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Uploaded byDaradia: The Pain Clinic
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Comprehensive Overview of Spinal Cord Stimulation for Pain Management

Detailed insights into spinal cord stimulation including mechanism, patient selection, procedural techniques, evidence, programming, and complications for neuropathic pain treatment. Read more: https://daradia.com/failed-back-surgery-spinal-cord-stimulation/

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Spinal Cord Stimulation Dr. Shirish Prasad Amatya, MD, FIPM, FIPP, CIPS Fellowship in Musculoskeletal Ultrasound in Pain Medicine Fellowship in Spine Endoscopy Daradia: The Pain Clinic
Dorsal Cord Stimulation 1st done by Dr Norman Shealy, Neurosurgeon 1967
Pain Pathway
Mechanism of Action: • Gate Control Theory – Melzack & Wall 1965
Alteration of Local neurochemistry (Modulation): Suppresses the hyperexcitability of WDC Activation of inhibitory neurotransmitter: GABA, Glycine, Serotonin Inhibition of Excitatory neurotransmitter: Glutamate, Aspartate Alteration of Sympathetic tone : Increased vasodilatation and improve flow of Blood and Oxygen ( for Vascular Dz, Refractory Angina)
Evidence (WIP) Indication Level of evidence Failed Back Surgery Syndrome 2A+ Complex Regional Pain Syndrome 2B+ Painful Diabetic Polyneuropathy 2C+ Ischemic Pain of Extremity 2 B ± Chronic Refractory Angina 2B+
Evidence (ASIPP) Spinal cord Stimulation Evidence Failed Back Surgery Syndrome Level II Complex Regional Pain Syndrome Diabetic Neuropathy Level IV Abdominal/ Pelvic Pain Ischemic Pain Syndrome
Patient Selection Predominant Neuropathic pain not managed with conservative pharmaco- polytherapy Chronicity of greater than 6 months No major/ significant Psychiatric problem
Relation Between Spinal Cord Segment & Vertebra
Relation Between Spinal Cord Segment & Vertebra Spinal Segment : region of Spinal cord from which a pair of spinal nerve arises Spinal cord segment ( 31 segments: C 8,T 12, L 5, S 5 and Co 1) Vertebra level ( 33: C 7, T 12, L 5, S 5 and Co 4) C 1 to C 4 C 1 to C 4 ( - 0 ) C 5 to T 4 C 4 to T 3 ( - 1) T 5 to T 8 T 3 to T 6 ( - 2) T 9 to T 12 T 6 to T 9 ( - 3 ) L 1 to L 5 T 9 to T 12 S 1 to C1 ( sacral & Coccygeal, Conus Medullaris L 1 Cauda Equina fibers and filum terminalis Below L1 to Tip of Coccyx
Anatomy • Target is posterior Epidural Space, to stimulate the dorsal column Pain Target Tip of Catheter Epidural Entry Level ( 2 Level below the target tip ) Skin Entry level ( 2 level below the Epidural entry) Neck Pain C 2/3 C 5/6 T 1 / 2 Arm Pain C3/4 C 6/ 7 T 2 / 3 Leg Pain T 9/10 T 12 – L 1 L 2 /3 Foot Pain T 11- L1 L 3/4 L 5- S1 Back Pain T 8/11 L 1/ 2 L 3 – L 4 Abdomi nal Pain T 4/5 to T5/6 T 8/9 T 11 – L 1
Type of Electrodes • Percutaneous/ Catheter ( pain physicians, percutaneous) • Surgical/ Paddle ( Neurosurgeon, Laminectomy/ laminotomy is required to slip the flat plate electrode) Connected to Implantable Pulse Generator (IPG) or RF unit Should be charged in 7 – 14 days IPG can last up to 10 years
Technical consideration • Technically challenging interventional pain management technique. • Involves placement of electrode leads in Posterior or Postero- lateral epidural space under fluoroscopic guidance. • Anchoring the lead, tunneling and connection of the connecting wires • Trial period • Positioning and implantation of Implantable Pulse Generator or Radiofrequency receiver ( lower abdominal or posterior superior gluteal area, should be located where patient can access with his/ her dominant hand for adjustment of setting with remote control).
Fluoroscopy Technique • Non Coaxial technology • Out of tunnel , max 30 * angle • Skin entry point just lateral to midline 2 level below the target inter-laminar space; 2 segment below the Target spinal segment ( most popular, facilitate placement of lead in posterior epidural space) • Coaxial Technology • Tunnel vision • 30* caudal tilt of the C-arm • Skin entry just paramedian of the spinous process below the target interlaminar space ( breakage and migration issues)
Fluoroscopy Technique • Consent, IV cannula, and basic ASA monitoring, Pre procedural antibiotics, Resuscitation equipment’s and medicines, Prone Position with pillow under abdomen, all aseptic precautions, • True AP image • Non Coaxial view technique ( preferred) and Coaxial View technique • 12 to 15 G ( 3.5 inch ie 10cm or 6 inch ie 15 cm ) Coude Epidural needle inserted at an angle 0f 30* or less. • Skin entry (paramedian) 1- 2 vertebral level below the inter laminar epidural level which is 2 segment below lower margin of target final placement of the lead. • Walk needle off the cephalad edge of lamina (Midline ) to penetrate ligamentum flavum . • After LOR, check lateral view to see the depth of the needle tip.
Take a lateral view of Fluoroscope Tip/ Bevel of the needle facing up (so that lead goes to post. Epidural space) Insert the guide wire to facilitate the entry of the lead. Thread lead using forefinger and thumb “ pill rolling” manner to confirm posterior epidural position placement and final anatomical spinal cord segment. Stimulate the lead to check whether it covered the painful anatomical area of distribution. Secure the lead to skin or fascia once best pain area coverage. Connect the lead to external IPG or RF and start few days of trial period with oral antibiotic coverage. ( precaution: avoid excessive forward / backward / lateral bending) After successful trial, external IPG/ RF generator is implanted subcutaneously and connected with the implanted lead.
Trial Period • Essential to avoid the failed implant • Trial period is about 3-14 days; if < misleading success , if > risk of infection ( oral antibiotics during trial stimulation) normally 5-7 of trail period is better
Program 4 basic parameters • Rate: frequency 20 – 120 Hz ( lower rate patient feel thumping, higher rate buzzing) • Amplitude: intensity of current eg 0.1 – 10 V • Pulse width/Time: 100 – 400 ms • Electrode selection {electrons flow from cathode (-) to Anode (+) , selection is complex, electrode selection is changed until the patient obtains adequate anatomical coverage) ( electrode selection, rate and time of pulse is adjusted in trial period; patient is left with increase or decrease of amplitude and duration of stimulation to achieve adequate analgesia) All movement permitted: except: excessive bending and lateral rotation Battery has to charged via external recharger every 7- 14 days depending upon mode and use. Preset mode is available : patient can choose ; turn on/ off; increase the Amplitude or duration etc
Goal / Successful Trial • ≥ 50% pain relief • Decrease in Drug requirement • Improvement of Daily lifestyle/ activity / work
Complication: • Simple to life threatening eg Skin infection to Cardio/ pulmonary arrest to Death 1. Dural puncture 2. Neurologic Injury: Nerve injury, paralysis 3. Motor Blockade 4. Lead Breakage (13%) 5. Lead Migration 6. Infection: ( skin infection, epidural Infection/ abscess; 5% ) 7. Device failure 8. Bleeding ( surface to Epidural bleeding ) 9. Post procedural Pain 10. Vasovagal reaction
Thank You • Any Questions?