Suffering from pain that cannot be controlled? You may benefit from Spinal cord stimulation, an advanced pain relief procedure……
Spinal cord stimulation is a remedy that disguises pain signals before they reach the brain. It is a method used to apply pulsed electrical signals to the spinal cord to treat chronic pain, but can also be used to switch spinal spasticity.
A small percentage of patients suffer chronic pain which does to respond to simpler interventions. It is this group which requires advanced pain therapy which requires implantation of device called as Neuromodulator to provide ongoing and effective pain relief. It is also brings about modulation of perception of pain and significantly improves quality of life.
The two categories are:-
Electrical [Spinal cord stimulation] and
Chemical [Intrathecal pump] neuromodulator.
Spinal cord stimulation is the most common mode of electrical neuromodulation used in managing chronic intractable low back and leg pain. It is also used to control intractable neck and arm pain. This modality has been increasingly used over the past two decades with more refined and improved hardware technology. It is minimally invasive and reversible as opposed to nerve ablation. The implantation is preceded by a trial during which the patient can experience the degree of relief the system is likely to offer. Once fully convinced the second stage of permanent implantation is performed.
Our center has the largest experience in offering this therapy with comprehensive approach and we have done this for various indications over the past 12 years. There is stringent selection criteria followed at our center to ensure the best outcome.
Use of spinal cord stimulation involves thorough understanding of the system by the patient. Spinal cord stimulation uses a pulse generator which is a small implanted device that generates low-level electrical impulses that stimulate targeted nerves along the spinal cord. This stimulation interferes with the transmission of pain signals to the brain.
Chronic back and leg Pain symptoms can vary widely like; Delayed Pain, Spinal stenosis, Spondylolisthesis, Osteoarthritis… Your body keeps aching weeks, months, or even years after the injury. Managing pain properly at an early stage can help limit indications in both time and severity.
Spinal cord stimulation is effective for a number of chronic pain conditions, such as neck pain, back pain, complex regional pain conditions etc.
Every patient is unique and one patient’s experience cannot be translated for advising the other patient. However, if the patient has any weakness, sensory loss or bladder or bowel symptoms surgery is a rule rather than exception and he should be urgently seen by a neurosurgeon.
There are two main components of the system implanted in the patient’s body.
a) First a thin wire called the lead is positioned in epidural space above spinal cord.
Different types of leads including the flattened paddle leads, programmers and stimulators
b) Second, is the implantable pulse generator or IPG [similar to cardiac pacemaker]
Different physician and patient programmers and IPG.
Which is placed just under the skin in a practical location that is acceptable to you and your doctor; and the leads are connected to the IPG or receiver
One of the most important attribute of using spinal cord stimulation is that it helps you to select the right patient after careful titration. At the Jaslok Hospital we perform stimulation trial by implanting percutaneous electrodes which are then connected to an extension device which in turn is connected to the programmer.
During the postoperative period the patient is provided with several programs through a trial stimulator. These programs will cover the area of his pain by paraesthesia (tingling sensation). Once that is confirmed we then remove the extension device and connect the percutaneous lead to the permanent IPG or the pacemaker which is implanted either at the level of the navel or over the buttocks. The second part of the procedure is done under general anesthetic.
After implantation of the electrodes during the next few days our pain physician would try several programs to find out the most optimal stimulation parameter to control the pain of the
patient with minimal side effect and the lowest possible voltage. This is a tedious task and achieved by lot of experience. Once the patient has been put on a stable programming parameter by the pain physician, we can then decide to discharge the patient. The patient is provided with 5 to 6 sets of different programming parameters which he can use with the help of the controller given to him even after discharge.
