Spinal Cord Stimulators

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

Spinal Cord Stimulation Therapy

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

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 patient’s pain Conventional IPG system Rechargeable IPG System Radiofrequency (RF) system

Spinal Cord Stimulator Procedure

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

Benefits of SCS

Pain reliefReduction in pain medication intakeImprovement of depression symptomsReturn to workReturn to daily activitiesIncrease quality of life

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 PlacementPatients must be motivated and willing

to try the treatment

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

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

FBSS Results

Leveque, J et al. Randomized Controlled Trial of 16

patients with FBSSANS St. Jude Medical Company Case

Study Case Study of a patient with FBSS

Complex Regional Pain Syndrome

AKA: Reflex Sympathetic DystrophyMulti-symptom/ Multi-system Characteristics:

Soft tissue injury/ immobilization Temperature difference between affected

and unaffected extremity of at least 1°C Tactile hypersensitivity Cutaneous changes

CRPS and SCS Research Results

Kemler, M et al. Randomized Control Trial of patients with

Chronic Reflex Sympathetic DystrophyHarney, 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

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.

Leg painCharacteristics

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.

Questions??

ReferencesANS: 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., & O’Keeffe, 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.

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.