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Spinal Cord Stimulation for Back Pain

Spinal Cord Stimulation for Back Pain. Vikram Patel, MD FIPP DABIPP Medical Director ACMI Pain Care Algonquin, Illinois. Disclaimer. No financial relationships with any manufacturing companies or pharmaceutical companies Some indications are not FDA approved –yet

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Spinal Cord Stimulation for Back Pain

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  1. Spinal Cord StimulationforBack Pain Vikram Patel, MD FIPP DABIPP Medical Director ACMI Pain Care Algonquin, Illinois

  2. Disclaimer • No financial relationships with any manufacturing companies or pharmaceutical companies • Some indications are not FDA approved –yet • Mention of any trade names is purely for the sake of clarification and simplicity

  3. What is it? • Electrical stimulation of the dorsal spinal columns (and perhaps deeper structures) • Achieved with the use of an electrical array to deliver the current using various sources • Used as a high end procedure in cases with intractable chronic pain not responsive to other less invasive maneuvers

  4. What is it? • History of spinal cord stimulation • First performed • 1967 published report by Shealy • Evolution of various types of leads, generators • Current state of the modality • Companies • Various types of equipment Shealy CN, Mortimer JT, Reswick, JB (1967). "Electrical Inhibition of pain by stimulation of the dorsal columns: Preliminary Clinical Report". Anesth Analg46: 489-91.

  5. Who does it? • Pain specialists (?) • Training • Experience • Neuro-surgeons • Ortho-spine surgeons

  6. How is it done? • Pain specialists • Percutaneous approach • Trial and permanent placements • Neuro-surgeons • Open approach • Trial and permanent placements • Joint effort • Percutaneous trial followed by an open permanent placement

  7. How does it work? • Gate control theory • Secondary neurons vs. primary neurons • Stimulation of inhibitory fibers • Release of endogenous opiates • Sympathetic blockade like activity • Increased peripheral blood flow • Decreased sympathetic pain perception

  8. The Procedure • Indications • Spinal • Post-laminectomy syndromes • Radiculopathy in a patient without prior surgery • Low back pain • Non-spinal • Complex regional pain syndromes • Peripheral vascular diseases • Angina pectoris • Pelvic pain • Neuropathic pain syndromes • Diabetes, peripheral neuropathies, central pain syndromes

  9. The Procedure • Contra-indications • Patient refusal • Infection (generalized as well as localized) • Coagulation abnormalities • Inappropriate psychological overlay to the pain • Unaddressed psychiatric issues • Pacemaker and/or defibrillator (?) • Anatomical abnormalities (relative) • Body habitus, surgical hardware • Secondary gain issues (relative?)

  10. The Procedure • Types of leads

  11. The Procedure • Types of leads

  12. The Procedure • Types of power sources

  13. The Procedure • Choice of system • Percutaneous vs. surgical placement • Number of electrodes • Number of leads • Unilateral vs. bilateral • Power source • RF systems • Lithium battery • Rechargeable systems

  14. The Procedure • The trial • Psychological clearance • Insurance approval • Venue • Office procedure room vs. operating room • Pre-operative preperation • Consent • Antibiotics • IV sedation (precautions)

  15. The Procedure • The trial • Positioning • Monitoring • Prep & drape • Placement of the lead (the entry site) • Positioning the lead (the end point) • Trial stimulation • Fine tuning • Duration of trial stimulation

  16. The Procedure • Permanent placement • Pre-operative evaluation • Wait period between the trial and permanent placement • Placement of the lead • Same as the trial • The pocket • Site and size • Post-operative follow up

  17. The Procedure • Maintenance • Short term • Immidiate post-operative period • Complications • 4-6 weeks after placement • Long term • Routine maintenance • Complications • Final outcome • Removal ? • Replacements

  18. Stimulation for Back Pain • Post laminectomy syndrome • Axial low back pain in combination with radicular symptoms • Complex low back pain

  19. Low back pain Spinal cord stimulation with hybrid lead relieves pain in low back and legs. de Vos CC, Dijkstra C, Lenders MW, Holsheimer J. Neuromodulation. 2012 Mar-Apr;15(2):118-23 Hybrid lead was placed surgicallyin FBSS patients Average VAS score at baseline was 8.0 for lower limb pain and 7.5 for low back pain, after 6 months, average VAS scores were reduced to 3.2 and 3.5, respectively, and also pain medication was reduced  Single hybrid lead positioned over the physiological midline of the spinal cord, is capable of alleviating both low back and leg pain in patients with FBSS

  20. Low back pain Patient satisfaction with spinal cord stimulation for predominant complaints of chronic, intractable low back pain. Ohnmeiss DD, Rashbaum RF.Spine J. 2001 Sep-Oct;1(5):358-63.  41 patients who underwent SCS for predominant complaints of low back pain. The mean symptom duration was 82.9 months, and the mean age was 47.9 years, all but 3 had spine surgery  60% of patients considered themselves improved from their preoperative condition  Majority of patients were satisfied with the results of SCS and would have the procedure again knowing what their outcome would be

  21. Low back pain Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Burchiel KJ, Anderson VC, Brown FD, Fessler RG, Friedman WA, Pelofsky S, Weiner RL, Oakley J, Shatin D. Spine 1996 Dec 1;21(23):2786-94. 219 patients were entered at six centers throughout the United States All pain and quality-of-life measures showed statistically significant improvement during the treatment year using VAS, McGill Pain Questionnaire, OswestryDisability Questionnaire, Sickness Impact Profile, and the Back Depression Inventory. Spinal cord stimulation can be an effective therapy for management of chronic low back and extremity pain

  22. Case Study 1 • 58 y.o. W M, injured at work • H/O spinal fusion (3rd spine surgery) • C/O low back pain and bil. Leg pain • Treated with • lumbar facet joint interventions above the fusion level • Transforaminal steroid injection • Epidural adhesiolysis • Only short term relief • Finally agrees to a spinal cord stimulator trial • Permanent placement provided >90% long term relief

  23. Case Study 1

  24. Case Study 1

  25. Case Study 2 48 y/o male. Motor cycle accident with multiple injuries S/P lumbar micro(?)discectomy C/O bil leg pain while at rest and low back pain while on both feet Pharmaceuticals not very effective Lumbar facet interventions provided short term relief For leg pain transforaminal injections did not help much Adhesiolysis not approved by his insurance company Failed psychological evaluation due to anger and hostility Treated by psych for 6 months, passed eval after that SCS approved by insurance company

  26. Case Study 2

  27. Summary Spinal cord stimulation approved for radiculopathy after spine surgery and Complex regional pain syndrome Effective for many other syndromes, esp. vascular phenomena, headaches, angina, visceral pain syndromes Low back pain currently not an approved indication unless accompanied by radicular pain Many newer types of leads (16 contacts, 5 arrays, perc. Paddle) and pulse generators are now available to effectively treat low back pain

  28. Thank You Questions??

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