Role Of Spinal Cord Stimulation Research Articles

Spinal Cord Stimulation in Refractory Postherpetic Neuralgia in Portugal: A Case Report.

Postherpetic neuralgia is one of the most severe complications after herpes zoster infection. Patients who experience persistent pain despite conservative treatment may benefit from interventional therapies, such as spinal cord stimulation. We present the case of a patient with severe refractory postherpetic neuralgia in the right T8 to L1 distribution who responded effectively to spinal cord stimulation. After its implantation, the patient had improvements in pain intensity, pain-related interference, quality of life, and satisfaction, with a simultaneous reduction of previous medications. This case report highlights the role of spinal cord stimulation in refractory neuropathic pain secondary to herpes zoster.

The Role of Spinal Cord Stimulation in Reducing Opioid Use in the Setting of Chronic Neuropathic Pain: A Systematic Review.

The aim was to examine research on the impact of spinal cord stimulation (SCS) on the reduction of preimplantation opioid dose and what preimplantation opioid dose is associated with a reduction or discontinuation of opioid use postimplantation. Systematic review of literature from PubMed, Web of Science, and Ovid Medline search of "opioid" and "pain" and "spinal cord stimulator." Inclusion criteria included original research providing data on SCS preimplantation opioid dosing and 12 months postimplantation opioid dosing or that correlated specific preimplantation opioid dose or opioid dose cutoff with significantly increased likelihood of opioid use discontinuation at 12 months postimplantation. Systematic review of the literature yielded 17 studies providing data on pre-SCS and post-SCS implantation dose and 4 providing data on the preimplantation opioid dose that significantly increased likelihood of opioid use discontinuation at 12 months postimplantation. Data from included studies indicated that SCS is an effective tool in reducing opioid dose from preimplantation levels at 12 months postimplantation. Data preliminarily supports the assertion that initiation of SCS at a preimplantation opioid dose of ≤20 to ≤42.5 morphine milligram equivalents increases the likelihood of postimplantation elimination of opioid use. SCS is an effective treatment for many types of chronic pain and can reduce or eliminate chronic opioid use. Preimplantation opioid dose may impact discontinuation of opioid use postimplantation and the effectiveness of SCS in the relief of chronic pain. More research is needed to support and strengthen clinical recommendations for initiation of SCS use at lower daily opioid dose.

Dorsal Column Stimulation and Cannabinoids in the Treatment of Chronic Nociceptive and Neuropathic Pain: a Review of the Clinical and Pre-clinical Data.

The main objective of this review is to appraise the literature on the role of spinal cord stimulation (SCS), cannabinoid therapy, as well as SCS and cannabinoid combination therapy for the management of chronic neuropathic and nociceptive pain. Current research suggests that SCS reduces pain and increases functional status in carefully selected patients with minimal side effects. As cannabinoid-based medications become a topic of increasing interest in pain management, data remains limited regarding the clinical efficacy of cannabinoids for pain relief. Furthermore, from a mechanistic perspective, although various pain treatment modalities utilize overlapping pain-signaling pathways, clarifying whether cannabinoids work synergistically with SCS via shared mechanisms remains to be determined. In considering secondary outcomes, the current literature suggests cannabinoids improve quality of life, specifically sleep quality, and that SCS decreases opioid consumption, increases functional capacity, and decreases long-term healthcare costs. These findings, along with the high safety profiles of SCS and cannabinoids overall, incentivize further exploration of cannabinoids as an adjunctive therapy to SCS in the treatment of neuropathic and nociceptive pain.

Updates on the Role of Spinal Cord Stimulation in the Management of Non-Surgical Chronic Lower Back Pain.

