Neurostimulation: The Pacemaker for Pain

Neurostimulation: The Pacemaker for Pain

Improving the Quality of Life for Patients with Chronic Pain

Dr. Sonia Pasi of Advanced Pain Consultants is improving patients’ quality of life with a unique neurostimulator device deemed the “pacemaker for pain”. Most widely used for patients suffering from various chronic pain disorders, the spinal cord stimulator (SCS) is an effective solution for patients who have not found relief through traditional therapies. “The stimulator can help reduce patients’ dependence on pain medication and return them to a more active lifestyle,” says Dr. Pasi, board certified in neurology and interventional pain medicine.

Other uses of neurostimulation include cortical stimulation for patients with intractable facial pain conditions such as trigeminal neuralgia; deep brain stimulation to help Parkinson’s patients suffering from tremors and dystonia; and vagal nerve stimulation for epilepsy patients.

The total cost associated with chronic pain in the U.S. reaches upwards of $635 billion each year, according to the American Pain Society. That includes indirect costs such as lost days of productivity. If left untreated, chronic pain is not only a financial burden but can severely affect a patients’ relationships with their loved ones and ultimately their quality of life.

“Spinal cord stimulation has been helping patients manage their chronic pain for decades, but many physicians are unaware that the treatment even exists let alone the impact it can have on improving their patient’s quality of life,” says Dr. Pasi.

According to Dr. Pasi, here are the most common questions referring physicians have when learning about the spinal cord stimulator (SCS) system and how it might benefit their patients.

What is a spinal cord stimulator (SCS)?

Spinal cord stimulation relies on low voltage electrical pulses of the spinal nerves to interrupt the pain signal sent to the brain. By blocking the feeling of pain, patients can potentially reduce or eliminate the need for pain medications and return to comfortable, productive lives. Utilizing electrical stimulation similar to a pacemaker, SCS has been called the “pacemaker for pain”.

How does it work?

An SCS is a device that is surgically placed under the skin to send a mild electrical current to the spinal cord. A small wire carries the pulse to the nerve fibers of the spinal cord and when turned on, feels like a mild tingling in the area afflicted by pain. The electrical current interrupts the pain signal from reaching the brain and thus reduces the amount of pain felt by the patient.

Patients are able to adjust the SCS system’s level of intensive through a transmitter device that can program the various electrical settings (amplitude, frequency, pulse width, and polarity). Patients have the ability to select the best setting for managing their pain as it changes throughout the day. The transmitter allows patients to turn the stimulation up or down, just like you would turn the volume up or down on a TV remote control. In fact, many refer to the transmitter device as a “remote control for pain”.

The SCS device is manufactured by three major companies: Boston Scientific, Medtronic and ANS.

How is the procedure performed?

Phase One: Trial Phase


SCS implantation is performed in two phases. In phase one, patients must undergo a trial to see if the device decreases their level of pain. “There are not many treatment options that give patients the ability to test drive them before they commit. With SCS, patients get the benefit of testing the device prior to making a decision about surgery,” says Dr. Pasi.

During the SCS trial phase, a lead(s) is implanted temporarily in the space above the spinal cord through an outpatient procedure that takes about an hour. The leads are connected to an External Trial Stimulator (ETS) which are worn on a soft belt. Patients are then taught how to use a remote control which allows them to turn the therapy on and off and increase or decrease the intensity of the stimulation.

Once the stimulator is turned on, patients can experience instant relief. After a one week trial phase, patients follow up with their physician to evaluate if the trial was successful or not. According to Dr. Pasi, a trial is considered successful if the patient experiences a pain reduction of more than 50 percent.

Phase Two: Implantation

If phase one is successful, patients are scheduled for surgery to permanently implant the device (known as phase two of treatment). Permanent implantation is usually performed by a neurosurgeon in a hospital or surgical center setting. Although it is called permanent, treatment can be discontinued at any time and the device safely removed.

Prior to the procedure, the patient is lightly sedated and local anesthesia is injected where the small incisions are to be made. The leads are placed in the epidural space above the spinal cord and secured with sutures. The surgeon will decide how many leads and the number of electrodes to implant.

The patient is then awakened during the procedure to help the surgeon determine how well the stimulation covers the pain pattern. Once the leads are in place, sedation is given again. An extension wire is then passed under the skin from the spine around the torso to the abdomen or buttock where the generator will be implanted superficially in the fatty tissue.

Patients are discharged the same day and the pulse generator is programmed before they leave. Approximately ten days after the procedure the patient returns to the office to remove the sutures or staples. Programming of the pulse generator can be adjusted at this time if needed.

What type of patient is a good candidate?

Before determining if SCS treatment is an option, patients must be thoroughly evaluated by a pain specialist. The doctor will want to review the patient’s previous treatments including medications, physical therapy, injections, and surgeries. “Spinal cord stimulation is not for everyone. The key is to properly select patients before pursuing the trial. Patients who have chronic nerve pain or fail conservative therapy should be good candidates,” says Pasi.

