EXPERT PANEL DISCUSSION ON NEUROSTIMULATION BETH ISRAEL MEDICAL by decree

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									             EXPERT PANEL DISCUSSION ON NEUROSTIMULATION
                      BETH ISRAEL MEDICAL CENTER
                           New York, New York

00:00:11
WOMAN 1: The pills aren't working. And that's the problem. Sometimes the pills will
not work. I don't care how -- methadone, morphine, you name it, it does not help.
00:00:23
JULIE GORDON: Not only weren't they doing what they were supposed to do for the
pain, they were also giving me adverse after-effects. So it was really a catch-22
situation I was in. So I really needed to find an alternative, not just for the pain but
it was affecting my whole lifestyle.
00:00:42
ANNOUNCER: For many people suffering from chronic pain, physical therapy, pills,
and surgery have had little success in helping them regain their lives. In just
moments, from Beth Israel Medical Center, you can see how these and other
patients have found a way to reduce their pain with an innovative chronic pain
therapy called neurostimulation. Learn firsthand how this alternative treatment for
pain is bringing some patients relief where pills and surgery have failed. OR-Live
makes it easy for you to learn more. Just click on the "request information" button
on your webcast screen and open the door to informed medical care. Now to the
program we hope will help you find a new way to treat your pain.
00:01:25
LARA DHINGRA, PhD: Good evening, everyone. I'm Dr. Lara Dhingra, psychologist in
the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in
New York. As you've heard, we have a special program tonight that can go a long
way in helping people who have chronic pain, pain that can have a devastating
impact on a person's quality of life. Between 40 and 70 million Americans have
chronic pain. Tonight, you will see not only the medical procedure that can provide
comfort but also hear the stories from patients whose physical and psychological
well-being have been improved as a result of this procedure. Now I'd like you to
meet my colleague, Dr. Robert Sheu, director of the Pain Division in the Department
of Pain Medicine and Palliative Care here at Beth Israel Medical Center in New York.
Dr. Sheu, thank you for being here.
00:02:17
ROBERT SHEU, MD: Thank you, Dr. Dhingra.
00:02:19
LARA DHINGRA, PhD: You have a great deal of experience with performing
implantation for spinal cord stimulation. Can you tell the audience what exactly is a
neurostimulator and how does it work?
00:02:31
ROBERT SHEU, MD: Certainly. Neurostimulation, or spinal cord stimulation, is
achieved by gently stimulating nerves within the spinal cord, thereby blocking or
closing the gate to painful sensory stimuli as they're being transmitted to the brain.
Now, this is achieved by precisely placing a lead wire in the epidural space adjacent
to the spinal cord and thereby stimulating nerves that then, through those electrical
impulses, are able to block the painful sensation coming up towards the brain.
00:03:07
LARA DHINGRA, PhD: Wow. That's really something. We have some footage here,
Dr. Sheu, of a patient who actually underwent the procedure several weeks ago.
Here's what she had to say about how pain was affecting her quality of life. Let's go
to the tape.
00:03:25
SUZANNE LAMOUREUX: Around this past Thanksgiving, I got out of bed and I felt
like my thigh was tearing, the muscle was tearing. Physically, the thigh is absolutely
fine. The problem was the nerves going between my spinal cord because of the
disease I have. After that, it kept getting worse, happening more and more
frequently. Especially when I got tired, it really started bothering me to the point
where it started feeling like a needle turning into an ice pick to I couldn't walk from
one end of my apartment to the other. And as a teacher, it made it very difficult for
me to get through my day teaching. Not to mention, I didn't have elevators. So it
really stopped me from doing everything I should be able to do. I'm 31. I shouldn't
be forced to use a cane and stuck inside my house instead of going out and doing
the things -- I couldn't go grocery shopping. I had to do internet grocery shopping,
get them delivered to me, because I couldn't actually get to the grocery store. And
that was so difficult for me, because I can do everything. I don't need any help. Well,
I do, unfortunately, because of, well, my leg doesn't cooperate with me.
00:04:44
LARA DHINGRA, PhD: Well, here she is, in person, Suzanne, Lamoureux. And you
also have someone with you, another one of Dr. Sheu's patients, Julie Gordon.
00:04:55
JULIE GORDON: Nice to be here.
00:04:56
LARA DHINGRA, PhD: Thank you for being here, both of you. Now, I'm wondering if
you could tell us a little bit, Suzanne, about how chronic pain was affecting your life.
00:05:06
SUZANNE LAMOUREUX: Well, I'm a teacher. I teach third grade in a hard-to-staff
high-need school, and that's my mission in life is to help kids who really need it. And
it really impacted everything in my life and it made it even harder for me to really
follow my dream, which is helping out these kids. It takes a lot of energy to be a
teacher, and the pain was sapping my energy and making it so difficult for me to
teach, much less live the rest of my life.
00:05:36
LARA DHINGRA, PhD: So, Suzanne, you suffer from chronic pain that is associated
with multiple sclerosis. Chronic neuropathic or nerve pain.
00:05:44
SUZANNE LAMOUREUX: that's correct.
00:05:45
LARA DHINGRA, PhD: How are you feeling now?
00:05:46
SUZANNE LAMOUREUX: Oh, I can't -- I can't articulate the difference between then
and now. It's been eight weeks and three days, and after the surgery, my cane went
in the back of the closet and I haven't taken it out.
00:06:01
LARA DHINGRA, PhD: Is that right?
00:06:02
SUZANNE LAMOUREUX: I haven't needed it. That stabbing pain that I was
experiencing isn't there anymore. Now, do I still hurt, do I still have pain? Yes. But
it's not at the level that's stopping me anymore. I can go do my own grocery
shopping now.
00:06:16
LARA DHINGRA, PhD: Wow, that's a really fantastic story.
00:06:19
SUZANNE LAMOUREUX: I'm -- I can't articulate it. My life is back. I can walk again. I
can walk.
00:06:27
LARA DHINGRA, PhD: Julie, you've also undergone the procedure for
neurostimulation. Tell us a little bit about how pain was affecting you and how you're
feeling now.
00:06:37
JULIE GORDON: Well, about four years ago, I was diagnosed with a congenital
disease that I didn't even know I had. And at the time, I was -- had the pleasure of
being able to babysit for my grandchildren, and that became more and more difficult
as the pain in my left arm became more and more severe. That it got to the point
where it really debilitated me to the point where I could barely do anything, no less
pick up a preschooler. So it really affected the whole quality of my life, and I wasn't
able to enjoy any of the things that I was used to doing and looking forward to. I
mean, I had also taught and was retired at this point and looking forward to a whole
new life. And all of a sudden, that life was taken away from me because of the pain.
00:07:26
LARA DHINGRA, PhD: Wow. Wow. Tell us a little bit about how you're feeling now.
00:07:31
JULIE GORDON: Well, it's been three weeks, and I've gone through a little bit of a
roller-coaster ride in the last three weeks, but right now I'm feeling really much
better. The pain is definitely under control and each week, as the stimulator gets
adjusted, the pain becomes more and more under control. And my goal is to get to
the point where I'm no longer even aware that there ever was pain and that my life
goes back to being normal again. And that I can go back to my babysitting chores
and I can go back to being a grandmother and be able to pick up my grandchildren
and not have to worry that I'm hurting myself or that I'm causing any permanent
damage, which would have occurred had that gone on indefinitely.
00:08:20
LARA DHINGRA, PhD: You know, in hearing you speak, it struck me, you mentioned
your grandchildren so many times. How many grandkids do you have?