Studies have shown that spinal cord stimulation (SCS) therapy is effective in the management of chronic low back pain. It plays a role by minimizing the intensity of chronic pain, improving the quality of life index, reducing the intake of narcotic analgesics, and increasing the functional improvement in the working environment. However, spinal cord stimulation therapy is not universal because of the complications in the procedure itself, the invasive nature of the treatment, and cost-effectiveness. Therefore, the proper selection of the patients is necessary to get the maximum benefit from the treatment. The study's main objective is to determine the role of spinal cord stimulation in treating non-surgical patients with chronic low back pain. The article will review the mechanism, outcomes, efficacy, predisposing factors in the success and failure of the treatment and indications, contraindications, and selection of patients undergoing spinal cord stimulation therapy. A manual search of the literature was done using databases like Google Scholar and PubMed using the keywords: spinal cord, stimulation, chronic, and low back pain. A total of 37 articles were included in the study after considering the inclusion and exclusion criteria. Spinal cord stimulation therapy effectively treats refractory lower back pain, considering the technology and mechanism of action. The authors conclude that spinal cord stimulation therapy can be used to manage chronic low back pain, other neuropathic pain, and ischemic pain when other standard treatment methods have failed and the pain persisted for more than six months.

Surgical Back Risk Syndrome and Spinal Cord Stimulation: Better Safe Than Sorry

Recurrent and chronic low back pain, caused by degenerative lumbar spondylosis, commonly affects elderly patients, even those with no previous low back surgery. These patients, like those affected by failed back surgery syndrome (FBSS), may become unresponsive to medical conservative treatment and their quality of life could be easily compromised. Moreover, general comorbidities, obesity, and other typical conditions of the elderly may make surgery under general anesthesia riskier than the natural history of the disease. These patients could be considered affected by surgical back risk syndrome (SBRS). In this article, we report our preliminary observational prospective study on the role of spinal cord stimulation (SCS) in 3 groups of patients: the FBSS group, the SBRS group, and the "other" group. Selection criteria, treatment modality, and outcomes for each patient group are described and discussed. Moreover, a potentially useful diagnostic and therapeutic flowchart on the management options for lumbar back diseases is discussed. The FBSS group included 25 patients, the SBRS group included 10 patients, and the other group included 3 patients. In 22/25 patients with FBSS (88% of the total), the implantation of a definitive neurostimulator was successful. In almost all patients in both the SBRS and the other groups, the implantation of a definitive neurostimulator was successful. In our opinion, SCS could be considered as a valid alternative treatment not only in selected patients affected by FBSS but also in selected patients affected by SBRS, in whom back surgery under general anesthesia may be challenging and overcome the potential benefit of the surgery itself. SBRS could be considered a new disease entity to be managed through SCS.

Role of spinal cord stimulation in failed back surgery syndrome

Role of spinal cord stimulation in failed back surgery syndrome

Spinal Cord Stimulation and Augmentative Control Strategies for Leg Movement after Spinal Paralysis in Humans.

Severe spinal cord injury is a devastating condition, tearing apart long white matter tracts and causing paralysis and disability of body functions below the lesion. But caudal to most injuries, the majority of neurons forming the distributed propriospinal system, the localized gray matter spinal interneuronal circuitry, and spinal motoneuron populations are spared. Epidural spinal cord stimulation can gain access to this neural circuitry. This review focuses on the capability of the human lumbar spinal cord to generate stereotyped motor output underlying standing and stepping, as well as full weight-bearing standing and rhythmic muscle activation during assisted treadmill stepping in paralyzed individuals in response to spinal cord stimulation. By enhancing the excitability state of the spinal circuitry, the stimulation can have an enabling effect upon otherwise "silent" translesional volitional motor control. Strategies for achieving functional movement in patients with severe injuries based on minimal translesional intentional control, task-specific proprioceptive feedback, and next-generation spinal cord stimulation systems will be reviewed. The role of spinal cord stimulation can go well beyond the immediate generation of motor output. With recently developed training paradigms, it can become a major rehabilitation approach in spinal cord injury for augmenting and steering trans- and sublesional plasticity for lasting therapeutic benefits.