Types of patients who may benefit from SCS treatment:

  • Patients who have chronic pain from (RSD) reflex sympathetic dystrophy or CRPS
  • Back or neck pain from failed back or neck surgery syndrome
  • Radiating neuropathic pain in back or neck
  • Legs or arm pain from peripheral neuropathy
  • Spinal nerve injury pain such as arachnoiditis or nerve root injury
  • Chest wall pain from intercostal neuralgia
  • Phantom limb pain syndrome
  • Post herpetic neuralgia pain
  • Chronic pelvic pain from intisticial cystitis
  • Other indications widely used in Europe are peripheral vascular disease and intractable angina
  • Patients may be a candidate for SCS if they meet the following criteria:
  • Conservative therapies have failed
  • The source of pain has been verified
  • The patient would not benefit from additional surgery
  • No serious dependence on pain medication or other drugs
  • No depression or other psychiatric conditions that may contribute to the pain
  • No other medical conditions that would prohibit implantation

Is it FDA approved?

SCS is approved by the U.S. Food and Drug Administration (FDA) for the management of chronic pain in the back, neck, arms, or legs.

Does insurance cover it?

SCS is a cost-effective treatment that is covered by Medicare, most major health insurance plans, and workers’ compensation programs.

Is it safe?

Spinal cord stimulation is a proven and safe treatment option that has been used by doctors to manage chronic pain for more than 40 years. Thousands of patients worldwide have benefited from SCS therapy.

What are the goals of SCS treatment?

The goals of SCS treatment are to help patients better function during normal activities, return to work, and fully participate in family and community life. Although relief will vary for each person, even a small amount of pain reduction can be significant if it helps patients to be more productive with less pain.

For some patients, SCS works so well that they are able to go off all pain medications. For others, it can mean a reduction in the amount of pain medication. While SCS does not work for everyone, most patients are able to report a 50 to 70 percent reduction in their overall pain.

In the future, will there be additional indications for SCS treatment in the U.S. other than chronic pain?

Yes, in Europe the device has been indicated for broader uses, such as to treat peripheral vascular disease by improving circulation and chronic pain. Dr. Pasi also hopes to use the treatment for intractable angina and peripheral nerve stimulation in the future.

What are the pros and cons of spinal cord stimulation?

Pros of SCS

  • Trial of device prior to committing to implantation
  • Procedure is reversible
  • Implant is non-destructive to the nerves
  • Treatment is long-term and cost-effective (North, 2007)

Cons of SCS

For safety reasons the device cannot be turned on while driving, but it may be used several hours prior to driving in order to provide residual relief.

MRIs are prohibited, but CAT scans are acceptable. (a new version of the device allows for head MRIs)

Battery life is limited (lasts an average of 5 years with maximum life of 11 years)

What are the results?

The results of spinal cord stimulation treatment vary greatly depending on the patient’s condition. This is why it’s important to carefully select proper candidates and have patients undergo a trial phase to ensure SCS treatment is a feasible option.

“I feel like I’ve been given my life back,” says Debbie Howard of Raleigh who reveals that SCS allowed her to reduce her pain medications by more than 50 percent. Howard, who has been out of work for 22 years due to chronic pain, says “I had almost given up hope before I met Dr. Pasi.”

Diagnosed with fibromyalgia and osteoarthritis of the spine, Howard is now able to perform activities she hasn’t been able to in years. “Until you are active again, you don’t know what you’ve been missing. It’s the little things like walking to the mailbox and being able to drive that have made a big difference,” says Howard who reports that her friends can even tell a difference in her voice.

Janet Teague of Greensboro is another patient of Dr. Pasi’s with a similar story. “I remember the exact day, December 9, 2010, when I woke up and realized that I couldn’t walk,” says Teague who suffered from back pain for years. After trying every treatment possible, nothing worked.

Teague, who is still in the trial phase of the SCS procedure, says the device is already making a big difference. “All of my co-workers, friends and family noticed an immediate difference in me,” says Teague who was thrilled just to be able to walk up and down the aisles of her local supermarket again.

SCS: A Safe, Cost-Effective Option for Chronic Pain Sufferers

The U.S. spends billions of dollars each year on the treatment and lost productivity resulting from chronic pain. Spinal cord stimulation is a safe, cost-effective and long-term treatment option for patients who have not found relief through traditional therapies (Kumar, et al., 2007). “For those who are good candidates, I’ve seen SCS give patients back a quality of life they thought was no longer possible,” says Dr. Pasi.

Dr. Pasi’s practice, Advanced Pain Consultants, is located in Raleigh and provides a multidisciplinary and state-of-the-art approach to chronic pain management. Dr. Pasi is fellowship trained in interventional pain management from Duke University Medical Center and is also board certified in neurology. Dr. Pasi offers a number of minimally invasive procedures under fluoroscopy in her office, as well as, more advanced treatments such as radiofrequency nerve ablation, spinal cord stimulation (SCS), and intrathecal pain pumps.

Journals Cited

Kumar, K., & al., e. (2007). Spinal cord stimulation versus conventional medical management for neuropathic pain: A multicentre randomized controlled trial. Pain Journal 132, 179-288.

North, R. B. (2007). ( Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost-effectiveness and cost-utility analysis based on a randomized, controlled trial. Neurosurgery, 61:361-369.

If you believe your patient might be a good candidate for SCS, please contact Dr. Pasi at:

Advanced Pain Consultants

Sonia Pasi, M.D. MBBS

Interventional pain medicine and Neurology

3200 Blue Ridge Road, Suite 216
Raleigh, NC 27609

Office: (919) 510-7901

Fax: (919) 510-7902

www.apcpaincare.com

 

A Holistic Approach to Pain Management

919-510-7901