00:08:25
JULIE GORDON: Two.
00:08:27
LARA DHINGRA, PhD: And what do those two think about you now?
00:08:31
JULIE GORDON: Well, one -- the only one -- the older one, who's 4, is aware that
Grandma's in pain, Grandma has a boo-boo, as he calls it. The younger one has no
knowledge of what's going on. He's only a year. And I feel badly, because it's so
hard. I can't barely -- you know, I can't really see him without adult supervision
because if he should come over to me and want to be picked up, I can't do that. And
that's -- right now, that's because of the surgery, but it would've been like that in
any case, because as the pain had gotten worse, I was able to do less and less with
my arm. And it was really affecting the whole quality of my life. There wasn't any
part of my life that wasn't affected by the pain. The pain actually took over my life.
00:09:17
LARA DHINGRA, PhD: So it sounds like not only are you feeling better, but those
around you are affected by this as well in a positive way.
00:09:24
JULIE GORDON: There's no question. And actually, you find out about that after the
fact. They don't tell you while you're going through it, but after the fact is when
they'll say to you, "You know, Mom, now I can really see a difference." Or, "You
know, I'm really looking forward to the future." And it gives you a whole new outlook
on life, it really does.
00:09:42
ROBERT SHEU, MD: Suzanne, how has your outlook changed and how has your
career changed now since spinal cord stimulation?
00:09:50
SUZANNE LAMOUREUX: I want to start a family. That's -- I mean, I work with kids
and it's really reinforcing the fact that I want to become a mom. And when this pain
got to the point where I couldn't walk across my apartment, the thought came to
mind, "Well, what if I have children? What -- would I be putting a child in danger, in
jeopardy because I'm in so much pain I can't function?" But now that pain is under
control enough that I feel, "You know what, if I had to run across the room and pick
up a kid, I could." And I couldn't do that before. So it's reminding me that, "Wait a
second, I can be a whole person. I don't have to have my third leg, my cane,
attached to my side. I can walk from here to there. And so I can continue being a
teacher." I don't even have to think about going on disability, and that was
something I was considering. As much as I didn't want to think about it, I really had
no choice because the level of pain made it difficult for me to function at home, the
rest of my life, and not to mention with third-graders. Hey, if you're not up at the
same energy level, you're toast. So really, it's -- my career, I can still continue being
a teacher. And I can become a mom. And that's one of the reasons why I did this.
00:11:08
ROBERT SHEU, MD: That's great.
00:11:10
LARA DHINGRA, PhD: Well, we have some actual footage of Suzanne getting the
neurostimulation procedure done. Dr. Sheu, would you be able to talk us through
this and explain to us how this procedure actually works?
00:11:24
ROBERT SHEU, MD: That'd be great. Let's take a look at that video now. And here
we are with Suzanne. She's meeting with the anesthesiologist in the preoperative
area, and we're just reviewing with her the procedure as it's about to take place and
discussing with the anesthesiologist the nature of the procedure.
00:11:49
LARA DHINGRA, PhD: Suzanne, what are you feeling right now?
00:11:50
SUZANNE LAMOUREUX: I was nervous, as you can tell by my face. I was exhausted.
I mean, I didn't sleep so well the night before, but I was so hopeful. I mean, man, I
really was walking bad. And I was really so attached to that cane, but I was looking
forward to burning it. I'm not kidding. I was really ready to get rid of that. Man, I
was in a lot of pain that day.
00:12:13
ROBERT SHEU, MD: And this was just two months ago.
00:12:15
SUZANNE LAMOUREUX: This was just eight weeks and three days ago.
LARA DHINGRA, PhD: It's amazing. Wow.
00:12:17
SUZANNE LAMOUREUX: And now I haven't touched that cane since.
00:12:20
ROBERT SHEU, MD: That's wonderful.
00:12:23
SUZANNE LAMOUREUX: That was an exciting day. That was a very exciting day.
00:12:28
ROBERT SHEU, MD: So you were feeling pain. You were also feeling anxious,
obviously.
00:12:31
SUZANNE LAMOUREUX: Well, I was feeling -- I mean, I was going into the operating
room. But there was such a sense of hope because I had done the trial. The trial was
so successful that I knew it would change my quality of life, that I'd be able to walk
up and down stairs again.
00:12:52
LARA DHINGRA, PhD: And, Suzanne, this is typically what your walking was like for
you, kind of slow and labored.
00:12:58
SUZANNE LAMOUREUX: Slow and labored, stairs took me forever to go up and down.
I would have to go -- I wouldn't be able to use my right leg going up and down
stairs. I would use my left and then go up from there.
00:13:10
LARA DHINGRA, PhD: Wow. Dr. Sheu, what are we seeing right now?
00:13:14
ROBERT SHEU, MD: Here's Suzanne really -- the anesthesiologist at this point is
merely setting up an intravenous access for her so that she can receive medication
and a little bit of hydration by way of her vein. We also use this to administer
antibiotics prior to initiating the procedure. And this is one of the precautions that we
take to try to prevent any operative infections. And here we're positioning Suzanne
and making sure that she's comfortable, in a good position. And we see Suzanne's
tattoo on her back here. And we're cleaning her skin with a number of antiseptic
solutions, again, for infection prevention. And we're outlining here in the lower left
buttock area the site for the implantation of the pulse generator or the rechargeable
battery unit we will be placing.
00:14:11
LARA DHINGRA, PhD: Okay, so that's where it would go, right there.
00:14:14
ROBERT SHEU, MD: Yes.
LARA DHINGRA, PhD: Okay.
00:14:15
ROBERT SHEU, MD: And again, Suzanne is awake at this point and --
00:14:19
SUZANNE LAMOUREUX: It felt very cold, but I was comfortable. I was comfortable. It
felt odd but not bad.
00:14:25
LARA DHINGRA, PhD: Okay. So you're awake but kind of sleepy at this point. You're
alert but sleepy.
00:14:30
SUZANNE LAMOUREUX: I'm alert but sleepy. I felt everyth-- well, I felt everything
that was going on. I wasn't in pain, but I did feel what was going on.
00:14:40
ROBERT SHEU, MD: And here we are, we're using -- we're using an x-ray
fluoroscopy to guide the procedure to ensure that the lead wire is properly positioned
within the epidural space and for safety and to prevent any neural injury. And we're
right now just determining the exact position that we're going to begin the procedure
to ensure that we'll be able to place the lead properly for Suzanne so that we can
capture and stimulate the area that is causing her the greatest pain.
00:15:13
LARA DHINGRA, PhD: Okay.
00:15:15
ROBERT SHEU, MD: We've introduced some local anesthetic already into the skin.
Suzanne, again, is still awake. And here we're placing the needle and we're directing
the needle towards the epidural space, carefully again under x-ray fluoroscopy.
00:15:29
LARA DHINGRA, PhD: Wow, that's really something. And is that the needle there, Dr.
Sheu, in the epidural space?
00:15:36
ROBERT SHEU, MD: Yes, it is. This is the needle in the epidural space. This is the
lead wire here that we can see. And actually if we can pause the tape for just a
moment, I'm just going to illustrate for us here, this is the tiny lead wire that we're
talking about.
00:15:54
LARA DHINGRA, PhD: Wow, that really is small.
00:15:55
ROBERT SHEU, MD: And it -- it's very small, flexible, and this is one of the recent
advances that we've seen in spinal cord stimulation that has made the units much
more effective at treating patients with chronic pain. And they're really designed to
bend and very flexible for the patients to utilize.
00:16:17
LARA DHINGRA, PhD: So those bend with your body.
