colleagues and friends,

A number of us may have occasionally felt that the promise potentially offered by neuromodulation therapies for chronic neuropathic pain appears to be “hiding in plain sight”: obvious to those of us who work in the field, but perhaps little-recognized among some groups of potential referrers, payers, or patients.

In fact, Neuromodulation: Technology at the Neural Interface Editor-in-Chief Dr. Robert Levy aptly titled his August 2017 editorial, “Neuromodulation: The ‘Not-so-Hidden’ Cure for the Opioid Crisis”.

In spite of that predicament, I have lately seen increasing interest that leaves me optimistic – interest in advanced medical technologies that can be more cost-effective in the long run. Among its other advantages, neurostimulation, for example, can enable chronic pain patients who benefit to be more productive, with better function and quality of life. Pain management specialists know that long-term opioid administration is not optimal for chronic pain, and carries inherent drawbacks (such as the risks of sensitization, need for escalating doses, potential physical dependence, immune and hormone system dysfunction, and possible overdose).

Seeking to encourage pain-management alternatives to opioids, last month, 37 attorneys general from U.S. states and territories wrote to a health insurance trade association, America’s Health Insurance Plans. In their letter, they asserted that advanced medical technologies can be more cost-effective in the long run, and called for payers to incentivize this approach through their reimbursement policies.

Although their letter did not refer to neuromodulation by name, it did cite an interview I had given a business publication last year. In it, I pointed out the cumulative costs of ongoing office visits and prescription payments in chronic pain that can total more over time than opting for a more advanced technology.

This point was reiterated recently in an article by INS members Nandan Lad, MD, PhD and Aladine Elsamadicy, MD and colleagues. They wrote in Pain Physician in September 2017 that an analysis of more than 5,000 patients who received spinal cord stimulation for failed back surgery syndrome indicates costs fell 68% compared to conventional medical management the first year following the year of implant, and over the next nine years, dropped an average of 40% annually.

To carry the message about neuromodulation’s potential benefits to a broader audience, the INS Full Board proposes that all regional meetings – such as annual scientific meetings or interim meetings –include a free-of-charge educational event, tailored to the region and open to the public. To support that, the board initiated development of a public education event plan that can be used as a template for future events. Such outreach is sorely needed. We look forward to future accomplishments as public education event plans are implemented regionally.
 
In another regional development, the INS Executive Board is working on expanding opportunities for regional representation on the Full Board. Please stay tuned. (In other regional news, this issue has a special report of observations by INS Director-at-Large Dr. Lawrence Poree, who is an invited lecturer there in November for the Cuban Pain Society.)

Meanwhile, plans for our biennial 14^th World Congress in 2019 in Sydney, Australia are taking shape under the guidance of Congress Chair Dr. Marc Russo. The Neuromodulation Society of Australia and New Zealand is enthusiastically aiding local organizing. I know this will be a fantastic opportunity to hear from your colleagues at a world-class event that continually breaks new ground, and to visit a fascinating part of the world. Please be sure to mark May 25 – 30, 2019 on your calendars.

Meanwhile, all 11 INS committees have been hard at work. For example, during our 13^th World Congress in Edinburgh, Drs. Levy, Russo, and I attended the International Women in Neuromodulation (iWIN) meeting. Co-chairs Dr. Luz Elena Caceres, Dr. Julie Pilitsis, and Dr. Halena Gazelka solicited suggestions for how INS can support their group. The suggestions included: inclusion in INS leadership, meeting planning and speaking opportunities. Others asked iWIN to become more involved in clinical and research mentorship. With a rotation in co-chair duties, Dr. Kiran Patel will replace Dr. Gazelka on the committee. I commend the work of each and every committee – thanks to all of you for your service to the society.

I hope you will agree that the dynamism these activities represent offers good cause for optimism as we look ahead, particularly in a climate where the need for access to non-pharmaceutical pain-relief methods is so great.

In closing, please allow me to share with you the following summary of plans that some of the INS committees anticipate for the coming six months:

1) Research and Scientific Oversight - A small working group drawn from INS and IMMPACT (the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials) will create a roadmap and engage stakeholders in 2018 to create well researched systematic reviews and eventually publications on guidelines, etc.

3) Interim Meeting - The Interim Meeting Committee has distributed a call for proposals to the full INS Board for the 2020 meeting, and committee members will help vet the proposals.

