Spinal Cord Stimulators in Neuropathic Pain
Introduction
• Chronic pain is very common
• Immense physical, psychological, societal impact
• Financial burden
Neuropathic pain
• Damage or dysfunction of the nervous system
• Typical symptoms - burning - shooting - allodynia - hyperalgesia
Case history (1)
• Mr X - Referred to the pain clinic
• PC - Right arm pain
• Hx PC - Day 1 post medical procedure - Tingling, weakness, numbness of right arm
Case history (1)
• Investigations - MRI - Nerve conduction studies - Electromyography
• Diagnosis - Brachial plexus injury
• Conservative management strategyEMG
Case history (1)
• Follow up at 6 weeks - Burning, painful to touch, skin discolouration
• Diagnosis - Complex regional pain syndrome (CRPS)
• Therapies in pain clinic - Neurogenic pain medications - Cervical sympathetic block
Case history (1)
SCS inserted 2013
Case history (2)
• Mr FF, 62 yrs - GP referral to pain clinic
• PC - Back pain radiating to both legs
• Hx PC - 20 year history of back pain - Physiotherapy/analgesia - Multiple surgical procedures
Case history (2)
• Diagnosis - “Failed back surgery syndrome”
• Therapies in pain clinic - Neurogenic pain medications - Epidural and facet joint injections - L5/S1 nerve root block
Case history (2)
SCS inserted 2013
Management of chronic pain
Management of chronic pain
Management of chronic pain
Management of chronic pain
Neuromodulation
• Therapeutic alteration of the nervous system
• Electrical or pharmacological
• Implanted devices
Gate control theory of pain
Gate control theory and spinal cord stimulators
History of spinal cords stimulators
Which patients might be suitable for a SCS?
• Failed back surgery syndrome
• CRPS
• Peripheral neuropathy
• Ischaemic limb pain
• Angina
SCS electrodes
SCS electrodes
Components of the SCS
Phases of SCS implantation
1. Assessment phase - appropriate pathology - appropriate patient
2. Trial phase
3. Implantation phase
Where are the electrodes placed?
• Upper extremity T1-T2
• Low back T8-T10
• Lower extremity T10-T12
Trial phase
What are the criteria for a successful trial?
• 50% pain
• Area of parasthesia = area of pain
• Parasthesia not unpleasant
• Functional improvement
Complications of SCS
• Additional revision of the device (23%)
• Hardware malfunction (10%)
• Infection (4.6%)
• Complications during insertion
Some issues for patients….
NICE Guidelines
Case history (1) Complex regional pain syndrome
4 months later
VAS scores 10 3
Some restoration of hand function
Reduction in analgesic medication
Improved mood
Case history (2)Failed back surgery syndrome
2 months later
VAS scores 10 2
Improved mobility
Reduced analgesic medications
Improved mood
Conclusion
• Neuropathic pain is common, some patients are refractory to standard therapies
• Neuromodulation is an alternative method for treating severe, intractable pain
• Excellent results can be achieved with selected patients
Thank You