00:16:19
ROBERT SHEU, MD: Absolutely. And a number of surgical advances have taken
place, and we'll talk about those in just a bit.
00:16:26
LARA DHINGRA, PhD: Just to clarify, though, for a minute, Dr. Sheu, that's what --
those -- that lead wire with the electrodes, that's what provides the gentle buzzing or
the neurostimulation, as it may be?
00:16:37
ROBERT SHEU, MD: Absolutely. We've placed -- and we'll see here in the operative
video, we'll see that we've placed two leads in position for Suzanne to help her. And
there are eight small electrodes at the end of the lead which conduct the electrical
current. And it's through this lead wire that we're able to achieve that stimulation
and block the pain signal coming from her leg, and in Julie's case, from her arm.
00:17:03
LARA DHINGRA, PhD: Okay, all right.
00:17:05
ROBERT SHEU, MD: So let's -- we'll continue with the video here. And we'll go
ahead.
00:17:11
LARA DHINGRA, PhD: And here we're looking at part of the --
00:17:15
ROBERT SHEU, MD: This is the lead wire with the eight electrodes again being
advanced. And we're looking at Suzanne's spine from the side. And we're carefully
advancing the lead wire. And here we are looking at her spine from her back to her
front. And the lead wire is carefully placed into position.
00:17:40
LARA DHINGRA, PhD: That's a brilliant picture.
00:17:42
ROBERT SHEU, MD: Thank you. It's -- it really -- the lead wire, in order to ensure
that it's going to operate properly, needs to be precisely placed over the proper area
of the epidural space because we need to ensure that the stimulation is going to
block that painful signal. And again, for safety and for insurance that this is going to
achieve the end result, this is why the procedure is done under x-ray fluoroscopy.
00:18:10
LARA DHINGRA, PhD: Makes sense.
00:18:14
ROBERT SHEU, MD: So here we see one of the leads being placed, and there's the
introducer needle. And again, Suzanne is awake during the entire procedure.
00:18:22
LARA DHINGRA, PhD: So, Suzanne, you were able to talk to Dr. Sheu? If he asked
you questions, you could respond?
00:18:27
SUZANNE LAMOUREUX: The whole time. Really, all I felt was pressure. It wasn't
painful. There was enough anesthetic right in the area that I just felt pressure. But
during the whole time I was being asked, "How are you feeling?" And we'll see in a
little bit, a little bit more how the type of questions I was being asked to make sure
that it was in the right spot.
00:18:49
LARA DHINGRA, PhD: Right. Right.
00:18:50
ROBERT SHEU, MD: And so we'll continue from here. And with the operative video.
Once the single lead has been correctly placed, we now want to ensure proper
position for a second lead. And so we'll be performing the same procedure, just on
the opposite side.
00:19:14
LARA DHINGRA, PhD: Okay. And this is the second lead that's going in here, Dr.
Sheu?
00:19:19
ROBERT SHEU, MD: This is actually the first lead which is there. We're just looking at
that final placement in that positioning video. And here we are identifying the entry
point for the second lead here. And once the needle is in the epidural space again,
we're advancing that tiny lead wire into the space using the x-ray fluoroscopy again.
00:19:48
LARA DHINGRA, PhD: And there you are.
00:19:54
ROBERT SHEU, MD: And the lead can be gently rotated and positioned correctly.
00:19:59
LARA DHINGRA, PhD: So you really have a great deal of control over the precision of
how you're placing these. I can see that.
00:20:04
ROBERT SHEU, MD: Absolutely. And again, there's been a number of advances in
spinal cord stimulation that have helped us to ensure that we can position the leads
properly for the patient. Here the leads are both in proper position for Suzanne.
They're just adjacent to the midline bilaterally, and we're ready to begin the trial
stimulation for her to make sure that she feels the stimulation where she needs it
most.
00:20:28
LARA DHINGRA, PhD: Wow, so you're really getting feedback from Suzanne in the
moment.
00:20:31
ROBERT SHEU, MD: We have to, absolutely. And this is why it's so essential that
during the operation, Suzanne is awake, she's able to communicate with us, she's --
she's able to participate because we really want to ensure that she feels this
stimulation where she needs it. It's not only important that the lead be positioned
anatomically correct but it's most important that the lead be functional for Suzanne.
And here what we're doing is we're connecting that lead, both leads, and we're
initiating a trial here. And the trial is conducted with an external device. And we're
talking with Suzanne at this point, making changes in the leads. Maybe we can pause
at this moment again, and I'd like to ask Suzanne and Julie how was your -- how
was it during the trial, the stimulation in the operating setting? What did you feel?
00:21:25
SUZANNE LAMOUREUX: Well, initially, what I was feeling is my torso was buzzing.
And I needed it more on my leg. And when I told you guys that, you made a few
adjustments until we got it to be primarily my right thigh, which is where I need it to
be. Initially it wasn't. It wasn't uncomfortable, but you guys made sure that it made
90% onto the area it needed to be.
00:21:50
ROBERT SHEU, MD: Great. And Julie, for yourself?
00:21:53
JULIE GORDON: I have to say that initially, it was the arm that I felt it in. Not the
whole arm, but it was enough of the arm that I think you knew that you were doing
it exactly where -- you had placed it exactly where you wanted it to be at that point.
So I was a little bit luckier than you were.
00:22:13
SUZANNE LAMOUREUX: Didn't hurt, though. It didn't hurt for them to change it at
all.
00:22:17
JULIE GORDON: I knew immediately that they had gotten the spot.
00:22:20
ROBERT SHEU, MD: You felt it?
JULIE GORDON: Yeah. Right away.
00:22:22
ROBERT SHEU, MD: And, Suzanne, what did the stimulation feel like to you?
00:22:25
SUZANNE LAMOUREUX: It -- almost like a tingle. And once it got into the right spot,
it was almost like seltzer water or carbonation or "champagne and clean sheets" I
guess is how I like to say it.
00:22:36
LARA DHINGRA, PhD: Sounds refreshing.
00:22:37
SUZANNE LAMOUREUX: It really -- it was. Compared to the stabbing, it was a
pleasant feeling. Really a pleasant feeling.
00:22:44
LARA DHINGRA, PhD: I think it also touches on how sort of patient-centered or how
individualized this approach really is. Between your feedback and Julie's feedback
and sort of helping Dr. Sheu to figure out exactly what combination of placement
was going to be ideal for the both of you.
00:23:00
ROBERT SHEU, MD: And as Suzanne and Julie have both talked about, the real
advantage to spinal cord stimulation is the ability to perform the trial. And at this
point, once confirming that the patient receives the stimulation where they need to,
we would really just remove the needles, secure the lead wires with tape and maybe
a single suture, and let the patient go home with an external device and try the
stimulation at home for themselves for about a week. And both Suzanne and Julie
were able to do that. Suzanne, what was your -- what was your trial experience like?
00:23:37
SUZANNE LAMOUREUX: Prior to this, when we did the trial, well, it was
uncomfortable. I had a wire sticking out of my back. But -- and I had to be very
careful with how I positioned myself, but I felt the stimulation. It was different, it
was odd. I had it in for -- on the third day is when I found out, "Okay, yeah, let's go,
let's do this." I was working in an old building, no elevator, it was the fourth floor.
And usually at the end of the day, I would hand over my books to my students and I
would slowly go down the four flights of stairs. But on that Thursday, I handed my
cane to one of my students and I walked down the stairs.
00:24:19
LARA DHINGRA, PhD: Yeah.
ROBERT SHEU, MD: Good for you.
