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Spinal Cord Stimulators for Chronic Radiculopathy, FBSS, and CRPS

Discussion in 'Pain Medicine' started by DigableCat, 03.28.06.

  1. DigableCat

    DigableCat Senior Member Lifetime Donor

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    In my experience(albeit limited), I've been less than impressed with their outcomes. Although patients do tend to complain of "less pain", and have successful trials prior to implantation, I've seen no improvements per se in
    1. Return to work.
    2. Decrease in opioid medication consumption.

    I've seen some improvement in ADLs. But given what insurance companies see as justification for reimbursement on procedures, I don't necessarily see them seeing this as a valuable end point. So, I sometimes wonder if it's nothing more than a $15,000 implantable TENS unit.

    Anyone care to elaborate on their experiences with SCS.
  2. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    #1 reason they don't work is poor patient selection.

    Right patient, right procedure, right time = highly effective treatment.

    The trick is to put the patient ahead of the payments and be strict regarding criteria for implantation. Trial everybody with the right ICD-9 if you want, just don't pop a computer in their body and act like you cured them.
  3. md2k

    md2k Member

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    I have seen improvements with stims. We had a pt with CRPS who ADL's were significantly diminshed. After the stim placement we weaned her off her pain meds and eventually she went back to work. Later, she lost about 45 lbs and is looking pretty hot. I would count her as a success with stims. However, the truth is more often than not they only partially alleviate the pain and then around 4-5 years they just dont work anymore. I agree with lobelsteve. You must have the proper patient selection.
  4. DigableCat

    DigableCat Senior Member Lifetime Donor

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    I don't think there has ever been an disagreement with "patient selection" being a key element in the success before implantation. Even those that "pass" their psychometric evaluation, have questionable outcomes despite their testing.

    But if you have to reach for success cases anectodally instead of it being more the norm, than I think that maybe some people in this field are being rather cavalier with their implantation practices.

    If you want to use "evidence based" decision making in your practice(and I think we should), there was a Cochrane Review by Mailis-Gagnon et al. in 2004 which found only 2 studies that were useful enough to be included. Two RCTs, with only 81 patients in total. One was judged as being of high quality and the other of low quality. With follow-up periods between 6 to 12 months.

    I am surprised that, despite the lack of quality long term outcomes published, physicians consider this venue for pain managment. Especially in the private practice sector.
  5. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Your comments are cavalier and clearly inflammatory.

    Read these first, or wait for Slipman's text to come out and read the Chapter on SCS for FBSS. I'm thinking the literature is convincing that they do work.

    References
    1. Abram S E 1985 Pain pathways and mechanisms. Seminars in Anesthesia 4:267-274

    2. Alo K, Yland M, Radko R, et al 1999 Lumbar and sacral nerve root stimulation (NRS) in the treatment of chronic pain: A novel anatomical approach and neuro stimulation technique. Neuromodulation 2(1):23-31

    3. Alo K, Ziddan A 2000 Selective nerve root stimulation in the treatment of end-stage, diabetic, peripheral neuropathy: A case report. Neuromodulation 3(4):201-208

    4. Alo K, McKay E 2001 Selective Nerve Root Stimulation (SNRS) for the Treatment of Intractable Pelvic Pain and Motor Dysfunction: A Case Report. Neuromodulation 4(1):19-24

    5. Alo K, Redko V, Charnov J 2002 Four year follow up of dual electrode spinal cord stimulation for chronic pain. Neuromodulation 5(2):79-88

    6. Augustinsson L E, Carlsson C A, Holm J et al 1985 Epidural electrical stimulation in severe limb ischemia. Pain relief, increased blood flow, and a possible limb-saving effect. Annals of Surgery 202(1):104-110

    7. Augustinsson L E 1996 Avoiding Difficulties in Spinal Cord Stimulation. In: Waldman S D, Winnie A P (eds) Interventional Pain Management, 1st ed, W B Saunders, Philadelphia, p 427-430

    8. Barolat G, Schwartzman R, Woo R 1989 Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy. Stereotactic and Functional Neurosurgery 53(1):29-39

    9. Barolat G, Oakley J, Law J et al 2001 Epidural spinal cord stimulation with a multiple electrode paddle lead is effective in treating intractable back pain. Neuromodulation 4(2):59-66

    10. Basbaum A I, Fields H L 1984 Endogenous pain control systems: Brainstem spinal pathways and endorphin circuitry. Annual Review of Neuroscience 7:309-338

