NEUROMODULATION FOR CHRONIC PAIN NEUROMODULATION FOR CHRONIC PAIN SYNDROMESSYNDROMES

Richard Kang, MDRichard Kang, MDJagdip Desai, MDJagdip Desai, MD

Jagdip Desai, MDJagdip Desai, MD

Richard Kang, MDRichard Kang, MDJagdip Desai, MDJagdip Desai, MD

Jagdip Desai, MDJagdip Desai, MD

Disclosure: NoneDisclosure: NoneSponsor: Boston ScientificSponsor: Boston Scientific

Disclosure: NoneDisclosure: NoneSponsor: Boston ScientificSponsor: Boston Scientific

‣ Locations: Lyndhurst, Fort Lee, AberdeenLocations: Lyndhurst, Fort Lee, Aberdeen

‣ Interventional Pain ManagementInterventional Pain Management

‣ Medical ManagementMedical Management

‣ Multi-Modal / Multidisciplinary Multi-Modal / Multidisciplinary

‣ Non-Operative OrthopedicsNon-Operative Orthopedics

‣ Locations: Lyndhurst, Fort Lee, AberdeenLocations: Lyndhurst, Fort Lee, Aberdeen

‣ Interventional Pain ManagementInterventional Pain Management

‣ Medical ManagementMedical Management

‣ Multi-Modal / Multidisciplinary Multi-Modal / Multidisciplinary

‣ Non-Operative OrthopedicsNon-Operative Orthopedics

CHRONIC PAINCHRONIC PAIN

‣ Neuropathic pain arises as a direct consequence of a Neuropathic pain arises as a direct consequence of a lesion or disease affecting the somatosensory system lesion or disease affecting the somatosensory system (Loeser and Treede,2008). (Loeser and Treede,2008).

‣ It is generally more severe and more likely to be drug-It is generally more severe and more likely to be drug-resistant and persistent than nociceptive painresistant and persistent than nociceptive pain

‣ Neuropathic pain arises as a direct consequence of a Neuropathic pain arises as a direct consequence of a lesion or disease affecting the somatosensory system lesion or disease affecting the somatosensory system (Loeser and Treede,2008). (Loeser and Treede,2008).

‣ It is generally more severe and more likely to be drug-It is generally more severe and more likely to be drug-resistant and persistent than nociceptive painresistant and persistent than nociceptive pain

The Precision Spectra™ SCS System is used as an aid in The Precision Spectra™ SCS System is used as an aid in the management of:the management of:

‣ A spinal cord stimulator is a device used to exert pulsed A spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic electrical signals to the spinal cord to control chronic painpain

‣ Spinal cord stimulation(SCS) is an adjustable, non-Spinal cord stimulation(SCS) is an adjustable, non-destructive, neuromodulatory procedure which delivers destructive, neuromodulatory procedure which delivers therapeutic doses of electrical current to the spinal cord therapeutic doses of electrical current to the spinal cord for the management of neuropathic painfor the management of neuropathic pain

The Precision Spectra™ SCS System is used as an aid in The Precision Spectra™ SCS System is used as an aid in the management of:the management of:

‣ A spinal cord stimulator is a device used to exert pulsed A spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic electrical signals to the spinal cord to control chronic painpain

‣ Spinal cord stimulation(SCS) is an adjustable, non-Spinal cord stimulation(SCS) is an adjustable, non-destructive, neuromodulatory procedure which delivers destructive, neuromodulatory procedure which delivers therapeutic doses of electrical current to the spinal cord therapeutic doses of electrical current to the spinal cord for the management of neuropathic painfor the management of neuropathic pain

Spinal Cord StimulatorSpinal Cord StimulatorSpinal Cord StimulatorSpinal Cord Stimulator

GATE THEORY OF PAINGATE THEORY OF PAIN

‣ Melzack and Wall : 1965Melzack and Wall : 1965

‣ This theory proposed that nerves carrying This theory proposed that nerves carrying painful peripheral stimuli and nerves carrying painful peripheral stimuli and nerves carrying touch and vibratory sensation both terminate touch and vibratory sensation both terminate in the dorsal horn (the gate) of spinal cord. in the dorsal horn (the gate) of spinal cord.