00:24:20
LARA DHINGRA, PhD: That's really something.
00:24:21
SUZANNE LAMOUREUX: So that's when I knew, "All right, let's go, let's do this."
00:24:24
LARA DHINGRA, PhD: That was a real breakthrough day.
00:24:26
SUZANNE LAMOUREUX: Huge. Huge. Because I thought, really, that I was going to
be incredibly limited with the rest of my life, and this was like, "No, no, I'm not done
yet. I'm not done yet."
00:24:35
LARA DHINGRA, PhD: So it sounds like it was that point in the trial when you knew
that this was going to be something that would work for you.
00:24:39
SUZANNE LAMOUREUX: I had no doubt.
00:24:40
LARA DHINGRA, PhD: And provide you with relief that actually has changed your life.
00:24:45
SUZANNE LAMOUREUX: It has. It's given it back.
00:24:46
LARA DHINGRA, PhD: Yeah.
00:24:47
ROBERT SHEU, MD: And, Julie, how was the trial for you? What was the experience
like?
00:24:50
JULIE GORDON: In the trial, I knew almost immediately that this was something that
I wanted to go ahead with. The device was very cumbersome. I had to come up with
some very innovative ways of carrying it. I think I shared one of them with you, I
took a purse and put it over my neck and then put the device inside the purse so
that I wasn't walking around with this thing hanging from me.
00:25:14
LARA DHINGRA, PhD: There you go, and you probably got a new handbag out of it.
00:25:17
JULIE GORDON: Well, I was told it was new. I don't really know. But in any case --
but I knew immediately. And I did have to come in for an adjustment. I mean, there
were a couple of adjustments along the way that I knew had to be done as well, but
I knew almost immediately that there was a change because of the way that the pain
had changed. It was a very different feeling than I had before. So there was no
question in my mind at that point.
00:25:45
LARA DHINGRA, PhD: Had you ever experienced a feeling like that before, Julie?
00:25:48
JULIE GORDON: Well, it was a feeling -- the feeling was that like of pins and needles,
but what it was really doing was deflecting the pain so that I really wasn't thinking
about pain. And that was the first time in four years I hadn't thought about pain. And
that was -- that was a miracle. It was an amazing experience. And that's when I
knew that at some point in the future, I was going ahead with this. There was no
question about it.
00:26:16
LARA DHINGRA, PhD: Two really powerful stories and accounts of what that was like
for you with the trial. Are we ready to go back and finish the procedure?
00:26:23
ROBERT SHEU, MD: Yeah, let's take a look now at the remainder of the procedure,
which would be the implant that occurs after having undergone a successful trial.
And here we've administered additional local anesthetic to Suzanne. And again, she
is still awake, in a little bit of a twilight sleep now. We've been able to give her a little
bit more medication. And we're making a careful incision in the midline. And this is a
small incision, as you'll see. It's only about two inches in length. We're using a small
retractor here just to open the area up and give us the ability to visualize the area
appropriately.
00:27:05
LARA DHINGRA, PhD: Okay.
00:27:09
ROBERT SHEU, MD: What's important at this point is to ensure that we have a good
solid secure place to anchor these lead wires.
00:27:17
LARA DHINGRA, PhD: Okay.
00:27:19
ROBERT SHEU, MD: Anchoring is essential in spinal cord stimulation to prevent the
leads from migrating or falling out of position. We'll see in just a moment some of
the different styles of anchors and the evolution that has taken place recently in the
development of various anchor types.
00:27:36
LARA DHINGRA, PhD: So it sounds like this technology has advanced in exciting
ways on many different levels.
00:27:41
ROBERT SHEU, MD: Absolutely. There have been dramatic changes in spinal cord
stimulation. Spinal cord stimulation initially began in the mid- to late-1960s, but only
in the past few years have we seen some revolutionary changes in spinal cord
stimulation that have really allowed for just renewed interest and the broader
application of this technology for treatment of chronic pain.
00:28:05
LARA DHINGRA, PhD: What are we looking at right now, Dr. Sheu?
00:28:07
ROBERT SHEU, MD: Right here what we're doing is the ligament structure's above
the spine, we've made no entry to the spine. We'll pause right here for just a
moment with the video.
00:28:16
LARA DHINGRA, PhD: Oh, okay, are these the anchors you were referring to?
00:28:17
ROBERT SHEU, MD: They are, Dr. Dhingra. And so we'll pause here for a minute and
take a look at them. Some of the older anchoring types were a little bigger and
clumsier and Medtronic has come a long way in the evolution of spinal cord
stimulation with the development of these anchoring devices. This is a new titanium
anchor developed by Medtronic which really ensures a much more stable lead
position and prevents the lead from migrating.
00:28:42
LARA DHINGRA, PhD: So that really keeps the leads in place. It anchors it.
00:28:45
ROBERT SHEU, MD: Absolutely. And it's a real, real advantage over the prior
stimulator lead anchors that were in production. So here we're securing them down
and we're securing the lead again to the ligament structures so that they are
extremely solid. And we'll be demonstrating that in just a moment.
00:29:06
LARA DHINGRA, PhD: Now, it looks like you're -- are you sewing? Are those stitches?
00:29:10
ROBERT SHEU, MD: Absolutely. What we're going to do here is suture the anchor
appropriately into the skin, and you can see how firmly they are in position.
00:29:17
LARA DHINGRA, PhD: Yeah, look at that.
00:29:18
ROBERT SHEU, MD: We really want to make sure that this lead, with Suzanne
leading such an active lifestyle and Julie also having such an active lifestyle --
00:29:26
LARA DHINGRA, PhD: Picking up those grandchildren.
00:29:27
ROBERT SHEU, MD: We have to prevent these leads from falling out of place. Now,
here we are at the site that we designated in the left gluteal area for Suzanne for the
placement of the pulse generator. And we can talk about that for a moment. The
newer pulse generators are really what have led to all the excitement in spinal cord
stimulation in the past two years. Prior to this, we did not have a rechargeable
system, and so patients often had a concern with how much they would use their
spinal cord stimulator. Or if they would wear the battery down, that would
necessitate having to replace the battery unit. The greatest advance that's happened
is the evolution of an implanted and rechargeable pulse generator, which is a
rechargeable cell. And Medtronic has gone a long way to this in the creation of the
RESTOREADVANCED system. This system is much smaller than the previous systems
that we used to use. And that is so important when you're dealing with young
patients who are wanting to have the device but they're concerned about aesthetics.
They want the unit to be small.
00:30:42
LARA DHINGRA, PhD: Dr. Sheu, is this the unit right here, actually? Do we have
that?
00:30:44
ROBERT SHEU, MD: It is.
LARA DHINGRA, PhD: Excuse me for jumping in there.
00:30:46
ROBERT SHEU, MD: This is the unit, and you can see how small it is. And it's --
00:30:51
LARA DHINGRA, PhD: It's really tiny. It looks like one of those iPod --
00:30:56
ROBERT SHEU, MD: Nanos or something, yeah. It's -- and it's very streamlined. And
this can be placed into a small pocket in the gluteal area or in the abdominal tissues.
And this serves as the power source for spinal cord stimulation. And we can see here
that this is exactly how that works. So this power source here can be placed down
here in the gluteal area with the wires then extending into the spine, up into the
epidural space, and providing the level of pain relief that the patient needs. And in
Julie's case, these lead wires are placed within the cervical spine or in the neck area.
00:31:43
LARA DHINGRA, PhD: Dr. Sheu, how long would one of those devices last, the
charge on that?
