An estimated 70 million people in the United States live with chronic pain. In addition to the billions it costs the economy in lost productivity, the human toll is even greater. While in many cases pain can be managed with different classes of drugs and/or surgical procedures, a significant number of patients continue to suffer the devastating effects of pain that can cost them their careers, their livelihoods and their quality of life.
For patients who do not achieve sufficient pain control from standard therapies, or who need alternatives due to side effects, a risk of addiction, or diminishing effectiveness, spinal cord stimulation (SCS) is an adjunct therapy that may offer a new option for relief. This modality has proved successful in treating thousands of people around the world each year.
“This pain-relieving technology places small, metallic, programmable leads into the epidural space through a needle, much like an epidural catheter is introduced for labor analgesia. Under fluoroscopic guidance, the leads are then advanced to the appropriate vertebral level and tested until the patient reports paresthesias covering the painful area,” Brian Thoma, MD said.
Thoma performs the SCS procedure as part of his practice at Alabama Pain Physicians in Birmingham
“The beauty of this technology is that patients get to “test drive” it before deciding if they want the permanent device implanted,” Thoma said. “If a patient returns to our office and reports either minimal benefit or is simply not sure how helpful the device was during the trial, I am not going to recommend the permanent device. I want the patient to come in the office at the end of the trial and demand it.”
The trial procedure can be performed in the physician’s office, with leads secured to the skin. Patients then wear the system for the next three to five days to determine how well the therapy alleviates their pain.
If the device has provided adequate pain relief during the trial, the patient will have the option of scheduling the implantation of a permanent spinal cord stimulator, which is typically done at an outpatient surgery center. The permanent device usually consists of two leads and a battery that is roughly the same size as a pacemaker.
The mechanism of action for producing pain relief is based on Gate Control theory. The dorsal horn of the spinal cord contains both pain and non-pain sensory pathways. It is believed that the activation of non-pain afferents “closes the gate” on pain pathways.
“Depending on the individual and the programming, the patient may report a vibration or tingling sensation that is either neutral or pleasant covering their painful areas,” Thoma said. “Interestingly, the pain-relieving benefits of SCS do not depend on the patient feeling the paresthesias. Even unperceivable stimulation may be adequate for good analgesia.”
SCS is most commonly used for patients who continue to have back and leg pain following previous spine surgery.
“Despite technically sound back surgery, some patients will continue to experience significant back and leg pain,” Thoma said. “If there is no indication for repeat back surgery, they may be candidates for spinal cord stimulation. There are studies demonstrating both the clinical benefit and the cost effectiveness of SCS in this patient population.
“It is important to realize that SCS is not indicated for every spine patient. In some cases, repeat back surgery may be necessary. We rely on the opinions of our surgical colleagues when they refer patients to us. We are often asked to see people who have already been evaluated for spine surgery, but have no surgical option.”
SCS is also used to treat other conditions including complex regional pain syndrome (CRPS). This may develop after an orthopedic injury even when a patient has had successful corrective surgery. CRPS typically includes some aspect of physical changes in the affected limb, and may include pain that is independent of activity.
Research is also suggesting that SCS may be an effective tool in dealing with problems ranging from angina pectoris to peripheral vascular disease and peripheral neuropathy.
“As further evidence emerges, we are hopeful that more patients will benefit from spinal cord stimulation in the future. Just recently, at the 6th World Congress of the World Institute of Pain, reports were presented of successful use of SCS in patients suffering from HIV neuropathy,” Thoma said.
Another area where SCS is likely to bring welcome relief is in helping physicians find a middle ground between the growing awareness that chronic pain has all too often been under treated, and continuing concerns about opiate addiction and the role pain medications play at the epicenter of illegal drug use.
“It is easy to be cynical about opiate pain management for nonmalignant chronic pain,” Thoma said. “While many patients are able to enjoy an improvement in function and quality of life, there are those who require escalation of opiates, yet fail to report any improvement. Escalation of opiates can be harmful on many fronts. In fact, we know that for many men, chronic opiate therapy can lead to symptomatic hypotestosteronism, which has its own devastating consequences. There is also the risk of developing opiate addiction, which appears to be at least as prevalent among pain patients as alcoholism is in the general population.
“As comprehensive pain management physicians, we would like to avoid therapies that may compromise our patients’ ability to function. Our approach to every patient is quite simple: 1) spend the time to make an accurate diagnosis 2) utilize as many appropriate interventions available to treat the emotional and physical aspects in order to improve the quality of life of our patients. This includes medication and interventional pain management in one office.
“We also understand the importance of utilizing adjuncts which help us provide safe, reliable long term pain relief while increasing function and improving the quality of life of our patients,” Thoma said. “We have had excellent long term results with spinal cord stimulation.”
