Spinal Cord Stimulators

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					Spinal Cord Stimulators
     Spinal Cord Stimulation
 FDA-approved therapy to treat chronic
  pain of the trunk and/or limbs
 Used to treat patients with neuropathic
 SCS is considered a third tier pain
 SCS is not a cure
   Nociceptive Pain
       Harmful stimulus is applied to skin, joints,
        muscles and nociceptive nerve endings are
       Sharp shooting/ dull aching pain
       Typically lessens over time
       Responds well to traditional treatments
   Neuropathic Pain
     Arise spontaneously without activation of
     Typically Chronic pain
     Does not respond well to traditional treatments
     Tactile Hypersensitivity- allodynia and
How does SCS Therapy work?
 Stimulator leads placed along the
  dorsal column of the spinal cord
  produce paresthesia sensation to help
  mask pain signals
 There are 3 types of SCS systems that
  can be used depending on the
  patient’s pain
     ConventionalIPG system
     Rechargeable IPG System
     Radiofrequency (RF) system
Spinal Cord Stimulator
Theories Behind SCS Therapy
   Gate Control Theory
       By stimulating the large A beta blocks the
        transmission of pain signals via the small C
       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
   Descending Inhibition of Pain pathways
       Stimulation of the adrenergic sympathetic
        neurons close the gate
   Stimulation of Dorsal Nerve root fibers
         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
         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
    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
          Failed Back Surgery
   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
   Characteristics: back/ leg pain,
    numbness/tingling & weakness in legs,
    stabbing burning and shooting pain
               FBSS Results
   Leveque, J et al.
     Randomized    Controlled Trial of 16
      patients with FBSS
   ANS St. Jude Medical Company Case
     Case   Study of a patient with FBSS
      Complex Regional Pain
 AKA: Reflex Sympathetic Dystrophy
 Multi-symptom/ Multi-system
 Characteristics:
     Softtissue injury/ immobilization
     Temperature difference between affected
      and unaffected extremity of at least 1°C
     Tactile hypersensitivity
     Cutaneous changes
     CRPS and SCS Research
   Kemler, M et al.
     Randomized   Control Trial of patients with
      Chronic Reflex Sympathetic Dystrophy
   Harney, D et al.
     Review  of case studies with patients with
      CRPS treated with SCS
     Overall all SCS groups had a 60-70%
      success rate, narcotic intake was reduced
      and improvement in activity and quality of
              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.
                  Leg pain
   Characteristics
     Pain in leg when walking
     Numbeness/tingling in leg
     Burning pain that is worse at night
     Phantom limb sensation- uncontrollable
     Sensitive Pain
   Research
     Jivegard et al.
     Raina, et al.
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,
Greenwald, T., RN., & Ryan, B., RN. (2004, June). Spinal
  Cord Stimulation Overview. In Mayfield Clinic.
  Retrieved January 15, 2009, from
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
      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.