Spinal Cord Stimulation

Many people with the following conditions have received tremendous pain relief from Spinal Cord Stimulation:

Failed Back and Neck Surgery

Cervical, Thoracic and Lumbar Radiculopathy

Reflex Sympathetic Dystrophy (RSD)

Complex Regional Pain Syndrome

Peripheral Neuropathy Pain

Phantom Limb Pain

Post-Herpetic Neuralgia

Other nerve-related pain syndromes

Spinal Cord Stimulation (SCS) is a safe and effective treatment method for various pain syndromes. In order for you to perceive pain, an electrical pain signal must travel from the origin of pain to your brain. The spinal cord stimulator delivers an array of electrical stimulation that blocks these pain signals. It replaces them with a pleasant tingling sensation referred to as a paresthesia.

When discussing SCS with patients, I use the analogy of dropping a hammer on your toe. There is an obvious source (the hammer) and location (your toe). The pain signal travels up nerves in the foot and leg to the spinal cord. It then travels up the spinal cord into the brain. At that point, you perceive the pain. One instinct is to rub your foot or ankle (not the toe). This rubbing creates an alternate signal that confuses your nervous system. This reduces the amount of pain signals transmitted to your brain. The SCS device delivers an electrical stimulus (a.k.a. the rubbing) directly over the area in the spinal cord where the pain signal is traveling. It prevents your brain from perceiving the full pain signal.

A SCS trial consists of placing one or two catheters into the epidural space utilizing X-Ray guidance.  No incisions are needed for this.  Each catheter contains between 4 and 8 electrical contacts.  The catheters are connected to an external battery.  The device is programmed to provide comfortable coverage of painful areas.  The patient can turn the device on/off, up/down, and change programs during the trial with a remote control.  If greater than 50% of pain relief is achieved with significant functional improvement, the trial is considered successful.  If we are both in agreement that this device will provide a significant improvement in quality of life, permanent SCS implantation is then scheduled.  I perform these on an outpatient basis under moderate sedation and local anesthesia (not general anesthesia).   On average, a trial takes 20-30 minutes and a permanent implant takes 75-90 minutes.

As an example, I recently performed a SCS trial for a patient who had 4 previous lumbar spine surgeries with continued low back and leg pain.  After conservative management was exhausted,  a two-lead SCS trial was performed 2 weeks ago.  During the trial, my patient reported 80% pain reduction.  As she enjoys gardening, she spent the entire week doing yard work that she has not been able to perform for years.  She stated that it was the first time in years that she woke up in the morning with no pain.  Permanent implantation is scheduled.

It is very important to realize that not everyone will benefit from a SCS device.  Success begins with proper patient selection.

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Peripheral Neuropathy

Peripheral neuropathy is a common cause of chronic pain.  Causes of peripheral nerve damage include diabetes, autoimmune disorders, nutritional deficiencies, alcohol abuse, inherited diseases, and toxic drug exposure.  Approximately 15% of diabetics experience some form of peripheral neuropathy.

Initially, patients develop numbness and/or weakness in the hands or feet.  Early on, this involves the fingers and toes, but can work its way up the limbs.  Patients experience burning pain in the extremities – most commonly involving the feet.

Treatment is centered on the underlying disease.  Pain therapy involves medication management centered on neuropathic pain medications. In some cases, Spinal Cord Stimulation can be an effective long-term therapy.

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Neuropathic Pain Medications

The treatment of neuropathic pain can be very difficult.  It is often necessary to conduct trials of multiple medications before finding the best regimen.  It is important to be patient as effective medications for one individual may be different than others.   These medications include:

Anti-epileptic (anti-seizure) medication – gabapentin, pregabalin, carbamazapine, etc.

Antidepressant medication  - tricyclics (e.g. amitriptyline), SSRIs (e.g. duloxetine)

Topicals – Local anesthetic preparations (creams, gels, patches), other compounded creams

Opiates

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Post-Amputation Pain

After limb amputation, chronic pain can be a major issue.  Pain at the stump site can be a nagging problem due to recurrent infection, skin breakdown, pressure ulcers from prosthetic devices, etc.  Neuromas (abnormal overgrowth of nerve fibers) can also form at the site of amputation and can cause severe neuropathic pain.

After amputation, patients often have phantom limb sensation.  They sense the feeling of the body part that is no longer there.  Normal sensation is generally not a problem, but occasionally these can be painful (Phantom Limb Pain).  Patients experience severe shooting and burning pain in the limb that was already amputated.

Treatment initially involves medication management centered on neuropathic pain medications.  Psychological / cognitive behavioral therapy is also very important.  Spinal Cord Stimulation has been shown to be a very effective long-term therapy.

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Sacroiliac Joint Arthropathy

Pain that is localized to the low back, hips and buttocks is commonly caused by sacroiliac (SI) joint pain.   SI joint pain commonly radiates to the outside of the thigh, but rarely past the knee.  Stress applied to the joint on physician exam can suggest this as the source of pain, but is very non-specific.  A targeted injection with local anesthetic under fluoroscopic (X-Ray) guidance is really the only way to diagnose SI joint pain.  If the pain is relieved completely after injection, a definitive diagnosis can be made.  The addition of a concentrated low dose of steroid to this injection can provide long-term pain relief.  Other treatment of SI joint Arthropathy involves NSAIDs (Non-Steroidal Anti-inflammatory Drugs), local anesthetic patches (5% Lidocaine, but is off-label), and most importantly physical therapy.  Physical therapy involves gait training (how you walk) and muscle strengthening.  The results of Aquatherapy have been promising.  Radiofrequency treatment of the nerves that supply the SI Joint has also shown some promise as a long-term tratment.

Rare causes of SI joint pain include trauma, infection and tumor involvement.

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Medial Branch Nerve Blocks

Medial branch nerve blocks are a diagnostic test for facet joint arthropathy.  This test can be done in the cervical, thoracic, and lumbar spines.  I perform this procedure under intermittent X-ray guidance to localize the exact area of the nerve.  Each facet joint has two nerves that supply it.  By performing a local anesthetic block, facet arthropathy can be diagnosed or excluded.  After the injection, facet-loading maneuvers are performed.  In the low back, I have the patient bend back at the waist and to the affected side.  In the neck, this is done by the patient laterally flexing the neck (touching the ear to the shoulder).  If the pain is absent after the block, a diagnosis can be made.  This normally will only result in short-term relief.  However, with this information, radiofrequency ablation of these nerves can now be performed.  That will result in long-term relief.

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Facet Joint Arthropathy

Facet arthropathy can affect the cervical, thoracic, and/or lumbar spine.  These small joints, also known as z-joints or zygapophysial joints, can be affected acutely or damaged from chronic wear and tear.  In the low back, these joints can be loaded or stressed by extension and lateral rotation (bending back at the waist and to one side).  If your usual pain is reproduced when making this motion without any leg pain, this is likely pain from your facet joints.  Pain can sometimes radiate to the buttocks and/or thigh, but rarely below the knee. 

 

In the neck, facet pain is reproduced when laterally flexing the neck (trying to touch your ear to your shoulder), as well as extending the neck (looking upwards).

 

Each individual joint has two nerves that supply it called medial branches.  These nerves are important in the treatment of facet-mediated pain.  This treatment involves medial branch nerve blocks and radiofrequency nerve ablation.

 

X-rays and MRIs can sometimes be helpful in diagnosing facet pain, but physical exam and diagnostic medial branch nerve blocks are most accurate.

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