Presentation discuss the principle of spinal cord stimulation in management of pain

1. SPINAL CORD STIMULATION
Khaled Fares Al-Ali, MD, FRCS,

2. SPINAL CORD STIMULATION THERAPY
• FDA-approved therapy to treat chronic
pain of the trunk and/or limbs
• Used to treat patients with neuropathic
pain
• SCS is considered a third tier pain therapy
• SCS is not a cure

3. PAIN
• Nociceptive Pain
• Harmful stimulus is applied to skin, joints, muscles and
nociceptive nerve endings are activated
• Sharp shooting/ dull aching pain
• Typically lessens over time
• Responds well to traditional treatments
• Neuropathic Pain
• Arise spontaneously without activation of nociceptors
• Typically Chronic pain
• Does not respond well to traditional treatments
• Tactile Hypersensitivity- allodynia and hyperalgesia

4. THEORIES BEHIND SCS THERAPY
• Gate Control Theory
• By stimulating the large A beta blocks the transmission of
pain signals via the small C fibers
• Stimulating supraspinal pathways sends signals up the
dorsal column to the brain stem and is then returned to
spinal cord via dorsal Longitudinal fasciculus to mediate the
pain pathways
• Descending Inhibition of Pain pathways
• Stimulation of the adrenergic sympathetic neurons close the
gate
• Stimulation of Dorsal Nerve root fibers

5. A-Beta
A-Delta

6. PERIPHERAL VASCULAR DISEASE

7. REFRACTORY ANGINA PECTORALIS
• Possible mechanisms:
• stimulation-induced increase in blood flow or redistribution of the blood supply
• direct inhibitory effect on cardiac nociception

8. Spinal Cord Stimulator
Procedure

10. BENEFITS OF SCS
• Pain relief
• Reduction in pain medication intake
• Improvement of depression symptoms
• Return to work
• Return to daily activities
• Increase quality of life

11. SCS CANDIDATES
• SCS is a last resort treatment of chronic pain when other therapies have failed
• Patients must have a multidisciplinary screening to determine if they would be a good
candidate
• Successful Trial Placement
• Patients must be motivated and willing to try the treatment

12. MULTIDISCIPLINARY TEAM
Pain MD Surgeon
PT Psych
One team!

13. A MISSING MEMBER!

14. SCREENING PROTOCOL
• Percutaneous placement of temporary epidural trial
• Intraoperative stimulation to assess placement
• Period of the trial, debatable
• Retrospective study of 52 patients for 15 min vs 5 days trial
• Successful trial was higher in 5 days group
• Some authorities (EU) required prolonged trial, 30 day
• SE: infections, epidural scaring

15. SUCCESSFUL SCS TREATMENTS
• SCS has been used since 1967 for the treatment of chronic
pain
• SCS has successfully treated numerous painful disorders
• Failed Back Surgery Syndrome/ Arachnoiditis
• Reflex Sympathetic Dystrophy (Complex Regional Pain Syndrome
• Angina
• Stump Pain/ Phantom Limb Pain
• Peripheral neuropathies
• Radiculopathies
• Peripheral Vascular Disease/ Ischemic Pain

16. “Failed” Back Surgery Syndrome
• Pain that persists after one or more surgical procedure
on the lumbo-sacral spine
• Most common diagnosis for patients who receive SCS
• Etiology is difficult to pinpoint
• Most common cause of FBSS- improper patient
selection
• 1-10% of patients will be worse after surgery
• Characteristics: back/ leg pain, numbness/tingling &
weakness in legs, stabbing burning and shooting pain

17. FBSS RESULTS
• PROCESS Trial
• International RTC
• N= 100
• Conventional (meds, PT, Blocks, injections ) vs SCS
• By 6 month: SCS group achieved significantly greater pain relief and improved
functional capacity and health-related quality of life
• EVIDENCE trial
• underway

18. COMPLEX REGIONAL PAIN SYNDROME
• AKA: Reflex Sympathetic Dystrophy
• Multi-symptom/ Multi-system
• Characteristics:
• Soft tissue injury/ immobilization
• Temperature difference between affected and unaffected extremity of at least 1°C
• Tactile hypersensitivity
• Cutaneous changes

19. PERIPHERAL VASCULAR DISEASE
• Various outcome criteria, including pain relief, limb salvage, and various measures of
peripheral microcirculation.
• Kemler M.A. et al
• N Engl J Med 2000; 343(9):618-624,
• Ann Neurol 2004; 55(1):13-18.
• One included 51 patients and found a clear, though not significant, trend for a
limb-saving effect of SCS
• Limitations: no trial done
• Dutch RCT

20. SCS AND ANGINA
• Number 1 Reason for Spinal Cord Stimulator implantation
in Europe
• Main Clinical Symptoms are related to ischemic heart pain
• Pain in chest, arms, throat and neck
• Results:
• Improved Coronary blood flow but no increase in totally flow
• Altered sympathetic/ parasympathetic balance
• Research- Ferrero, P et al., De Jongste et al.

21. THANKS

22. REFERENCES
ANS: St. Jude Medical Company. (n.d.). Spinal Cord Stimulation: A
Promising Treatment Option for Your Patients With Chronic Pain
[Pamphlet].
Boston Scientific. (2007). Taking Control of Your Pain: The First Step
[Pamphlet]. USA: Precision Plus.
Cameron, T., Ph.D. (2004, March). Safety and Efficacy of Spinal Cord
Stimulation for the Treatment of Chronic Pain: a 20-year Literature
Review. Journal of Neurosurgery: Spine, 100, 254-267.
Ferrero, P., MD., Grimaldi, R., MD., Massa, R., MD., & Chiribri, A.,
MD. (2007, January). Spinal Cord Stimulation for Refractory ANgina
in a Patient Implanted with a Cardioverter Defibrillator. PACE, 30,
143-146.
Greenwald, T., RN., & Ryan, B., RN. (2004, June). Spinal Cord
Stimulation Overview. In Mayfield Clinic. Retrieved January 15,
2009, from http://www.mayfieldclinic.com/PE-STIM.htm
Harney, D., Magner, J. J., & O’Keeffe, D. (2004, June). Complex
Regional Pain Syndrome: the case for Spinal Cord Stimulation (a
Brief Review). Injury: International Journal of the Care of the Injured,
(36), 357-362.

23. References Continued…
Kemler, M. A., MD., Barendse, G. A., MD., & Van Kleef, M., M.D.,
Ph.D. (2000, August). Spinal Cord Stimulation in Patients with
Chronic Reflex Sympathetic Dystrophy. The New England
Journal of Medicine, 618-624.
Leveque, J.-C., Villicencio, A. T., & Bulsara, K. R., MD. (2008,
October). Spinal Cord Stimulation for Failed Back Surgery
Syndrome. Neuromodulation, 4(1), 1-9.
North, R., MD. (2007). Practice Parameters for the Use of Spinal
Cord Stimulation in the Treatment of Chronic Neuropathic Pain.
American Academy of Pain Medicine, 8(S4), S20-S275.
Raina, G. B., Piedimonte, F., & Micheli, F. (2007). Posterior Spinal
Cord Stimulation in a Case of Painful Legs and Moving Toes.
Stereotactic and Functional Neurosurgery, (85), 307-309.