A hypothesis on possible neurochemical mechanisms of action of cervical spinal cord stimulation in prevention and treatment of cerebral arterial vasospasm after aneurysmal subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is associated with the high incidence of development of cerebral vasospasm that results in morbidity and mortality due to delayed cerebral ischemia. So far there are no consistently effective therapies for treatment of vasospasm in patients suffering from SAH. It is well known that cervical spinal cord stimulation (SCS) can induce vasodilatation and increase cerebral blood flow (CBF). Based on the experiments in animals and the studies in humans, we have proposed the possibility to use SCS as a therapeutic strategy for prevention and treatment of cerebral vasospasm after SAH. However, the physiological mechanisms of action of SCS in this regard are poorly understood. Better understanding of the pathophysiology of vasospasm after SAH may provide insight into the role of SCS in such conditions. We hypothesize that effect of SCS on vasodilatation may be related to modulation of activity of phosphodiesterases 5 (PDE-5) and nitric oxide synthase (eNOS), resulting in enhancement of nitric oxide (NO)-cyclic guanosine monophosphate (cGMP) pathway, which may help prevent and/or treat vasospasm after SAH. Further investigations on the physiological mechanisms of action of SCS would be necessary to support this hypothesis.

Management of angina pectoris: the role of spinal cord stimulation.

Progress in prevention as well as drug and interventional therapy has improved the prognosis of patients with cardiovascular disorders. Many patients at risk have advanced coronary artery disease (CAD), have had multiple coronary interventions, and present with significant co-morbidity. Despite adequate risk factor modulation and often several revascularization procedures, some of these patients still have refractory angina pectoris. Apart from advanced CAD and insufficient collateralization, the cause is often endothelial dysfunction. For this situation, one treatment option is neuromodulation. Controlled studies suggest that, in patients with chronic refractory angina pectoris, spinal cord stimulation (SCS) provides a relief from symptoms equivalent to that provided by surgical therapy, but with fewer complications and lower rehospitalization rates. SCS may result in significant long-term pain relief with improved quality of life. In patients with refractory angina undergoing SCS, some studies have shown not only a symptomatic improvement, but also a decrease in myocardial ischemia and an increase in coronary blood flow. Discussion is ongoing as to whether this is a direct effect on parasympathetic vascodilation or merely a secondary phenomenon resulting from increased physical activity following an improvement in clinical symptoms. Results from nuclear medical studies have sparked discussion about improved endothelial function and increased collateralization. SCS is a safe treatment option for patients with refractory angina pectoris, and its long-term effects are evident. It is a procedure without significant complications that is easy to tolerate. SCS does not interact with pacemakers, provided that strict bipolar right-ventricular sensing is used. Use in patients with implanted cardioverter defibrillators is under discussion. Individual testing is mandatory in order to assess optimal safety in each patient.

Spinal Cord Stimulation and Psychosomatic Conditions

To the Editor: We have read with great interest the article about back pain and the role of spinal cord stimulation by Rigoard et al.1 We agree that failed back surgery syndrome represents one of the most frequent etiologies of chronic back pain and is a major public health issue. Spinal cord stimulation (SCS) has been used both for failed back surgery syndrome and complex regional pain syndrome with variable results. Management of post lumbar surgery syndrome with numerous modalities of treatments, including interventional techniques, results in moderate improvement, because it leaves a proportion of patients with intractable pain. The international literature concerning to the effectiveness of SCS in relieving chronic intractable pain of post lumbar surgery syndrome indicates a level of evidence of II-1 or II-2 with 1B or 1C/strong recommendation for clinical use on a long-term basis.2,3 As well discussed in the article by Rigoard et al,1 chronic pain is a complex condition that requires a multidisciplinary team made up neurosurgeons, anesthetists, and psychologists to manage these patients safely and accurately. Psychological assessment seems to be of crucial importance in such an issue, because psychiatric pathologies can negatively modify the effectiveness of the technique. In particular, panic attack syndrome is an unpredictable psychiatric disorder that may be not suspected on the initial clinical interview and may limit the effectiveness of the SCS in the long run. In brief, we can provide a case of a young woman experiencing chronic low back pain syndrome caused by a degenerative spondylolisthesis at L4-L5 segment. She underwent regular fixation. After 2 years of mild health, she reported severe low back pain, numbness of the legs, and painful walk. She underwent L5-S1 laminectomy and radicular decompression. For 1 year after surgery, she underwent pain medical therapies and physiotherapy without beneficial effects. Therefore, the patient was enrolled for SCS device implantation. Patient underwent regular clinical pain psychological interview, and she did not reveal any psychiatric disorders such as signs of depression, suicidal ideation, or anxiety. Therefore, a rechargeable neurostimulator (Restore-Ultra, Medtronic, Minneapolis, MN) was implanted. The patient experienced a relatively long period free of pain, thus improving her quality of life. However, 2 months later, she presented with severe anxiety, chest tightness, and insomnia, she was irritable, and the pulse generator was making difficult the decubitus on the side where it was implanted. The frequency of the generator was changed several times, but the symptoms did not change. Subsequently, the generator was turned off, but the patient was continuously complaining her symptoms. The patient underwent a new psychological interview, which documented a panic attack syndrome. During such an examination the patient affirmed her assumption that she could not tolerate the device because it was, in her opinion, the cause of her mental disorder. After thorough discussion with the patient by the specialist, the patient accepted her condition and preferred to keep the device in place because it was providing her with some beneficial effects. The mental disturbance of the patient, unpredictable and rare, interfered with the possibility of fully recovering from her painful condition, limiting and confusing the effectiveness of the SCS. Our experience points out that, even though psychological tests may be able to predict outcomes in SCS treatment, panic attack syndrome could not be predictable and could be considered as a secondary condition following the device implantation.4 Despite its rarity, panic attack syndrome is to be taken into account in the preoperative evaluation of all the patients selected as candidates for neurostimulation, because it may affect the final result. Disclosure The study, in part, has been supported by academic funds (ex 60% of the first author).