4) Biennial Congress - A site inspection with the Executive Officers, Local Organizing Committee and new Congress organizer, Kenes Group, will take place in December in Sydney. Scientific program development will begin thereafter.

5) Globalization along with 6) Membership and Chapter Creation - Members of these two committees have been active in encouraging new chapters to form — most recently in the Middle East / Gulf States.

7) Public Education, Outreach and Website – With completion of the INS website transition to a mobile-friendly format, efforts have turned toward revamping, updating, and expanding some patient-education content, while organizing a coming series of Expert Panel sessions.

8) Education and CME – Select members of this and the Young Neuromodulator Committee are developing and reviewing neuromodulation curriculum content with the aim of having final drafts prepared by the end of the year.

9) International Women in Neuromodulation – iWIN will be communicating with members over the next six months and brainstorm towards a mentorship program.

10) Young Neuromodulators – The co-chairs plan to add a web page to the INS website and facilitate communications to support mentor/mentee relationships.

11) Advocacy and Society Liaison – The committee is devising a plan for the coming year. Dr. Sam Eldabe, co-chair of this committee and chair of IASP’s special interest group on neuromodulation (SIGN), has organized a joint meeting with the Neuromodulation Society of the United Kingdom and Ireland and SIGN on November 11-12, 2017 in Oxford, UK.

With best regards,

Timothy Deer, MD
President of INS

New International Neuromodulation Society Executive Officers

At the meeting of the INS Board in June, Dr. Robert Levy, editor-in-chief of the INS journal, Neuromodulation: Technology at the Neural Interface, was voted in as INS president-elect. Dr. Levy will become INS president in September 2018, when INS president Dr. Timothy Deer's three-year term ends.

At the same meeting, Dr. Konstantin Slavin was elected to become INS secretary this September, at the end of the term of INS secretary Dr. Marc Russo.

Dr. Russo will serve as chair of the INS 14th World Congress. During his term as congress chair, he will participate on the board as a director-at-large. 

International Neuromodulation Society Expert Panel: “The Potential and Limitations of Recent Innovations in Deep Brain Stimulation" Nov. 1 - 15, 2017

From Nov. 1 – 15, 2017, Alex Green, MD, will moderate an online Expert Panel for INS members only, in the INS Global Discussion Forum (logon required), on "The Potential and Limitations of Recent Innovations in Deep Brain Stimulation."

Discussion may cover segmented or "directional" leads for deep brain stimulation (DBS); as well as "asleep" implantation under general anesthesia; frameless stereotaxy; the usefulness of microelectrode recording; the value of new imaging methods, like diffusion tensor imaging (DTI); and future perspectives such as: How to facilitate surgery? Do we save time by means of segmented leads? Does it improve outcomes? How to increase the implant rate among the suitable population?

A functional neurosurgeon at Oxford University Hospitals in the UK, our panel moderator has implanted more than 30 directional DBS leads. His center was one of the first to implant and assess directional leads. He has also used intraoperative local field potential recording and other techniques to localize electrodes. He is immediate past president of the British Society of Stereotactic and Functional Neurosurgery and an active member of the UK DBS network, where innovations in technology and the use of DBS are debated and promoted.

If your practice involves DBS, please join us to raise questions and share your views during this multifaceted discussion.

The Neuromodulation Society of Australia and New Zealand (NSANZ) Will Hold a Cadaver Workshop on Oct. 29, 2017

Following the success of the inaugural NSANZ Cadaver Workshop 2016, NSANZ is pleased to offer its members and associates a second Cadaver Workshop to be held on Sunday, 29 October 2017 at Macquarie University, Faculty of Medicine and Health Sciences, Building F10A | 2 Technology Place, Macquarie University, Sydney NSW from 8:00 a.m. – 4:00 p.m. 

The clinical timetable will focus on the hands-on aspects of neurostimulation. It will aim to support those starting out but also cater for more experienced implanters.  It will mainly focus on spinal cord stimulation but will also feature DRG and sacral nerve neurostimulation and with enough cadavers, will also feature a station on peripheral nerve stimulation like cluneal nerve and craniofacial stimulation.

