Spinal Cord Stimulators for Chronic Radiculopathy, FBSS, and CRPS

[DigableCat]

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.

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[lobelsteve]

#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.

 

[md2k]

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.

 

[DigableCat]

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.

 

[lobelsteve]

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
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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

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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

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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

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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

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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

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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

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[lobelsteve]

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.

 

[DigableCat]

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?

 

[lobelsteve]

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".

 

[C Fiber]

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?

 

[Aether2000]

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