“The failed back surgery syndrome”: Definition and therapeutic algorithms – An update

Approximately 30% of patients experience persistent or recurrent low back and/or pain projecting into the legs following technically adequate lumbosacral surgery. Such pain conditions are often alluded to as the failed back surgery syndrome (FBSS). FBSS represents a significant clinical and economic concern. The treatment of FBSS presents a challenge to physicians, as conservative therapies and spinal reoperations are often unsuccessful – if not a significant cause (besides fibrosis) of the persistent pain syndrome is found at the post-operative examinations. Neuropathic pain radiating into the leg(s) is often the main component of this persistent and disabling syndrome. In this case, spinal cord stimulation (SCS) has been shown to be a successful therapeutic option. Studies have demonstrated that up to 60% of implanted patients experience 50% or more pain relief following SCS. Moreover, SCS has been shown to improve both quality of life and functional status in a significant number of patients. In order to address the challenge of managing both chronic back and leg pain, a multidisciplinary group of physicians experienced in pain management and spinal surgery assembled to discuss and formulate a treatment strategy for FBSS, based on a systematic review of the literature that focused on the role of SCS. The outcome of these discussions however remained unpublished why an update, taking into account also the moderns technologies has been performed. The development of new treatment algorithms should allow, easier, more rational and effective management of this common and clinically – as well as economically – important problem.

Managing chronic neuropathic pain: the role of spinal cord stimulation

In October 2008 the National Institute for Health and Clinical Excellence issued guidance supporting the use of spinal cord stimulation for people with chronic neuropathic pain, considering it to be a cost-effective use of resources within the NHS. This paper will provide an overview of chronic neuropathic pain. Spinal cord stimulation (SCS) will be explained, including the physiological mechanism and technology behind this treatment. The recent NICE guidance will be discussed along with information relating to the potential impact the guidance will have on Primary Care Trusts, GPs and community practitioners. A guide is provided for clinicians in primary care regarding access to this treatment and routes for referral.

Spinal Cord Stimulation for Failed Back Surgery Syndrome: Technical Advances, Patient Selection and Outcome

Spinal cord stimulation (SCS) has been used to treat intractable pain syndromes for over 30 years ( 1. Shealy CN Mortimer JT Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: Preliminary clinical report. Anesth Analg. 1967; 46: 489-491 Crossref PubMed Google Scholar ). For many years this technique was used and reported as case series, without supporting prospective studies for the most common indication, the failed back surgery syndrome ( 2. North RB Ewend MG Lawton MT Kidd DH Piantadosi S. Failed back surgery syndrome: Five-year follow-up after spinal cord stimulator implantation A prospective, randomized study design. Neurosurgery. 1991; 28: 692-699 Crossref PubMed Scopus (242) Google Scholar ). In the last several years there have been several prospective studies ( 3. North RB Kidd DH Lee MS Piantadosi S. Spinal cord stimulation versus reoperation for the failed back surgery syndrome: a prospective, randomized study design. Sterotact Funct Neurosurg. 1994; 62: 267-272 Crossref PubMed Scopus (116) Google Scholar , 4. Burchiel KJ Anderson VC Brown FD et al. Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine. 1996; 21: 2786-2794 Crossref PubMed Scopus (267) Google Scholar , 5. Ohnmeiss DD Rashbaum RF Bogdanffy GM. Prospective outcome evaluation of spinal cord stimulation in patients with intractable leg pain. Spine. 1996; 21: 1344-1351 Crossref PubMed Scopus (111) Google Scholar ) which have helped to clarify the overall role of SCS.