The panel of educators will include the NSANZ Executive Board: Dr. Richard Sullivan, Dr. Nick Christelis, Dr. Frank Thomas, Dr. Murray Taverner, Dr. Marc Russo, Dr. Paul Verrills and Dr. James Yu as well as Associate Professor Tillman Boesel and Dr. Willem Volschenk.

This is a valuable opportunity to have one-on-one time with these experts in Neuromodulation.  Spaces are limited, allowing for a more targeted and individualized experience for you so we advise to register early.

The Neuromodulation Society of the UK & Ireland Annual Scientific Meeting (NSUKI) – A Joint Congress with the IASP Special Interest Group on Neuromodulation

www.nsukiasmoxford2017.com

As a satellite meeting, there will be an “NSUKI Half-Day Spinal Cord Stimulator Training Workshop” on Friday, the 10^th of November 2017.

Details can be found on the main meeting website.

Mark Your Calendars: International Neuromodulation Society Expert Panel on Facial Pain, Feb. 20 – March 6, 2018

As this issue of the newsletter was being completed, early plans were forming to hold a future INS Expert Panel for members only from Tuesday, Feb. 20 through Tuesday, March 6, 2018.

INS Expert Panels take place in the Members Only Section of the INS Website.

The co-moderators will be: Christopher Honey, MD, DPhil, FRCSC; Stana Bojanic, BSc MB BS FRCS (SN); and Andre Machado, MD, PhD. Please watch for future announcements.

Neuromodulation in Cuba: Worlds Apart or Just a Stone's Throw Away

Editor’s note: Dr. Poree will be traveling back to Cuba Nov. 2 – 3, 2017 to give a lecture to the Cuban Pain Society. He submitted the following article after initially visiting in July.

At first glance, a visit to Havana conjures up images of walking into a time capsule or a classic car museum. Upon entering the corner hotel room that Ernest Hemingway called home for 7 years on the 5^th floor of the Hotel Ambos Mundos one can imagine the inspiration he garnered to write the novel For Whom the Bell Tolls while gazing out over old Havana and the Caribbean Sea to the north.

It is easy to lose oneself in the past while sipping mojitos at the hotel’s rooftop bar and listening to the acoustic quartet. However, a glimpse eastward to the harbor revealing a mega cruise ship quickly brings you back to the present. So while the plethora of old U.S. cars is a testament to the departure of Detroit over 58 years ago, one wonders if the Carnival cruise ship is bringing anything more than tourists looking for a good time. For this Interventional Pain Physician the question was, “is there a role for interventional pain and specifically neuromodulation in the Cuban health care system?”

Fortunately, these questions could be answered by Dr. Jorge Yera and Dr. Gisele Coutin. Dr. Yera an anesthesiologist and pain physician is the current president of the Cuban Chapter of the International Association for the Study of Pain. Dr. Coutin, an internal medicine physician, is also a leading Cuban epidemiologist. With rolled tobacco being a major source of income for this island nation it came as no surprise when Dr. Coutin revealed that cancer, and lung cancer in particular, consumes a significant portion of the national healthcare budget.

However, it was a surprise to learn that back pain is the most common reason for taking time off from work and that spinal decompression surgery with residual back and leg pain is common in Cuba, just as it is in the U.S.

The challenges to implementing neuromodulation to treat these patients in Cuba are similar to those encountered in the U.S. In the U.S. we struggle to convince insurance adjusters of the long-term cost benefit of neuromodulation and in Cuba it is the ministry of health that needs to be convinced. In both systems, the gatekeepers to coverage need to be encouraged to look beyond the immediate implant cost of spinal cord stimulation and instead embrace the mid-term fiscal neutrality of spinal cord stimulation and the long-term cost savings.

In addition, employing pain therapies that limit opioid usage has been a longstanding goal in Cuba and has recently become the topic of a national emergency in the U.S.

Thus, both countries would benefit significantly by employing spinal cord stimulation earlier in the treatment algorithm. While these are the similarities our health care systems share, Cuba has some unique challenges and opportunities related to spinal cord stimulation.

First, and most obvious, is the trade embargo with its closest neighbor, the USA. The embargo has resulted in significant impediment to the flow of some of the latest neuromodulation technology, but there are some options from Canada, their biggest North American trading partner.