00:31:48
ROBERT SHEU, MD: The new RESTOREADVANCED systems, which are rechargeable,
are rechargeable very easily by the patient at home for about nine years.
00:31:57
LARA DHINGRA, PhD: Nine years, is that right?
00:31:59
ROBERT SHEU, MD: Yep. And so it's given patients a much greater degree of
flexibility with the use of the unit. They don't have to be concerned that they might
use the battery up too soon, necessitating a repeat surgery for the replacement of
the battery. And it also, the units themselves are much more user-friendly. Patients
find that they're easier to use, they have a broader range of applications, and they're
also better at targeting the painful sites and much more effective because of the
evolution that we saw in the lead wires that have been developed.
00:32:31
LARA DHINGRA, PhD: Wow, that's really fantastic. It sounds like both the size of the
unit as well as the length of the battery and the precision with which you can target
the actual painful areas has vastly improved since the '60s.
00:32:44
ROBERT SHEU, MD: Absolutely. And again, just in the past few years, it has really
broadened the use of this amazing technology. And it's now been able to help more
than a quarter of a million patients.
00:32:57
LARA DHINGRA, PhD: A quarter of a million. Let's see if we can get back to the rest
of the surgery here.
00:33:02
ROBERT SHEU, MD: Certainly. So here we are, we're creating that small pocket in
the gluteal area just in the fatty tissues. Again, we've obviously given Suzanne an
appropriate amount of local anesthetic in this area, but she is not uncomfortable.
She was awake for this part of the procedure. And here's the system here, and we
can see again, how small the unit is. And we're measuring the pocket just to ensure
that the size of the unit will fit into the pocket. And we can see that the unit itself is
just about two and a half inches in length. So very small. And a great advance over
the prior units that were used. This is a tunneling shaft which is used to bring the
lead wire from the posterior spinal incision down towards that pulse generator. We
do this so that we don't have to make any additional incisions. And we can therefore
cause less trauma to the patient. And in Suzanne's case, we were able to maintain
the integrity of her tattoo, which is very important to her.
00:34:16
SUZANNE LAMOUREUX: Very important.
00:34:20
ROBERT SHEU, MD: Maybe we could -- maybe we could pause here for a moment.
Suzanne, maybe you could tell us a little bit about that tattoo, because I know it's so
personal and so meaningful to what we're here to talk about.
00:34:31
SUZANNE LAMOUREUX: Well, just as a little bit of a history, I was diagnosed with MS
four days before I graduated from college, and I thought essentially my life was
over. Because the only image of MS I had was an aunt not related by blood,
wheelchair, in mind of a 6-year-old. And so I had just decided, "Okay, fine, my life is
over." Then I got to a point where I was ready to dream again. That symbol is called
the Auryn. It's actually from the book and the movie The NeverEnding Story.
Whoever holds the Auryn speaks for the childlike empress. Well, on the back of that
medallion which the hero wears, it says, "do what you dream, do what you wish."
And it guides and it guards. So for me, that was reclaiming my life. Now I have an
addition to that tattoo. I have two scars. And once again, it's a claiming, a reclaiming
of my life, because now that I have this, now that I have this stimulator, I have my
life back again. Once again I can fulfill my dream of helping children. So the fact that
my tattoo is unscathed and actually is enhanced by this was really important to me,
was really important to me. And I was really glad that we were able to keep that, my
two intertwining snakes, uninterrupted.
00:35:49
ROBERT SHEU, MD: Absolutely.
00:35:51
LARA DHINGRA, PhD: That's really a touching story, and I think it shows that this --
that neurostimulation was a tool that really helped you find more meaning and
purpose in life.
00:35:59
SUZANNE LAMOUREUX: Oh, it gave me back my ability to fulfill my meaning and my
purpose. Because I changed careers to become a teacher. Once I realized my energy
was precious to me, I was going to spend it someplace where it mattered. And the
pain was taking away even more of that energy. Now I have that back. So now I
have that dream back again, and I can live it.
00:36:22
ROBERT SHEU, MD: Now you're pursuing your dream as well, right, Julie? To be a
grandmother and to --
00:36:26
JULIE GORDON: Well, and new dreams, because now it opens up doors which I
never even knew I had. I mean, when you live with pain, that's your life. There isn't
anything that you do or think or say that doesn't revolve around that pain. And when
that pain is gone, it opens up doors that you didn't even know were there to begin
with. And possibilities. So above and beyond my grandchildren, who I adore, I hope
to have, you know, a life above and beyond that that I can enjoy. And travel and do
things that I would not have been able to do otherwise, because there was no
question that as time went on, the pain was getting worse. And the pain was
interfering more and more with my life. So there would've been no doubt that, you
know, within a few years -- as a matter of fact, had the pain not been...I want to say
taken care of, but had there not been surgery, surgical intervention, there was a
possibility that I might have become paralyzed. So it was very important to me on
many levels to make sure that this be done. And who knows what the possibilities
are now? I mean, it's endless.
00:37:43
ROBERT SHEU, MD: Wonderful.
00:37:44
LARA DHINGRA, PhD: Really is. Really is.
00:37:46
ROBERT SHEU, MD: Let's take a look again at the completion of Suzanne's surgery
here.
00:37:56
LARA DHINGRA, PhD: So just to bring us back to where we left off, Dr. Sheu, here
are you guiding with the device here?
00:38:02
ROBERT SHEU, MD: We are. We're guiding that tunneling device from the left gluteal
pocket to the spinal incision, and we're bringing that through here. And we're going
to use this device by removing the center portion as a vehicle to conduct the wires
down under the skin without having to, again, disrupt the skin. And thereby leaving
Suzanne with only two small incisions rather than a much larger incision.
00:38:40
LARA DHINGRA, PhD: And here, are these the lead wires?
00:38:42
ROBERT SHEU, MD: These are the -- these are the ends of the lead wires. And we're
cleaning them off. We're going to put on a small extension. The purpose of the
extension is to create a generous amount of slack within the lead wire system,
because as Suzanne bends forward and also particularly as Julie bends forward, we
don't want the lead wire to be under tension and, again, cause the lead to possibly
dislodge or fall out of that position where it's operating. And so we want to ensure
that there's an appropriate amount of slack at both sites for when the patient moves
and performs their activities.
00:39:21
LARA DHINGRA, PhD: And what are these covers that we're seeing?
00:39:23
ROBERT SHEU, MD: These are connecting boots that just ensure that this system
remains sealed and intact. We place them over the connector site. And here we're
placing those connectors or extensions into the RESTOREADVANCED system. And we
-- once the lead wires are connected here, we secure them with a small wrench to
ensure that they are in the proper position. And again, you can even once again just
see the size of the unit in comparison to my thumb over here.
00:39:53
LARA DHINGRA, PhD: Looks just like a matchbox.
00:39:56
ROBERT SHEU, MD: And this is the small wrench which secures the extensions in
proper position. Here's the entire unit now ready to be assembled. It's already been
assembled, ready to be installed. So the lead wires are in the position, her spine.
00:40:11
LARA DHINGRA, PhD: What does this device right here do?
00:40:14
ROBERT SHEU, MD: Right here what we're doing is we're pulse irrigating or flushing
both pockets with a combined antibiotic solution. This is one more thing that we do
here at Beth Israel Medical Center to try to ensure that the patients do not have a
postoperative infection in addition to some of the other precautions that you saw
that we took: administering IV antibiotic therapies as well as cleaning her back and
using these special dressings. But this pulse irrigation helps to cleanse the pocket
and reduce the risk of possible infection, which is a major concern.