The role of spinal cord stimulation in the treatment of chronic pain postlaminectomy

Since the inception of spinal cord stimulation (SCS) as a modality for the treatment of chronic pain, the most common indication has been postlaminectomy pain, or failed back syndrome.This article describes our experience using SCS as a method of treatment in 182 patients with postlaminectomy pain in which 53% successful pain relief was obtained over a mean follow-up period of 8.8 ± 4.5 years. We also discuss the experience of other authors as reported in the literature. This paper discusses the surgical technique of SCS, the prognostic factors of SCS, and the anticipated benefits of a new electrode, the transverse tripolar electrode with a dual-channel voltage stimulator, which will be available for use in the near future. The constraints of double-blinded and randomized procedures in this pathophysiology are considered.

1-09-03 The role of spinal cord stimulation in the treatment of spasticity in children with cerebral palsy

1-09-03 The role of spinal cord stimulation in the treatment of spasticity in children with cerebral palsy

Current Status of Epidural Spinal Cord Stimulation

Summary: Spinal cord stimulation is the most widespread application of neurostimulation, which includes electrical stimulation of the sensory-motor cortex, thalamus, spinal cord, sacral roots, peripheral nerves, and vagus nerve. Its popularity, although with variable acceptance over the past two decades, has steadily increased and is now a well-established part of the pain specialist's armamentarium. Several published studies (none of which, however, is prospective) have consistently shown a 50% efficacy in producing a satisfactory degree of long-term pain relief in a variety of chronic pain conditions. In Europe the most widely accepted application is for the management of peripheral vascular disease in the lower extremities. The effects on ischemic pain have been reported consistently to be very positive. Intractable pain due to angina pectoris is also showing promising results. The role of spinal cord stimulation in the management of hypertonic motor disorders has been controversial and has recently been overshadowed by the development of intrathecal baclofen infusion. In the author's experience, spinal cord stimulation remains the procedure of choice for athetosis or dystonia. Some evidence also exists that spinal cord stimulation might have a role in regulating the blood flow to the brain. This has been confirmed by animal experimental studies. Isolated reports have also shown some beneficial effects in persistent vegetative status due to brain injury or stroke.

The role of spinal cord stimulation in contemporary pain management: A commentary

T he focus article by Dr. North examines the role of spinal cord stimulation (SCS) in contemporary pain management. The time is right to do so because, after an initial period of enthusiasm with the introduction of the method in the late sixties, followed by a period of decline, the method is again on the rise. Many factors can be identified for this renouveau of the method, the most important oneprobably being reports of better longterm results. Although I do not share the very optimistic tone I think I can distinguish in Dr. North's focus article, I want to make it clear that I have adopted the method from the beginning and have never abandoned it. The reversibility of the method, the low rate of complications, .better selection criteria, and improved devices and implantation techniques appeal to me.

The role of spinal cord stimulation in contemporary pain management

Improvements in spinal cord stimulation devices, techniques, and patient selection over the past 20 years have enhanced the safety and efficacy of the procedure, leading to an expanding role for spinal cord stimulation in the treatment of chronic, intractable pain. Percutaneous electrode placement has reduced morbidity, facilitated patient screening, and furthered the technical goal of matching stimulation paresthesias to the distribution of a patient's pain. Programmable implants have been developed to take full advantage of implanted electrode arrays. The morbidity of spinal cord stimulation is very low, and its benefit/risk ratio compares very favorably with alternative procedures.