    11. Bayliss W M 1901 On the origin from the spinal cord of the vaso-dilator fibres of the hind-limb, and on the nature of these fibres Journal of Physiology 26(3):173-209

    12. Bedder M D 1996 Spinal Cord Stimulation and Intractable Pain: Patient Selection. In: Waldman S D, Winnie A P (eds) Interventional Pain Management, 1st ed, W B Saunders, Philadelphia, p 412-418

    13. Bell G K, Kidd D, North R B 1997 Cost-effectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. Journal of Pain and Symptom Management 13(5):286-295

    14. Bonica JJ 1990 Anatomic and physiologic basis of nociception and pain. In: Bonica J J (ed): The management of pain, Vol 1, 2nd ed, Lea & Febiger, Philadelphia, p 28-94

    15. Bowsher D 1983 Pain mechanisms in man. Resident and Staff Physician 29:26-34

    16. Broseta J, Roldan P, Gonzalez-Darder J et al 1982 Chronic epidural dorsal column stimulation in the treatment of causalgia pain. Applied Neurophysiology 45(1-2):190-194

    17. Broseta J et al 1986 Spinal cord stimulation in peripheral arterial disease. Journal of Neurosurgery 64:71-80

    18. Burchiel K J, Anderson V C, Wilson B J et al 1995 Prognostic factors of spinal cord stimulation for chronic back and leg pain. Neurosurgery 36(6):1101-1110

    19. Burchiel K J, Anderson V C, Brown F D et al 1996 Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine 21(23):2786-2794

    20. Burton C V 1977 Session on spinal cord stimulation: Safety and clinical efficacy. Symposium on the safety and clinical efficacy of implanted neuroaugmentative devices Neurosurgery 1:214-215

    21. Campbell J N 1981 Examination of possible mechanisms by which stimulation of the spinal cord in man relieves pain. Applied Neurophysiology 44(4):181-186

    22. Crue B L 1983 The neurophysiology and taxonomy of pain. In: Brena SF, Chapman SL (eds) Management of patients with chronic pain, Spectrum, Jamaica, NY, p 21-31

    23. Dario A, Fortini G, Bertollo D et al 2001 Treatment of failed back surgery syndrome. Neuromodulation 4(3):105-110

    24. De La Porte C, Van de Kelft E 1993 Spinal cord stimulation in failed back surgery syndrome. Pain 52(1):55-61

    25. Devulder J, De Colvenaer L, Rolly G et al 1990 Spinal cord stimulation in chronic pain therapy. Clinical Journal of Pain 6(1):51-56

    26. Erickson D L, Long D M 1983 Ten-year follow-up of dorsal column stimulation. Advances in Pain Research and Therapy 6:583-589

    27. Fedorcsak I et al 1991 Peripheral vasodilation due to sympathetic inhibition induced by spinal cord stimulation. In: Proceedings of the IBRO World Congress of Neurosciences, Paris, France, p 126

    28. Feldman R A 1975 Patterned response of lamina V cells: Cutaneous and dorsal funicular stimulation. Physiology & Behavior 15(1):79-84

    29. Fields H 1991 Depression and pain: A neurobiological model. Neuropsychiatry, Neuropsychology, and Behavioral Neurology 4:83-92

    30. Foreman R D, Beall J E, Coulter J D et al 1976 Effects of dorsal column stimulation on primate spinothalamic tract neurons. Journal of Neurophysiology 39(3):534-546

    31. Groth D E 1985 Spinal cord stimulation for the treatment of peripheral vascular disease. Advances in Pain Research and Therapy 9:861-870

    32. Handwerker H O, Iggo A, Zimmerman M 1975 Segmental and supraspinal actions on dorsal horn neurons responding to noxious and non-noxious skin stimuli. Pain 1(2):147-165

    33. Heideche V, Rainov N, Burket W 2000 Hardware failures in spinal cord stimulation for failed back surgery syndrome. Neuromodulation 3(1):27-30

    34. Hoppenstein R 1975 Percutaneous implantation of chronic spinal cord electrodes for control of intractable pain. Preliminary report. Surgical Neurology 4(1):195-198

    35. International Association for the Study of Pain 1986 Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. Pain Supplement 3:S1-S225

    36. Jacobs M J, Jorning P J, Joshi S R et al 1988 Epidural spinal cord electrical stimulation improves microvascular blood flow in severe limb ischemia. Annals of Surgery 207(2):179-183