00:40:49
LARA DHINGRA, PhD: Sounds like every precaution is taken.
00:40:52
ROBERT SHEU, MD: Absolutely.
00:40:54
LARA DHINGRA, PhD: You know, this might be a good time to even just talk about
some of the potential risks or if there are any risks, what are they?
00:41:01
ROBERT SHEU, MD: Certainly. With spinal cord stimulation, this is a surgical
procedure. And there's always a risk with surgery. Risks such as infection, bleeding,
and any time we're operating in the area of the spine, there's always a concern
about neural injury or a spinal headache. Here at Beth Israel Medical Center, we do
everything that we can to reduce these risks, and we do so by preoperatively
performing numerous lab tests, including x-rays and EKGs to ensure that the patient
is ready for surgery. We also again administer antibiotics and take infection control
precautions in the operating room setting. And we also, as you've seen, perform the
procedure under x-ray or fluoroscopic guidance to reduce the possibility of neural
injury and to ensure that the lead is properly positioned.
00:41:54
LARA DHINGRA, PhD: On that note, maybe we can explore a little bit later how
someone might know whether this is the right procedure for them. But in the
meantime, let's cut back to the footage here and see how the rest of this surgery
goes.
00:42:08
ROBERT SHEU, MD: Excellent. We'll go ahead. And so we've now placed the unit into
the pocket. And you can see that it fits very nicely into the pocket. We want the
pocket to fit appropriately. We don't want it to be too tight or too loose. It needs to
just fit appropriately so that we can close the pocket without causing any undue
strain. And here we're just examining the pocket. And again, you can notice that
there's not a lot of bleeding. We haven't entered the spine. All we've done is made
incisions into the skin and into the fatty tissues. We've not entered the spinal canal,
we have in no way changed the architecture or structure of the spine. And therefore,
if need be, the unit can be removed without having destroyed or changed any of the
structure of the spine.
00:43:06
LARA DHINGRA, PhD: That's just one of the features of the flexibility, I think, with
this procedure, with neurostimulation. And the fact that right now, Suzanne, you're
not feeling pain, actually. Just some pressure, as you mentioned.
00:43:16
SUZANNE LAMOUREUX: I -- at this point, really I'm not uncomfortable at all. Maybe
a little cold. The operating room was cold, but that's nothing. That' nothing.
00:43:28
LARA DHINGRA, PhD: Wow, that's really something. You know, while we have a
moment now, I'm wondering if we could touch on, Dr. Sheu, how you go about
knowing whether a person is a good candidate for neurostimulation and what type of
criteria you use to judge that?
00:43:44
ROBERT SHEU, MD: Certainly. Patients that are candidates to undergo this procedure
are those patients who suffer from chronic pain. Chronic pain involving the neck, the
spine, or the extremities. This obviously would not be an intervention that would be
someone's first choice, so this is something that would be considered in patients who
have tried more conservative approaches such as physical therapy or initial
medication management and have not found success.
00:44:10
LARA DHINGRA, PhD: I see.
00:44:12
ROBERT SHEU, MD: Also, in looking at patients that are appropriate for this
procedure, it is important to consider pre-procedure psychological screening. And
you know this well, this is an area that we find is very beneficial because it can help
us to identify what patients are going to be appropriate for the procedure, that they
really understand the limitations of spinal cord stimulation. Because as you've heard
today from Julie and from Suzanne, it hasn't taken away all of their pain. Rather
what it's done is reduce their pain to, as Julie pointed out and Suzanne, so that pain
isn't the primary focus of their day. They're able to function. They have a quality
back in their life. But they still do suffer from pain. And so it's important for patients
to understand that because they may still have pain, they may still need some
medication. Our goal and objective would be to try to reduce their pain and thereby
reduce their medications. But we need to have a very practical understanding and
real understanding of what spinal cord stimulation can and cannot do.
00:45:24
LARA DHINGRA, PhD: So it sounds like a meeting with a psychologist like myself can
really help determine whether someone's emotionally prepared to take on the
procedure and also whether they have realistic expectations about what the result
might be.
00:45:37
ROBERT SHEU, MD: Absolutely. And again, as we've talked about before, the other
true advantage to spinal cord stimulation over other interventions is the fact that the
patients for themselves will get to try the procedure and see if it's right for them. I
think it's obviously very important for anyone who suffers from chronic pain to meet
with a qualified pain physician, a clinical pain psychologist, review with them their
history, physical examination, and see if they are appropriate for the procedure. And
if they are, then they can go ahead, have a trial performed, and decide really for
themselves if it worked for them. Because that's the most important thing, that the
trial works and that they have found that it's going to help to improve their quality of
life.
00:46:24
LARA DHINGRA, PhD: You know, this would be a good time -- I think we have some
e-mail questions coming in from our viewers, and the first one that we have here --
oh, actually, it's about you, Suzanne. What this person wants to know is what sort of
the cosmetic appearance of your back is, how's your body image, do you feel the
device, can you see it?
00:46:46
SUZANNE LAMOUREUX: I can -- underneath the skin, it's a little stiffer than I guess
my butt normally would be. It's a small incision. It was uncomfortable initially with
the healing. I mean, there was a pocket there that wasn't there when I laid down on
that table. But cosmetically, really, Dr. Sheu looked at it today. You can hardly tell
that one side of my lower back is different from the other. I have a very small
incision. One small kind of dark line in the middle of my back which I've actually
noticed has started to fade. Really, you can hardly tell unless I actually lift up my
shirt and show someone and be like, "Okay, here is where it happened."
00:47:32
LARA DHINGRA, PhD: That's amazing.
SUZANNE LAMOUREUX: So cosmetically, it really hasn't changed much, except those
scars are now part of my tattoo. And for me, that's important, but you can't really
see them that much.
00:47:44
LARA DHINGRA, PhD: Wow.
00:47:45
SUZANNE LAMOUREUX: And I expect them to fade, but for me, I know they're there.
And I know that's me taking control. I can control how much I tingle. So really, I can
control my pain. It's not controlling me.
00:48:00
ROBERT SHEU, MD: And do you feel that the device is noticeable under your clothing
at all?
00:48:05
SUZANNE LAMOUREUX: No, you can't see it at all. Unless I say, "Here, let me show
you." I would have to either lift my shirt or push my pants down a little bit. Then you
could see the scar, but you can't actually see the device. It doesn't actually make a
visible lump or anything.
00:48:21
LARA DHINGRA, PhD: So if you want to wear a backless gown when you're out on
the evening?
00:48:24
SUZANNE LAMOUREUX: I might put a little bit of cover-up right in the middle where
the scar is, but you really couldn't see it.
00:48:30
LARA DHINGRA, PhD: Wow, wow. And, Julie, how about you? How have you noted --
I guess the question asks here what it's like trying to adjust the device or find the
right combination of stimulation. How has that been for you?
00:48:45
JULIE GORDON: It's been an interesting trial, because every week -- this is the third
time -- once a week, I've come back for an adjustment. And today was a different
kind of adjustment than I've had in the past. And I think that we're getting -- each
week we get closer and closer to the adjustment that is going to do the trick, so to
speak. Because that's really the key to it, is finding the right adjustment. Once
everything is done and once everything is healing and you're feeling better, then
that's the next step is finding the right adjustment. And then you're home free. I
mean, it sounds easy, but along the way, there -- whatever complications come into
play, you know, if you have that in the back of your mind, it really gives you the
impetus to go ahead and to keep doing what you need to do. And eventually you
make it.
