Spinal Cord Stimulators

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Spinal Cord Stimulators
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Spinal Cord Stimulation Therapy

• FDA-approved therapy to treat chronic pain of the
  trunk and/or limbs
• Used to treat patients with neuropathic pain
• SCS is considered a third tier pain therapy
• SCS is not a cure

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Pain

• Nociceptive Pain
• Harmful stimulus is applied to skin, joints,
  muscles and nociceptive nerve endings are
  activated
• Sharp shooting/ dull aching pain
• Typically lessens over time
• Responds well to traditional treatments
• Neuropathic Pain
• Arise spontaneously without activation of
  nociceptors
• Typically Chronic pain
• Does not respond well to traditional treatments
• Tactile Hypersensitivity- allodynia and
  hyperalgesia

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How does SCS Therapy work?

• Stimulator leads placed along the dorsal column
  of the spinal cord produce paresthesia sensation
  to help mask pain signals
• There are 3 types of SCS systems that can be used
  depending on the patients pain
• Conventional IPG system
• Rechargeable IPG System
• Radiofrequency (RF) system

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Spinal Cord Stimulator Procedure
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Theories Behind SCS Therapy

• Gate Control Theory
• By stimulating the large A beta blocks the
  transmission of pain signals via the small C
  fibers
• Stimulating supraspinal pathways sends signals up
  the dorsal column to the brain stem and is then
  returned to spinal cord via dorsal Longitudinal
  fasciculus to mediate the pain pathways
• Descending Inhibition of Pain pathways
• Stimulation of the adrenergic sympathetic neurons
  close the gate
• Stimulation of Dorsal Nerve root fibers

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Benefits of SCS

• Pain relief
• Reduction in pain medication intake
• Improvement of depression symptoms
• Return to work
• Return to daily activities
• Increase quality of life

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SCS Candidates

• SCS is a last resort treatment of chronic pain
  when other therapies have failed
• Patients must have a multidisciplinary screening
  to determine if they would be a good candidate
• Successful Trial Placement
• Patients must be motivated and willing to try the
  treatment

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Successful SCS treatments

• SCS has been used since 1967 for the treatment of
  chronic pain
• SCS has successfully treated numerous painful
  disorders
• Failed Back Surgery Syndrome/ Arachnoiditis
• Reflex Sympathetic Dystrophy (Complex Regional
  Pain Syndrome
• Angina
• Stump Pain/ Phantom Limb Pain
• Peripheral neuropathies
• Radiculopathies
• Peripheral Vascular Disease/ Ischemic Pain

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Failed Back Surgery Syndrome

• Pain that persists after one or more surgical
  procedure on the lumbo-sacral spine
• Most common diagnosis for patients who receive
  SCS
• Etiology is difficult to pinpoint
• Most common cause of FBSS- improper patient
  selection
• 1-10 of patients will be worse after surgery
• Characteristics back/ leg pain,
  numbness/tingling weakness in legs, stabbing
  burning and shooting pain

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FBSS Results

• Leveque, J et al.
• Randomized Controlled Trial of 16 patients with
  FBSS
• ANS St. Jude Medical Company Case Study
• Case Study of a patient with FBSS

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Complex Regional Pain Syndrome

• AKA Reflex Sympathetic Dystrophy
• Multi-symptom/ Multi-system
• Characteristics
• Soft tissue injury/ immobilization
• Temperature difference between affected and
  unaffected extremity of at least 1C
• Tactile hypersensitivity
• Cutaneous changes

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CRPS and SCS Research Results

• Kemler, M et al.
• Randomized Control Trial of patients with Chronic
  Reflex Sympathetic Dystrophy
• Harney, D et al.
• Review of case studies with patients with CRPS
  treated with SCS
• Overall all SCS groups had a 60-70 success rate,
  narcotic intake was reduced and improvement in
  activity and quality of life

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SCS and Angina

• Number 1 Reason for Spinal Cord Stimulator
  implantation in Europe
• Main Clinical Symptoms are related to ischemic
  heart pain
• Pain in chest, arms, throat and neck
• Results
• Improved Coronary blood flow but no increase in
  totally flow
• Altered sympathetic/ parasympathetic balance
• Research- Ferrero, P et al., De Jongste et al.

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Leg pain

• Characteristics
• Pain in leg when walking
• Numbeness/tingling in leg
• Burning pain that is worse at night
• Phantom limb sensation- uncontrollable movements
• Sensitive Pain
• Research
• Jivegard et al.
• Raina, et al.

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Questions??
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References

• ANS St. Jude Medical Company. (n.d.). Spinal
  Cord Stimulation A Promising Treatment Option
  for Your Patients With Chronic Pain Pamphlet.
• Boston Scientific. (2007). Taking Control of Your
  Pain The First Step Pamphlet. USA Precision
  Plus.
• Cameron, T., Ph.D. (2004, March). Safety and
  Efficacy of Spinal Cord Stimulation for the
  Treatment of Chronic Pain a 20-year Literature
  Review. Journal of Neurosurgery Spine, 100,
  254-267.
• Ferrero, P., MD., Grimaldi, R., MD., Massa, R.,
  MD., Chiribri, A., MD. (2007, January). Spinal
  Cord Stimulation for Refractory ANgina in a
  Patient Implanted with a Cardioverter
  Defibrillator. PACE, 30, 143-146.
• Greenwald, T., RN., Ryan, B., RN. (2004, June).
  Spinal Cord Stimulation Overview. In Mayfield
  Clinic. Retrieved January 15, 2009, from
  http//www.mayfieldclinic.com/PE-STIM.htm
• Harney, D., Magner, J. J., OKeeffe, D. (2004,
  June). Complex Regional Pain Syndrome the case
  for Spinal Cord Stimulation (a Brief Review).
  Injury International Journal of the Care of the
  Injured, (36), 357-362.

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References Continued

• Kemler, M. A., MD., Barendse, G. A., MD., Van
  Kleef, M., M.D., Ph.D. (2000, August). Spinal
  Cord Stimulation in Patients with Chronic Reflex
  Sympathetic Dystrophy. The New England Journal of
  Medicine, 618-624.
• Leveque, J.-C., Villicencio, A. T., Bulsara, K.
  R., MD. (2008, October). Spinal Cord Stimulation
  for Failed Back Surgery Syndrome.
  Neuromodulation, 4(1), 1-9.
• North, R., MD. (2007). Practice Parameters for
  the Use of Spinal Cord Stimulation in the
  Treatment of Chronic Neuropathic Pain. American
  Academy of Pain Medicine, 8(S4), S20-S275.
• Raina, G. B., Piedimonte, F., Micheli, F.
  (2007). Posterior Spinal Cord Stimulation in a
  Case of Painful Legs and Moving Toes.
  Stereotactic and Functional Neurosurgery, (85),
  307-309.