‣ It was hypothesized that input to the latter It was hypothesized that input to the latter could be manipulated to “close the gate” to could be manipulated to “close the gate” to the former.the former.

INDICATIONSINDICATIONS

‣ Post-Laminectomy PainPost-Laminectomy Pain

‣ CRPSCRPS

‣ Ischemic Limb Pain Ischemic Limb Pain

‣ AnginaAngina

‣ Visceral / Abdominal Pain : VisceratomesVisceral / Abdominal Pain : Visceratomes

‣ Cervical Neuritis PainCervical Neuritis Pain

‣ Spinal Cord Injury PainSpinal Cord Injury Pain

‣ Post-Herpetic NeuralgiaPost-Herpetic Neuralgia

‣ Post Herniorraphary PainPost Herniorraphary Pain

‣ Neurogenic Thoracic Outlet SYndromeNeurogenic Thoracic Outlet SYndrome

‣ Cervicogenic Headaches / MigrainesCervicogenic Headaches / Migraines

EXPECTED OUTCOMESEXPECTED OUTCOMES

RELEVANT ANATOMYRELEVANT ANATOMY

‣ A basic tenet of SCS is to create an A basic tenet of SCS is to create an overlapping of paresthesia and pain region.overlapping of paresthesia and pain region.

‣ In order to do this, correlation of the In order to do this, correlation of the somatotopy and the level of the spinal cord is somatotopy and the level of the spinal cord is necessary. necessary.

SPINAL CORD TRACTSSPINAL CORD TRACTS

SPINAL CORD STIMULATIONSPINAL CORD STIMULATION

MECHANISM OF ACTIONMECHANISM OF ACTION

‣ BarolatBarolat

‣ 1993: Mapping of Sensory Responses1993: Mapping of Sensory Responses

‣ 1998: Anatomical and Electrical properties of 1998: Anatomical and Electrical properties of the intraspinal structures and clinical the intraspinal structures and clinical correlationscorrelations

‣ Chemical Level: studies suggest that SCS triggers Chemical Level: studies suggest that SCS triggers release of Serotonin, Substance P, GABA within release of Serotonin, Substance P, GABA within the dorsal hornthe dorsal horn

‣ Descending InhibitionDescending Inhibition

MECHANISM OF ACTIONMECHANISM OF ACTION

‣ Stimulate the neurons of the dorsal horn of the spinal cord to release Stimulate the neurons of the dorsal horn of the spinal cord to release increased amount of acetylcholine and GABA and decreased amounts of increased amount of acetylcholine and GABA and decreased amounts of aspartate and glutamate in rat modelsaspartate and glutamate in rat models

‣ Induce neurophysiological change, normalizing neuronal hyperexcitability Induce neurophysiological change, normalizing neuronal hyperexcitability in the dorsal hornin the dorsal horn

‣ Functional alteration at the supraspinal level has been suggested to play Functional alteration at the supraspinal level has been suggested to play an important role in pain reductionan important role in pain reduction

CONTRAINDICATIONSCONTRAINDICATIONS

‣ DiathermyDiathermy

‣ Pacemakers / Pacemakers / DefibrillatorDefibrillator

‣ MRI : Boston MRI : Boston Scientific - Scientific - MRI Head MRI Head ConditionalConditional

‣ Therapeutic Therapeutic UltrasoundUltrasound

COMPLICATIONSCOMPLICATIONS

CONCLUSIONCONCLUSION

‣ SCS Technology - constantly improvingSCS Technology - constantly improving

‣ Equipment and SoftwareEquipment and Software

‣ Reliable and SafeReliable and Safe

‣ Goal: Goal:

‣ Reduce PainReduce Pain

‣ Improve FunctionImprove Function

‣ Increasing Amount of UsesIncreasing Amount of Uses

‣ SCS is analgesia on demandSCS is analgesia on demand