Spinal Cord and Peripheral Nerve Stimulation

Dimitris Papadopoulos MD Fellow Of Interventional Pain Practice (FIPP)

Updated 25 January, 2011

GENERAL

Spinal cord stimulation is a neuromodulation therapy. The term “neuromodulation” refers to therapies which stimulate, inhibit or coordinate the activity of neurons or neuronal networks through the electric or chemical change of  signal transmission to the nervous system. In this way, pain signals are interrupted and modified during their course from the spinal cord to the brain. The patient does not feel pain any more and instead s/he feels a pleasant light paraesthesia.
For the chronic pain treatment, neuromodulation can be applied with spinal cord stimulation, peripheral nerve stimulation and subarachnoid drug injection by using special implantable systems in order to achieve the optimal therapeutic result.

WHO ARE CANDIDATES FOR NEUROMODULATORY THERAPIES

Neuromodulation therapies are indicated for carefully selected patients suffering from chronic pain
- who are not effectively relieved with pharmacotherapy or other less invasive methods,
- who present considerable drug side-effects,
-  for whom surgery is contraindicated or is not expected to have satisfactory results
- who are still in pain after surgery
These are reversible therapies which are applied after the application of a testing period during which the patient has observed significant pain relief.

DESCRIPTION OF THE METHOD

For the application of spinal cord stimulation, one or more electrodes are implanted to the epidural space, the dorsal horn of the spinal cord and to the level corresponding to the dermatome where the pain is manifested. This procedure is performed under local anaesthesia and fluoroscopic guidance. The electrodes are subcutaneously connected with an implantable generator. The electric energy produced by the generator is applied through the electrodes to the proper regions of the spinal cord.

Alternatively, in some cases, peripheral neurostimulation or combination of spinal and peripheral stimulation can be applied. In case of peripheral stimulation, one or more electrodes are subcutaneously placed to the area where the pain is localized and are subcutaneously connected with an implantable generator. The electric energy produced acts on the peripheral nerves in order to reduce pain.
For evaluating the therapeutic result of neuromodulation, a testing period of a few days takes place. As long as the patient experiences significant relief (50%) and gives his/her consent, a permanent system is implanted. In case there is no satisfactory result, then the electrode(s) placed are withdrawn. It is a fully reversible therapy, meaning that every neuromodulation system can at any time be removed in case of necessity without any adverse event.

The programming of the system is done telemetrically with a special remote control. There is the potential to change and apply various combinations, so that the patient receives the optimal therapeutic result. The patient also is equipped with a remote control to turn off, activate and turn up and down the stimulator.

ABSOLUTE INDICATIONS

Neuropathic pain

  • Radiculopathies with or without low back pain (chronic sciatica)
  • Failed Back Surgery Syndrome (FBSS)(2,10,12,13,14))
  • Complex Regional Pain Syndrome (CRPS) – Algodystrophy:(30,31,32,33,34,35,36,37)

- type Ι (reflex sympathetic dystrophy)
- type ΙΙ (causalgia)

OTHER INDICATIONS

Ischaemic pain (51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66)

  • Persistent drug-resistant stable angina
  • Peripheral Vascular Disease (PVD)/ painful lower limb ischaemia

Neuropathic Pain

  • Diabetic Peripheral Neuropathy(41,42,43,44)
  • Peripheral Neuropathy (post-herpetic neuralgia, phantom-limb pain, peripheral nerve injury etc(38,39,40)

EFFICACY

Neuropathic pain

• Spinal cord neurostimulation is very effective in the treatment of lower limb pain compared to conservative treatments and to revision spinal surgery
• Pharmacotherapy and other pain treatments are significantly reduced
• Quality of life and functional capacity of patients significantly improve

Ischaemic Pain

• Pain reduction, improvement of the microcirculation of the ischaemic limb and relief from the angina pain
• Significant reduction of the risk for amputation of the ischaemic limb compared to conservative treatment and even with surgical reperfusion techniques
• Reduction of drug use for pain treatment
• Reduction of myocardial ischemia and  ischaemic attacks
• Improvement of the patient’s heart function and quality of life

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