    37. Jensen M P, Turner J A, Romano J M et al 1991 Coping with chronic pain: A critical review of the literature. Pain 47(3):249-283

    38. Kemler M, Barendse G, van Kleef M et al 2000 Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. New England Journal of Medicine 343(9):618-624

    39. Kolin M T, Winkelmuller W 1990 Chronic pain after multiple lumbar discectomies-significance of intermittent spinal cord stimulation. Pain 40(5):S241

    40. Krames E S 1996 Mechanisms of Action of Spinal Cord Stimulation. In: Waldman S D, Winnie A P (eds) Interventional Pain Management, 1st ed. W B Saunders, Philadelphia, p 407-411

    41. Krieger D T, Martin J B 1981 Brain peptides. New England Journal of Medicine 304(15):876-885

    42. Kumar K, Wyant G, Ekong C et al 1986 Epidural spinal cord stimulation for relief of chronic pain. Pain Clinic 1(2):91-99

    43. Kumar K, Nath R K, Wyant G M 1991 Treatment of chronic pain by epidural spinal cord stimulation: 10-year experience. Journal of Neurosurgery 75(3):402-407

    44. Kumar K, Toth C, Nath R K et al 1998 Epidural spinal cord stimulation for treatment of chronic pain- some predictors of success: a 15-year experience. Surgical Neurology 50(2):110-121

    45. Kumar K, Malik S, Demeria D 2002 Treatment of chronic pain with spinal cord stimulation versus alternative therapies: Cost-effectiveness analysis. Neurosurgery 51(1):106-116

    46. Kupers R C, Van den Dever R, Van Houdenhove B et al 1994 Spinal cord stimulation in Belgium: A nation-wide survey on the incidence, indications and therapeutic efficacy by the health insurer. Pain 56(2):211-216

    47. Larson S J, Sances A, Riegel D H et al 1974 Neurophysiological effects of dorsal column stimulation in man and monkey. Journal of Neurosurgery 41(2):217-223

    48. Law J D 1983 Spinal stimulation: Statistical superiority of monophasic stimulation of narrowly separated, longitudinal bipoles having rostral cathodes. Applied Neurophysiology 46(1-4):129-137

    49. Law J D 1990 Percutaneous spinal cord stimulation for the “failed back surgery syndrome.” Pain Management Update l(l):12

    50. Law J D, Kirkpatrick A F 1992 Update: Spinal cord stimulation. American Journal Pain Management 2(l):34-42

    51. LeDoux M S, Langford K H 1993 Spinal cord stimulation for the failed back syndrome. Spine 18(2):191-194
  6. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Please note I left off #'s 52-109 in the actual bibliography.
    And that includes some of the better papers- from North, Robb, et al.
  7. DigableCat

    DigableCat Senior Member Lifetime Donor

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    Are we to assume that the Cochrane Reviews are without merit. I don't have anything against spinal cord stimulation. As a matter of fact, I've got to give a presentation(assigned to me) to the orthopaedics department at my program. Which was one of the reasons why my question was posed, that and to promote more discussion on this board.

    Could you cite your bibliography reference please?

    BTW, just how many of these do you do per month...or should I ask per week?
  8. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    I've been doing about 1 per month, but that number will increase shortly.

    PM me for a sneak peak of the textbook chapter.
    I do not own the rights to it and could not publish it here.

    The Cochrane reviews are with some merit. But they are held in much to high esteem to be clinically useful.

    Look at the reviews for LBP. They report that ESI is ineffective, but so were opioids and all other meds except NSAIDs. I defy you to rupture a disc and just tough it out on some Motrin. The advice based on EBM is weak at best- and this exists because RCT's are too costly or do not make much sense for painful conditions that are "ill-defined".
  9. C Fiber

    C Fiber Member

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    My experience, CRPS patients s/p implant, most want to be off their opiods, even in the trial phase. Most of the patient that I have implanted continue to work full/part time, even the fail back patients. In fact, that is one of my criteria before I implant them. If they are not working, I discuss goals of returning to work with them or send them to a vocational counselor before trial.

    May I ask what your patient population is like?
  10. algosdoc

    algosdoc algosdoc

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    Our criteria include: 1. Cannot get into a position that completely alleviates pain-pain is constant and unrelenting but may have exacerbations 2. Primarily burning dysesthetic pain treated rather than mechanical pain 3. At least 75% or greater improvement in overall pain before implantation 4. Trial for 1-3 weeks on everyone before implantation 5. No psych red flags

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