00:49:44
ROBERT SHEU, MD: But it's already working for you, we're just trying to --
00:49:48
JULIE GORDON: And I'm -- I didn't mean to interrupt you, it's just that you've got
eight weeks literally under your belt, and I've got three, and --
00:49:59
ROBERT SHEU, MD: So we'll get there.
00:50:00
LARA DHINGRA, PhD: It's a journey.
00:50:01
SUZANNE LAMOUREUX: He's tweaking it, that's all.
00:50:02
JULIE GORDON: Right, and I'm just finding that each week, it gets better and each
week there are less complaints. And each week it's becoming more a part of who I
am.
00:50:14
ROBERT SHEU, MD: And, Julie, the two incisions for you, are they uncomfortable, are
they bothersome at all? Have they healed well?
00:50:20
JULIE GORDON: Not at this point. I have to say the first week there was definitely
surgical issue, but not anymore.
00:50:26
ROBERT SHEU, MD: So already in three weeks you really have no post-procedural
pain?
00:50:30
JULIE GORDON: No, not at all. Not at all.
00:50:32
ROBERT SHEU, MD: Wonderful.
00:50:33
LARA DHINGRA, PhD: That's really terrific. You know, we have some other patient
stories about spinal cord stimulation, and be a great opportunity now if we could
share some of them with you. Let's take a look.
00:50:47
ROBERT SHEU, MD: That would be great.
00:50:49
WOMAN 1: It just soothes the pain somewhat. And then you become immune to it.
And it's for the good doctors, their knowledge to either increase it, take it away, find
something else. And this is where the stimulator came in, because the pills aren't
working. And that's the problem. Sometimes the pills will not work. I don't care how
-- methadone, morphine, you name it, it does not help, no matter how high the
dosage. And that's the real deal.
00:51:27
WOMAN 2: After 11 spinal surgeries, I can tell you that this is a godsend. I don't
take as much medication as I used to. It's not a cure-all. I'm not going to lie, I do
have pain here and there, but for the most part, I'm not taking my medications
anymore, I can ride my bike, I can go back to the gym, I can function on a daily
basis, I can clean my own apartment. There are things that I can do. Obviously I
can't do any heavy things, because I do have a compromised spine, but the
stimulator -- I don't know if it's more of a conscious thing that I'm saving my other
organs by not taking the drugs as much… That makes me feel better, that I don't
have to live on my medication, on muscle relaxers where I'm sleeping half of the
day. I can take my medicine at night, when I'm supposed to sleep, not all
throughout the day that I'm groggy, I'm foggy, and I can't function. So putting this
in my back has been the best thing I've ever done.
00:52:20
JULIE GORDON: It's the first time that I could actually say I was pain-free for any
length of time. And that was almost -- I still can't believe it. I'm still feeling like,
"Pinch me," you know. And I mean the feeling that I had instead of the pain, it's not
where you're just pain-free, you don't feel anything. I mean, the stimulator does
have its own effect, but it overrides the pain, and that's all that I cared about. And
that was really a major accomplishment for me. And everyone that I spoke to who
knows what I've been through has been really thrilled for me because they know the
effect it's had on me and on those around me. To have something offered to you that
gives you your life back really is an incredible gift. I feel myself -- I sound like a
Hallmark card, you know? But that's how I feel. It's been so long that I've lived with
this that I almost forgot what it felt like not to have to live with it.
00:53:47
LARA DHINGRA, PhD: Wow, that's very powerful information to share with us. Thank
you. We have some questions from our audience over e-mail, and I'm wondering if,
Dr. Sheu, you could answer this first one. How is the stimulator actually controlled?
00:54:07
ROBERT SHEU, MD: Okay. The patient is given a programmer, and this is a unit that
is, as you can see, small enough to be held in the palm of your hand. It's a small
remote control. And again, this is the programmer that's used with the Medtronic
RESTOREADVANCED system. It has a visual display, so the patients can clearly see
what they're doing in terms of making changes with the stimulation. They can turn it
on, off, up, down. They can change different parameters. Also, this is one of the
great advances in spinal cord stimulation that Medtronic has led to, which is there
can be set different programs. So we can set a program that would be suitable, for
example, for a patient to be running, a patient to go walking, a patient to be
sleeping. Because patients may desire more stimulation or need more stimulation
during different activity levels.
00:55:04
LARA DHINGRA, PhD: So they can control the level of stimulation based on the
activity that they're doing: running, walking.
00:55:10
ROBERT SHEU, MD: Absolutely.
LARA DHINGRA, PhD: Even sleeping.
00:55:12
ROBERT SHEU, MD: Exactly. And the importance of that, again, is that what we're
looking to do is give patients back control. And we're doing so in a way that they're
not having to rely as heavily on medications. So should they have a bad day, should
they want to be more active, rather than having to reach for more medication, which
obviously can have its own issues and side effects, the patient can use the resources
of their spinal cord stimulator to allow them to be more active and allow them to
function. And again, the unit is completely wireless and it's placed just over the
rechargeable battery cell which is implanted in the patient. And by placing it just
over the site, the patient is then able to change the program. Once the program is
set, they can place the remote in their pocket or in a purse and continue to go about
their activities. It doesn't need to be in direct connection with the unit.
00:56:12
LARA DHINGRA, PhD: Wow, that's amazing. And for those of you that can see this,
it's literally smaller than a television remote control. Okay.
00:56:20
ROBERT SHEU, MD: And, Suzanne, how have you found using the patient
programmer?
00:56:25
SUZANNE LAMOUREUX: I love it. I love it. It makes it really easy. In the morning, I
just put it up to the site in the back, turn it on, put it in my bag. I don't even touch it
again until late in the afternoon, evening, and then I can either turn it up or turn it
down, depending on what I'm doing next. I actually have my students remind me,
because if I forget to turn it on in the morning, so I have a monitor who is in charge.
"Ms. Lamoureux, did you turn on your machine yet?" So it's extremely convenient
and very, very handy.
00:57:00
ROBERT SHEU, MD: Great. And, Julie, how was it for you, learning how to use the
device? Was it difficult or did you find that you were pretty able to adapt to this
technology?
00:57:11
JULIE GORDON: The -- I really had no problem adapting to the technology, but I'm
still in the midst of learning how to use the device personally. In other words, the
technology itself, I think anybody can really learn. It's very easy. But in terms of
what settings work best for me, what settings work best for me under certain
circumstances, that's what I'm still working with and playing with and getting used
to. Because I do change it according to what I'm doing at any particular time. So
that's just a -- right now, I'm still in the learning process.
00:57:46
LARA DHINGRA, PhD: So the more experiences you have, that learning curve kind of
reduces.
00:57:49
JULIE GORDON: Yeah, exactly, exactly. It's very easy to use, it's just a matter of
personalizing it for your own needs.
00:57:56
LARA DHINGRA, PhD: And I think we've all kind of agreed that the personalized
approach of this procedure with neurostimulation is one of its best features. We have
another e-mail question here: will I get used to the stimulation and how has it
changed? I think we've kind of touched on that. I don't know if there were other
things in terms of getting used to the stimulation, Dr. Sheu or Suzanne or Julie, that
we should add.
00:58:19
ROBERT SHEU, MD: Well, I think what's important for patients to realize is that
although they are able to program the stimulator themselves by turning it on or off,
up and down, they can change from one program setting to the other, we, too, as
clinicians, have the ability to make vast changes in the programming to change the
pattern and to try to refine the stimulation so that the stimulation really covers
precisely the area that the patient needs to have that stimulation and that they're
getting adequate pain relief. And this is precisely what we have already done with
Suzanne and what we're currently working with Julie doing. We're refining that
stimulation. And this is something that can take a little bit of doing and modifying in
the initial post-operative period, and so patients are often asked to come back
maybe weekly for two to three weeks till we can get that more refined for them,
modifying stimulation. And then once it's pretty established, then the patients are
able to use the programmer themselves and make some changes for themselves.
