This document discusses spinal cord stimulation (SCS) for treating neuropathic cancer pain. It summarizes several studies and case reports that have found SCS to be an effective and safe treatment for neuropathic cancer pain when conventional medications fail. Specifically, SCS has provided satisfactory pain relief for patients with chemotherapy-induced or radiation-induced neuropathic pain. While the evidence is currently limited to case reports and case series due to the lack of randomized controlled trials, SCS shows potential as an alternative treatment for neuropathic cancer pain that is refractory to other options.

1. SPINAL CORD STIMULATION IN
NEUROPATHIC CANCER PAIN PATIENTS
– PRESENT LITERATURE SUPPORT
Dr Manish Raj
MD,DA,FMISS(US),FISP
Interventional spine & pain consultant
Max smart superspeciality hospital,Delhi
Jaypee hospital,Noida

2. SPINAL CORD STIMULATION IN TREATMENT OF
CANCER RELATED PAIN :
“ BACK TO ORIGINS”
Artemus Flagg II & Kai McGreevy & Kayode Williams
Curr Pain Headache Rep ;6-2012-0276-9

3. CANCER PAIN MANAGEMENT ACCORDING TO WHO
ANALGESIC GUIDELINES
MD Stephan A. Schug , MD Detlev Zech, Ulrike Dörr
Journal of Pain and Symptom Management
Volume 5, Issue 1, February 1990, Pages 27-32
11% of the patients required other methods of pain
management.
Do we need SCS ?

4. VALIDATION OF WORLD HEALTH ORGANIZATION
GUIDELINES FOR CANCER PAIN RELIEF: A 10-YEAR
PROSPECTIVE STUDY
 Zech DF, Grond S, Volume 63, Issue 1, October 1995, Pages
65-76
Marked efficacy and low rate of complications
associated with oral and parenteral analgesic therapy
as the mainstay of pain treatment in the palliative
care of patients with advanced cancer

5. ASSESSMENT AND TREATMENT OF NEUROPATHIC
CANCER PAIN : WHO GUIDELINES
Neuropathic cancer pain is not intractable and can
be relieved in the majority of patients by
treatment following the WHO guidelines.
Stefan Grond, Lukas Radbruch,Volume 79, Issue 1,
1 January 1999, Pages 15–20

6. •SCS may be a therapeutic alternative for patients who have
exhausted all available treatments or who have an increased risk for
or prefer not to have more invasive interventions.
•No risks for potential neurologic dysfunctions which can complicate
ablative procedures.
•Satisfactory symptom relief, an increase in QOL and
discontinuation of pain medications.

7. SCS RELIEVES NEUROPATHIC PAIN IN A PATIENT WITH
RADIATION-INDUCED TRANSVERSE MYELITIS.
Spinal cord stimulation may offer a therapeutic option for
patients with neuropathic pain resulting from transverse
myelitis and should be considered when other treatments
fail.
Hamid B, Haider N. Pain Pract. 2007
Dec;7(4):345-7

8. CATA ET AL
Case report of two patients at MD Anderson:
Pt A: 61M w/ R elbow melanoma, tx’d w/ IL-2
 Developed neuropathic pain refractory to
opioids, gabapentin
 Dual lead SCS placement at L1
Pt B: 46M w/ Ewing’s Sarcoma of R infraclavicular region,
tx’d w/ Vincristine
 Developed neuropathic pain refractory to
opioids, gabapentin, amitriptyline
 Dual lead SCS placement at T11
Spinal Cord Stimulation Relieves Chemotherapy-Induced Pain: A
Clinical Case Report. Journal of Pain and Symptom Management.
2004. 27(1): 72-78.

9. SCS RELIEVES CHEMOTHERAPY-INDUCED PAIN:
A CLINICAL CASE REPORT
SCS offers a therapeutic option for patients with
chemotherapy-induced peripheral neuropathy who have
poor pain relief with standard medical treatment.
Juan P Cata, MD,Joseph V Cordella, BS

10. SCS : CURRENT PERSPECTIVES
•SCS is an effective treatment option for neuropathic pain.
• Technical advancement of SCS has led to improvement in
stimulation patterns adapted to the patients’ needs.
• SCS for neuropathic pain is still underused.
• Careful preoperative diagnosis and proper patient selection is
most important for the success of the methods

11. • Level 2 evidence from 2 studies of high quality supports the
effectiveness of SCS to reduce pain in some neuropathic pain
conditions.
•There is supportive evidence from secondary outcomes from level
3a evidence that treatment with SCS improves functional status
and QOL.
• The need for SCS services is estimated at 300 to 660 people per
year. Current services provide SCS to 30 to50 people per year
Ontario Health Technology Assessment Series 2005; Vol. 5, No. 4

