Neurostimulation Effective for Chronic Back Pain

PAIN MANAGEMENT

Spinal Cord Stimulation Approved By  Food and Drug Administration

Dr. Stan Golovac

Dr. Stan Golovac

THE USE OF electrical stimulation to relieve pain began in ancient times with the placement of torpedo fish directly onto painful body parts. Since then, the application of electrical stimulation to the body for pain relief has become much more refined and sophisticated. In 1989, spinal cord stimulation (SCS) was approved by the Food and Drug Administration (FDA) as a treatment for chronic pain. SCS has since become a standard of care for patients with neuropathic chronic back and limb pain (nerve injury with abnormal nerve function producing pain). New technology has allowed for the development of neurostimulators that can allow patients with chronic back pain to reduce or eliminate their need for pain medications and return to comfortable, productive lives.

SALLY BURKE, a 63-year old karate instructor, has responded very well to spinal cord stimulation. Spinal cord stimulation is actually a subcategory of neurostimulation, which also includes peripheral nerve stimulation.

SALLY BURKE, a 63-year old karate instructor, has responded very well to spinal cord stimulation. Spinal cord stimulation is actually a subcategory of neurostimulation, which also includes peripheral nerve stimulation.

Q: How does stimulation work?
A: In spinal cord stimulation, a tiny programmable generator and electrical leads are implanted beneath the skin. Small electrical currents are applied to the areas of the spinal cord involved in pain. For reasons that are not completely understood, these electrical impulses interfere with the transmission of pain signals to the brain and relieve pain without causing the side effects that are common with the use of pain medications.
A pleasant tingling sensation is substituted for the pain and blocks the brain’s ability to sense pain in the stimulated areas. This is similar to the relief felt by rubbing an area after getting an injury. The electrical impulses can be targeted to specific locations and, as pain changes or improves, stimulation can be adjusted as necessary.

Q: What is the goal of spinal cord stimulation?
A: The goal of neurostimulation with SCS is to achieve significant or total relief from back pain and to be able to return to a happy productive lifestyle. While this therapy does not work for everyone, most patients with SCS are able to report a 50 percent to 70 percent reduction in their overall pain and are able to decrease or completely taper off narcotic painkiller medications. With successful SCS, patients can function during normal activities, return to work, and fully participate in family and community life.

pm-34-wQ: How is this done?
A: In spinal cord stimulation, the physician first numbs the skin using a local anesthetic. Soft, thin wires with electrical leads at the tip are placed through a needle (without any incision) into the back near the spinal column. The physician, either an interventional pain specialist or spine surgeon, determines the best location based on the individual patient’s pain. The leads are then connected to a special programming device that is used to program the electrical current in a pattern to target the specific areas of pain  for the best relief possible.

Q: What is the SCS trial? Why not implant the permanent system immediately?

A: To make sure the patient will benefit from SCS, a temporary system is implanted and tried for a few days or a week. For the SCS trial, leads are placed beneath the skin and attached to a small generator the patient carries. The generator is similar to a pager or cell phone. If the SCS trial is successful, a complete permanent system with a generator is implanted at another time. The leads for the permanent system can be inserted the same way as in the trial. A small generator is surgically implanted beneath the skin in the upper buttock or abdomen. The wires are then connected and the entire system is implanted beneath the skin. Nothing is visible on the body.

Using a programming device outside the body, the system can be programmed in a way similar to using a remote control to adjust a television. The area or intensity of stimulation can be changed, and the system can be turned on and off or adjusted to provide the best pain relief. Programming is initially done at the physician’s office, and patients can learn how to control the stimulation on their own at home to adjust it to their pain. Many systems today have rechargeable batteries that can easily be recharged at home. To recharge the batteries, the patient places the recharging unit over the skin where the generator is implanted. Batteries may require recharging several times a month.

The latest technology provides coverage of different pain types (sensations) simultaneously (i.e. burning, aching, stinging). It is referred to as multiple independent constant current technology (MICC). Using this technology, each electrode lying over the spinal cord can be controlled independently. Currently, this technology is available with an added feature; the patient can program the stimulator with user-friendly software.

pm-33-wQ: What is neuromodulation?
A: Electrical neuromodulation therapies (the formal name for pain therapies that ‘change’ the way the nervous system processes pain) have been around since the late 1960s. Over the last 15 years, the reliability of these therapies has reached 80 percent to 85 percent for nerve injury (also called neuropathic) pain. Examples of neuropathic pain are nerve root injury (such as when a disc compresses and thereby injures a nerve), complex regional pain syndromes (where nerves become ‘crazed’ leading to fire-like pain in a whole arm or leg), pelvic pain, and even diabetic neuropathy and headache. The way in which this is applied has long been by spinal cord stimulation (as described earlier, where electrodes are placed by the surgeon over the area of the spinal cord). More recently, however, stimulation of nerve roots (where electrodes are placed at a location in the spine that gives rise to a nerve) has been shown to be more effective in some pain states. Use of electrical neuromodulation has also been effective when applied to peripheral nerves (nerves that lie outside of the spinal canal or brain).

Q: What are examples of electrical neuromodulation?
A: Examples of this include occipital nerve stimulation for headache and stimulation of facial nerves in face pain. When compared to medications, which often carry significant side effects such as sleepiness and memory loss, electrical neuromodulation has about a 34 percent chance of long term success and no significant side effects, and can be as much as 85 percent effective long term. Unlike older technology where leads would break and stimulation effects would fade, newer technology in electrical neuromodulation does not have these problems. Once structural (“carpentry”) problems are addressed (such as spine fusion, discectomy, etc), it is now possible to address the nerve pain (“electrical”).

In the future, we now know that placement of similar electrodes on the surface of the brain (known as motor cortex stimulation) will allow for control of even more complex pain states such as trigeminal neuralgia and stroke pain.  This therapy also looks promising when a person’s pain cannot be reached by spinal cord, nerve root or peripheral stimulation, with low complication rates. It’s truly a remarkable technology, when applied by expert hands that gives hope to many who live with terrible pain.

Stanley Golovac, MD is the co-director of Space Coast Pain Institutue. Dr. Golovac completed his education at UTESA University in 1985, where he received his Doctor of Medicine. Upon graduation, Dr. Golovac completed his postgraduate training in Family Practice Residency Program at St. Mary Hospital in New Jersey and in the Department of Anesthesiology at Jackson Memorial Hospital in Miami. Dr. Golovac gained extensive clinical experience in anesthesiology, emergency room medicine, and alternative services. He served as Assistant Clinical Professor of Anesthesia at the University of Miami Jackson Memorial Center for several years, and then as a practicing Pain Consultant in the Miami area. He currently utilizes his expertise at Cape Canaveral Hospital/Health First Pain Management and the Space Coast Surgery Center of Pain Management. For more information log on to YourPainInstitute.com