00:59:26
LARA DHINGRA, PhD: So it sounds like once they're able to kind of work with you,
you're able to help them adjust the level of stimulation that will be most comfortable.
So that touches on another question, which is: what type of a follow-up is it? How
rigorous is that? How many times do they need to come back and see you or another
physician who might perform the procedure?
00:59:48
ROBERT SHEU, MD: Here at Beth Israel Medical Center, within the Department of
Pain Medicine and Palliative Care, I have my patients come back weekly for about
two weeks, sometimes three, so that we can, again, adjust the stimulation to make
sure that it's comfortable. But as in Suzanne's case, she's had the procedure done
now eight weeks and three days ago.
01:00:09
SUZANNE LAMOUREUX: Yep.
ROBERT SHEU, MD: And already has moved out of state and is having no issues and
will continue to utilize her stimulator for herself. This device as well, Medtronic is a
worldwide corporation, and there are representatives that can make contacts for
Suzanne or Julie out of state should they need to and help them to get in touch with
clinicians locally if they choose to transfer their care to another physician, being
located out of state. And in Julie's situation, again, we're working with her a little bit
more closely right now to try and modify that stimulator really to fine-tune it and to
make sure that it targets just the area that she needs it most.
01:00:58
LARA DHINGRA, PhD: That's great. That's great. You know, this might be a good
time to kind of revisit how will you know that neurostimulation is the right choice for
you and what makes a person a good candidate for this type of a medical procedure?
01:01:14
ROBERT SHEU, MD: Well, again, patients who suffer from chronic pain that has been
refractory to more traditional approaches --
01:01:22
LARA DHINGRA, PhD: "Refractory," what do you mean, Dr. Sheu?
01:01:24
ROBERT SHEU, MD: Not responsive to physical therapy or basic medication
management. They've tried some limited interventions such as injections without any
significant benefit and they're still troubled by chronic pain that's impacting their life,
their family's life, and affecting their quality of life. So those patients are candidates,
and I think that what's important for anyone who's considering spinal cord
stimulation is obviously to make an appointment with a qualified pain specialist so
that they can review with them their history, their physical examination, all their
prior documentation to see if they are appropriate. And again, as both Julie and
Suzanne have pointed out, really going ahead with that trial, because that is the
focal point on which spinal cord stimulation really allows the patient to decide for
themselves that this is going to work for them and they can do -- they know before
we do that surgery what the anticipated outcome will be. And they're able to really
go into it understanding what the benefit is going to be to them.
01:02:39
LARA DHINGRA, PhD: You know, we have a question here for either Julie or
Suzanne. What was it in your decision-making process that let you know that
neurostimulation was right for you? Julie, do you want to take that question?
01:02:52
JULIE GORDON: Sure. I think Dr. Sheu just hit on it: the fact that you could do the
trial. Especially in my particular case, because I had had very extensive surgery two
years previous to this for that -- for the congenital defect that had caused the pain in
the first place. And the surgery did not do anything for the pain. And as a result, I
tried many, many interventions, including medication, including acupuncture,
including -- I'm trying to think of what other things. I think short of dancing around
the floor, I think I did just about everything that one could do. The last thing in the
world I wanted to consider was more surgery. That was probably the very last thing I
would've considered. The fact that I could try it on a trial basis just for a week, that
was the deciding factor for me. And had it not been for that, I probably would not
have even gone ahead with it, because I was so turned off to any type of surgical
intervention because of the experience I had had and the fact that it didn't help that
I probably would not have even been sitting here today talking to you.
01:04:06
LARA DHINGRA, PhD: Wow, wow. So the trial can really help you determine whether
this works for you, and in most cases, you don't have that type of flexibility or even
that luxury to evaluate.
01:04:16
JULIE GORDON: Right.
01:04:17
ROBERT SHEU, MD: And I think the fact that the patients not only get to have a trial
but have a trial that they can do at home.
01:04:23
LARA DHINGRA, PhD: At home, right.
01:04:25
ROBERT SHEU, MD: We don't conduct the trial merely in the operating room setting
and make a determination at that point, but rather put the lead in the proper
position, give the patient an external device, and let them go home that very same
day. Because, again, what's important, as we've heard in both situations, it's not just
about pain relief. It's about quality of life. And what we need for these patients to do
is go home, experience it for themselves in their own life, and see what kind of
differences it's going to make for them. And you know, I think that we heard that.
We heard that in Suzanne's case that she started walking within days without the
use of her cane. That is so just paramount to knowing the value of this device and
this technology.
01:05:18
LARA DHINGRA, PhD: And you can take that home in your own natural environment
and adjust it to your lifestyle. We have another question here, which is -- oh, this is
an interesting one. Will the stimulator, I guess, mask me from having sensation in
the site of pain? In other words, will you no longer feel sensation, I guess, where you
once had pain?
01:05:40
ROBERT SHEU, MD: That's an excellent question. The stimulation that's provided, as
Suzanne and both Julie have indicated, is a sensation -- it can be a tingling sensation
or a bubbling sensation. It does not completely make the extremity or area that
we're providing that sensation without any sensation. So patients are able to feel
touch, they're able to feel hot, cold. And in fact, as we've also talked about, patients
do still have pain. If they were to cut themselves, they will feel that pain. This does
not remove all sensation. And so patients very much still have touch and sensory
feedback from the extremity, but it's that sharp, stabbing quality of the pain that's
reduced and not eliminated.
01:06:34
LARA DHINGRA, PhD: So patients aren't at risk of hurting themselves because they
can't feel pain or doing certain types of activities in some way not knowing of -- not
feeling that pain. They're not at risk of hurting themselves.
01:06:48
ROBERT SHEU, MD: No, in fact, they're not. And that's, again, spinal cord stimulation
doesn't damage the nerves. It doesn't destroy them in any way. And it's not
changing the nerve in its architecture or in its structure. And so patients aren't at
risk of not being able to feel that they're hurting themselves. If they -- if we were to
cause trauma to the extremity, in Suzanne's case, if we were to traumatize her right
leg or she were to bump her right leg, she can --
01:07:20
SUZANNE LAMOUREUX: Yeah, I can definitely feel if I run into my blanket trunk at
the end of my bed and slam my leg. Oh, I feel it. That doesn't change. But I don't
feel the stabbing that was from the damaged nerves.
01:07:32
ROBERT SHEU, MD: And Julie, do you still have sensation and touch in opening your
arm?
01:07:37
JULIE GORDON: Without a doubt. There's no question about it.
01:07:38
ROBERT SHEU, MD: And full movement of your arm/
01:07:40
JULIE GORDON: Absolutely, absolutely.
01:07:43
LARA DHINGRA, PhD: Well, you know, I think that we've all learned so much about
the procedure, and certainly from the both of you, Suzanne and Julie. On that note, I
want to thank you both for being here and I'd like to say good night. On behalf of Dr.
Sheu, Suzanne Lamoureux, and Julie Gordon and on behalf of the Department of
Pain Medicine and Palliative Care at Beth Israel, good night.
01:08:11
ANNOUNCER: This has been an expert panel discussion on neurostimulation from
Beth Israel Medical Center in New York City. OR-Live makes it easy for you to learn
more. Just click on the "request information" button on your webcast screen and
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01:08:40
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