12. At 24 months of SCS treatment, selected failed back surgery
syndrome patients reported sustained pain relief, clinically
important improvements in functional capacity and health-
related quality of life, and satisfaction with treatment
Neurosurgery. 2008 Oct;63(4):762-70;

13. TREATMENT OF CANCER PAIN
The advances of recent decades suggest a future
that includes increased evidence-based targeting of
specific analgesic interventions within an
individualised plan of care that is appropriate
throughout the course of illness.
Russell K Portenoy, Volume 377, Issue 9784, 25 June–1 July 2011,
Pages 2236–2247

14. Pain
Step 1
Nonopioid
 Adjuvant
Pain persisting or increasing
Step 2
Opioid for mild to moderate pain
Nonopioid  Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
Nonopioid Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
MODIFIED WHO ANALGESIC LADDER
Proposed 4th Step
The WHO
Ladder

15. MODIFIED WHO ANALGESIC LADDER

16. TIMING FOR SCS

17. SCS & FUNCTIONAL MAGNETIC RESONANCE
IMAGING : MODULATION OF CORTICAL
CONNECTIVITY WITH THERAPEUTIC SCS
SCS reduces the affective component
of pain resulting in optimal pain relief.
Study shows a decreased connectivity
between somatosensory and limbic
areas associated with
optimal pain relief due to SCS
Deogaonkar M1, Sharma M1.Neuromodulation. 2016 Feb;19(2):142-53

18. SCS modulates cerebral function:
an fMRI study.
Neuroradiology. 2012 Dec;54(12):1399-407
key role of the medial thalamus as a mediator and the
involvement of a corticocerebellar network implicating
the modulation and regulation of averse and negative
affect related to pain. The observation of a deactivation
of the ipsilateral antero-medial thalamus might be used
as a region of interest for further response SCS studies.

19. CHANGES AT CORD & NEURONAL LEVEL
P Honore,S.D Rogers .Neuroscience;Volume 98, Issue 3,
June 2000, Pages 585–598
Murine models of inflammatory,
neuropathic and cancer pain each
generates a unique set of neurochemical
changes in the spinal cord and sensory
neurons

20. FUTURE IN NEUROMODULATION
 Burst stimulation
 High frequency stimulation
 Peripheral nerve field stimulation
 DRG stimulation

21. A SYSTEMATIC EVALUATION OF
BURST SPINAL CORD STIMULATION FOR
CHRONIC BACK AND LIMB PAIN
New approach that possibly causes more pain reduction for
short-term duration than tonic SCS without eliciting paresthesia.
This is an AAN recommendation level U. Further research is
needed with a larger sample size and a standardized study
design.
Hou S, Kemp K, Grabois M, Neuromodulation. 2016 Jun;19(4):398-405

22. ONE-YEAR OUTCOMES OF SPINAL
CORD STIMULATION OF THE DORSAL ROOT
GANGLION IN THE TREATMENT OF CHRONIC
NEUROPATHIC PAIN.
• Comparable to traditional SCS in terms of
pain relief and associated benefits in mood and
quality of life.
• Ability to achieve precise pain-paresthesia
concordance, including in regions that are typically
difficult to target with SCS
• Consistently maintain that coverage over time
Liem L, Russo M, Huygen FJ,Neuromodulation. 2015 Jan;18(1):41-8

23. HIGH FREQUENCY SCS
First randomized double-blind study on SCS.
HFSCS was equivalent to sham for the
primary outcome (improvement of PGIC) as
well as for both the secondary outcomes (VAS
and EQ-5D index).
Christophe Perruchoud MD,Neuromodulation, Volume
16, Issue 4,July/August 2013 ,Pages 363–369

24. SPINAL CORD STIMULATION IN
NEUROPATHIC CANCER PAIN
 The incidence of neuropathic component in cancer pain is
estimated to be around 15% to 40%.
 Spinal cord stimulators have been reported as a safe and
effective management of neuropathic cancer pain.
 Cata et al showed benefit in chemotherapy –induced pain in two
patients.
 Hamid and Haider showed improved pain relief in radiatherapy-
induced transverse myelitis.
 Yakovlev et al presented two case reports of cancer patients,
with uncontrolled neuropathic pain using conventional
medications, who benefitted from the implantation of spinal
cord stimulator.
 In sum multiple case series, no RCT’s.

25. THANK YOU