Another challenge is more cultural. In the U.S. most physicians initially learn how to perform spinal cord stimulation during cadaver training workshops, but Dr. Yera related that due to cultural and religious customs, cadavers available for medical training are virtually unheard of in Cuba. In the USA cadaver cost remains one of the most significant costs to physician training programs and thus, an alternative to cadavers for training purposes would be a significant benefit to both countries.

One of the most significant advantages Cuba has is the centralization of the economy and the government responsibility for both the healthcare system, as well as employment of much of the workforce. This type of system will provide a strategic advantage to evaluate the global economic impact of spinal cord stimulation on both the healthcare cost as well as lost employee productivity. In this economic system one might predict that the time to fiscal neutrality for the treatment of post-laminectomy syndrome would be shorter than the two years estimated in the U.S. because the government pays for both healthcare and lost productivity.

Clearly, further exploration of our similarities and common goals will ultimately enhance the health of both of our patient populations and aid in the expansion of neuromodulation to improve the quality of life of all our fellow humans. I look forward to further collaboration between the Cuban pain and neuromodulation societies and the U.S. and international pain and neuromodulation societies.

Lawrence R. Poree, MD, MPH, PhD
Professor and Director of Neuromodulation Service
Department of Anesthesia and Perioperative Care
University of California at San Francisco
Treasurer of the North American Neuromodulation Society
Director at Large for the International Neuromodulation Society
Institute of Neuromodulation Council Member
UCSF Pain Management Center

Abstracts, Video Posted from the 13th World Congress

Abstracts from the International Neuromodulation Society’s 13th World Congress Neuromodulation: Technology Changing Lives in Edinburgh, Scotland, UK from May 27 – June 1, 2017 can be found in the online October 2017 issue of Neuromodulation: Technology at the Neural Interface at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1525-1403

The same online issue also carries abstracts from the 20th Annual Meeting of the North American Neuromodulation Society, Las Vegas, NV, USA January 19 – 22, 2017.

Meanwhile, as a special benefit to members, select videotaped recordings of sessions from the 13th World Congress are available in the Members Only Section of the INS Website.

Upon logging in, INS members may visit the “Congress Proceedings” link. Under the proceedings listed for each day, session titles display a link if a videotaped recording is available.

Public Education Event Template Available to Chapters

The International Neuromodulation Society Full Board decided at its meeting in June 2017 that it intends for all regional meetings – both interim meetings and annual scientific meetings – to include a public education event.

In support of that goal, Dr. Simon Thomson was asked to work with INS Public Education and Website Manager Nancy Garcia to produce a planning-and-implementation “template” that can be tailored to each location.

With the Executive Officers' endorsement, the template is now available as a resource to all chapter board members and secretariats to help promote public education in neuromodulation around the globe.

2nd International Neuromodulation Society Interim Meeting to Take Place in Rio de Janeiro, Brazil, Aug. 8-11, 2018

The Second International Neuromodulation Society Interim Meeting will be hosted in collaboration with the Brazilian Neuromodulation Society (Sociedade Brasileira Neuromodulação - SBNM) from Aug. 8 to 11, 2018 in Rio de Janeiro, Brazil.

Dr. Alexandre Amaral, the new president of SBNM, and colleagues in the local organizing committee have selected a beautiful venue, the Windsor Barra Hotel, and their work on the scientific program is underway. Please mark your calendars and stay tuned for more details!

The 1^st European INS-Chapter Meeting in Nijmegen, the Netherlands Sept. 20-22, 2018

In September, the call for abstracts opened for the first European INS-chapter Congress on Neuromodulation.

The meeting is intended to stimulate both collaboration and unification among the European chapters, through a scientific exchange and social program. The broad program will cover innovative research and the latest developments in neuromodulation through its plenary lectures, overview talks and poster sessions. A preconference cadaver course is planned. In addition, attention will be paid to specific nursing issues.

All INS members are cordially invited to participate.

The meeting will take place at the brand-new "Van der Valk Hotel" in Lent, 2 km from the city center. Nijmegen is the oldest city in the Netherlands, in a picturesque setting on the east side of the country. It can be easily reached by car, train or air travel. The city is convenient to several international airports, including ones in Amsterdam (Schiphol), and in Weeze or Dusseldorf in Germany.

Please watch for additional details from local committee chair Mike J.L. DeJongste, MD, of Groningen, and co-chair Robert T.M. van Dongen, MD, of Nijmegen.

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