By Marti Webb Slay
Patients with chronic, non-surgical low back pain now have access to a minimally invasive outpatient procedure that can bring relief and rehabilitate the muscles of the lower back. The treatment stimulates the multifidus muscle using an implanted neurostimulator.
“Primarily this is for patients with axial back pain without significant radicular complaints. It’s for the patient who typically would have been treated with lumbar radiofrequency ablation,” said Christopher Paul MD, assistant professor in the UAB Department of Anesthesiology and Perioperative Medicine and medical director of the UAB Pain Treatment Clinic. “We’ve found an element of muscular dysfunction in the low back, specifically with multifidus muscles, which provide a lot of microstability to the spine.”
Paul distinguishes between surgical instability and microstability. Patients who experience low back pain while brushing their teeth, doing dishes or simply standing will likely get the most benefit from this procedure.
“If they see a surgeon and they are deemed to not be a surgical candidate, this device could be an option for them,” Paul said. “The device is implanted in a 30 to 45 minute outpatient procedure under general anesthesia. There are two small incisions, and the device sits on top of the spine. It doesn’t go into the spinal canal, so the risk is less than with other implantable devices.”
While the device is relatively new in the US, it has been tested here and used in Europe long enough to publish three-to-five-year data which is encouraging. “According to the data, 77 percent of patients had a 50 percent reduction in the 0-10 pain score at three years, and 67 percent had what is statistically considered resolution of back pain, less than 2.5 on that scale,” Paul said. “Also, about 71 percent of the people in that data study were able to eliminate or reduce their opioid use.
“There is nothing else out there that will restore or regenerate muscular function. Most devices are for palliation after surgery. Instead of covering up the pain, this aims to regenerate the muscle that has been atrophied so it’s a unique indication.
“It’s important for patients to realize they have to do their part following the surgery. An internal battery powers the system, and patients use a remote control to initiate a session that feels like a deep tissue massage. This is a therapy that requires active participation from the patient. They have to use it for two 30 minute sessions a day. It causes contractions in these atrophied muscles that have been disused. They must set time aside to run the programming.
“The treatment sessions are done at home. People are doing this at home, watching the TV, drinking their coffee.
“Recovery typically starts with improved function, followed by pain relief. Over the first six to eight months, first there is an improvement in function. Fine motor movements start to come back as the muscle regenerates, but the pain relief tends to lag a little behind that. But over time the data would suggest the patients use this less and less as time goes on.
“Most patients when they hit the 12 to 18 month mark are using it maybe every other day or once a week or not using it at all, because they regenerate the muscle and they are able to use the muscle again. It’s patient driven. There’s a decrease in patient usage because they are getting better.”
UAB was one of the first hospitals in Alabama to perform this procedure, although other hospitals are now offering it as well. UAB has completed 10 procedures so far. “We did the first ones in October and those are having considerable success and doing well,” Paul said.
Paul expects the procedure will be more prevalent in future. “It’s really a matter of educating our referring physicians, particularly neurosurgical and orthopedic spine colleagues, that this is an option,” he said. “We want to work with our colleagues to identify these patients and steer them to the right therapy earlier.
“There is a little correlation between the degree of atrophy and how fast they respond to the therapy, but subset analyses of the study groups do not show any benefits to younger patients vs. older patients. The Medicare population performed equally as well on this.
“The data is very encouraging, and I am very excited about this in terms of improving long-term outcomes of our patients.”