In some cases where there is a lot of Fibrosis and there are the chances of displacement of the electrodes we perform an open surgical procedure to implant or convert the percutaneous electrodes into paddle electrodes. This paddle electrodes are more stable and the procedure is performed with the help of a neurosurgeon. The paddle electrodes are more stable and the chances of their migration is minimal. The success rate of spinal cord stimulation depends on accurate implantation of the electrodes and proper anchoring of the electrode so as that they do not slip out of the spinal canal. We make lot of effort to ensure this and hence our success rates are pretty good and comparable to International standard
We have several patients who have undergone spinal cord stimulation for pain of different origin, these includes, post cervical laminectomy pain, CRPS II, brachial plexus injury pain, back pain radiating to lower limb, etc. The results of spinal cord stimulation surgery vary between indications and between centers. At Jaslok hospital, the spinal cord stimulation procedure is performed jointly by the pain physician and the neurosurgeon and a dedicated post spinal cord stimulation surgical team assists in programming and rehabilitation of these patients.
The neurostimulation implant is placed below the skin surgically. So, surgical difficulties are likely, similar to other surgeries. These may include infection, pain at the site of surgery, bleeding into the epidural space, headache, etc.
Few risks that are specific to spinal cord stimulation may contains:
– Stimulation stops or only works occasionally
– Overstimulation
– Poor system connection
Once the neurostimulation system is fixed, it’s possible that device difficulties may occur. These comprise jolting, lead breaking, and movement of the lead within the epidural space, which may need reprogramming, surgical replacement of the leads, or corrective surgery. These actions may result in sore stimulation or loss of therapy.
Most of these complications can be minimized or avoided by an experienced team.
A 26 year female had severe intractable pain in the right upper abdomen radiating to the left side and to the upper back. All her investigations including the MR scan were normal and there was, as such, no surgically treatable cause. She was frustrated because of the excruciating and undiagnosed nature of the pain.
She consulted a pain specialist, who tried multiple options in the form of highest possible doses of pain killers, epidural injection and splanchnic nerve block. But all of his efforts were in vain and the pain continued to trouble her tremendously causing not only physical but psychological disturbances as well.
As last try, she consulted us. After due consideration and discussion, she was given a trial of Spinal Cord Stimulation. She experienced a significant pain relief, after which permanent implantation of the leads was done.
14th January 2014, was the most unfortunate day for this 24-year lady who was traveling by train from home to office. Her hand got caught between the train door. She was rushed to the hospital immediately. According to the doctor, there were no major injuries and they were managed conservatively.
No sooner as she heaved a sigh of relief, her pain recurred, associated with flushing of hand with severe night pain unremitted by all possible painkillers. She was diagnosed as a case of CRPS (Chronic regional pain syndrome), that is the pain of regenerating nerve roots.
To promote the healing of the nerves, she tried experimental stem cell therapy, which was also fruitless.
She underwent spinal cord stimulation at another center, which provided excellent relief. However, in few months’ time, the lead got dislocated with a severe recurrence of her pain.
As a last resort, she consulted us. We assessed her and found that due to repeated procedures she had high chances of failure of therapy and hence we offered her to undergo an open surgery of paddle lead placement. This worked well for her and she got excellent pain relief and relief from her symptoms following the procedure.
74 years retired male, but doing day to day activities effortlessly, he started experiencing severe low back pain radiator to both lower limbs. He consulted a spine surgeon who advised MR-Scan which showed degenerative spine disease (L5-S1 PIVD). He underwent decompressed spine surgery with pedicle screw fixation for the same.
Unfortunately, the pain did not reduce after surgery; on the contrary he was in agony. He consulted the same surgeon; a repeat surgery was performed to remove the pedicle screw which was pressing the nerve root.However, his pain worsened and it was not responding to any medications. Simpler interventions, like life transformational adhesiolysis or physiotherapy. With a last ray of hope he consulted us. We gave him a trial of spinal cord stimulation for 4 days. To his surprise, the pain reduced substantially so much that he was able to walk effortlessly; confirming the satisfactory pain control, internalization of lead was done. After 1 year follow-up, he is enjoying his retirement.
