A case for spinal cord stimulation—don't delay (original) (raw)

Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action

Bioelectronic Medicine

Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, nonpharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.

Is Spinal Cord Stimulation an Effective Treatment Option for Discogenic Pain?

Pain Practice, 2011

Introduction: In a prospective observational study conducted in an urban pain management center, we evaluated whether spinal cord stimulation (SCS) is effective in relieving discogenic pain of IDD origin. Methods: Thirteen patients with intractable discogenic low back pain were enrolled. Four patients never underwent permanent implantation due to insurance denial, medical reasons or failed trial and served as a control group. Nine patients underwent SCS implantation (treatment group). All patients were followed for 12 months and assessed at each interval for pain (NRS), disability (ODI), and opioid use. Results: Nine patients completed the SCS trial with > 50% pain relief. The pretrial NRS score was 7.8 ± 0.5 mm in treated patients vs. 6.5 ± 1.7 mm in control patients. At 3, 6 and 12 months, the NRS was reduced to 2.9 ± 0.7 mm, 1.7 ± 0.5 mm, and 2.9 ± 0.5 mm, respectively in treated patients. NRS was unchanged in the control patients (6.5 ± 1.9 mm). The ODI score prior to the SCS trial in treated patients was 53.1 ± 3.4% vs. 54.0 ± 20.5 in control patients. At 3, 6 and 12 months the ODI scores were 39.0 ± 8.0%, 38.7 ± 4.6%, and 41.1 ± 3.9%, respectively in the treated patients, and 48.5 ± 29.5 at 12 months in control patients. In 6 patients receiving opioids prior to the SCS trial, average consumption was reduced by 69% (P = 0.036) over 12 months of therapy as compared with a 54% increase in the control patients. SCS usage was stable over the 12-month study. Conclusions: The current study indicates that SCS may provide effective pain relief, improve disability, and reduce opioid usage in patients with discogenic pain. n

The use of spinal cord stimulation in pain management

Pain management, 2012

SUMMARY Pain is a complex behavior process, the anatomy and physiology of which is not completely understood, and is subject to continuous exploration and research. Following on the heels of Melzack and Wall's gate control theory of pain (1965), Shealey et al., in 1967, were the first to implant stimulation electrodes over the dorsal columns in an attempt to provide relief for patients with chronic, intractable pain. Since then, significant strides in both the technological and therapeutic sides have facilitated the evolution of spinal cord stimulation (SCS) in the management of a variety of pain pathologies. High-quality evidence attests to the efficacy and cost-effectiveness of this modality. In contrast to conventional medical management, SCS offers long-lasting symptom relief, improved quality of life and functional capability, often achieving these goals at a reduced cost. This article illustrates the present status, challenges and future of SCS.

Mechanisms , Actions and New Paradigms : Spinal Cord Stimulation for Pain Management

2021

Ever since the discovery of Spinal cord stimulation (SCS) in the late 1960s, it has been widely used as a treatment option for chronic neuropathic pain management. SCS has succeeded clinically in a subset of managing chronic neuropathic pain syndromic conditions. It has several limitations as well such as insufficient pain relief or control, uncomfortable sensation called paresthesia etc. These limitations pushed the conventional methods to the need of developing new targets or paradigms for Spinal Cord Stimulation like the dorsal root ganglion stimulation, burst waveform stimulation and high frequency Spinal cord Stimulation. The aim of this review is to provide a brief and concrete detail on the mechanisms and actions of SCS.

Spinal cord stimulation for the management of pain: Recommendations for best clinical practice

South African Medical Journal, 2013

Spinal cord stimulation (SCS) is a form of therapy with a supportive evidence base, and has been used for the treatment of pain since 1967. It is strategically aimed at reducing the unpleasant sensory experience of pain and the consequent functional and behavioural effects that pain may have. When SCS is used to treat patients with chronic pain, it is important that the treatment is delivered within the context of a full understanding of the impact that pain has upon the patient, including its effect on quality of life. Pain can and does affect patients' psychological well-being and social functions. These recommendations give guidance to practitioners delivering this treatment, to those who may wish to refer patients for SCS, and to those who care for patients with stimulators in situ. The recommendations also provide a resource for organisations that fund SCS. Spinal cord stimulation for the management of pain: Recommendations for best clinical practice A consensus document prepared on behalf of Pain SA in consultation with the South African Spine Society, the Neurological Society of South Africa, and the South African Society of Anaesthesiologists, with guidance from the British Pain Society. These recommendations have been produced by a consensus group (below) of relevant healthcare professionals, and refer to the current body of evidence relating to spinal cord stimulation (SCS).

Burst Spinal Cord Stimulation in the Management of Chronic Pain: Current Perspectives

Anesthesiology and Pain Medicine

Over the last several decades, opioid diversion, misuse, and over-prescription have run rampant in the United States. Spinal cord stimulation (SCS) has been FDA approved for treatment for a primary indication of neuropathic limb pain that is resistant to more conservative medical therapy. The disorders qualified for treatment include neuropathic, post-surgical, post-amputation, osteodegenerative, and pain related to vascular disease. Some of the most frequently cited conditions for treatment of SCS include failed back surgery syndrome, complex regional pain syndrome (CRPS) Type I and Type II, and post-herpetic neuralgias. Developments in SCS systems have led to the differentiation between the delivered electromechanical waveform patterns, including tonic, burst, and high-frequency. Burst SCS mitigates traditional paresthesia due to expedited action potential and offers improved pain relief. Burst SCS has been shown in available studies to be non-inferior to the traditional SCS, which can cause pain paresthesia in patients who already have chronic pain. Burst SCS does not seem to cause or need the paresthesia seen in traditional SCS, making SCS not tolerable to patients. Moreover, some studies suggest that burst SCS may decrease opioid consumption in patients with chronic pain. This can make burst SCS an extremely useful tool in the battle against chronic pain and the raging opioid epidemic. As of now, more research needs to be performed to further delineate the effectiveness and long-term safety of this device.

Spinal Cord Stimulation for Treating Chronic Pain

Spine, 2018

Background: Traditional spinal cord stimulation (SCS) requires that paresthesia overlaps chronic painful areas. However, the new paradigm high-frequency SCS (HF-SCS) does not rely on paresthesia. Study Design: A review of preclinical and clinical studies regarding the use of paresthesia-free HF-SCS for various chronic pain states. Methods: We reviewed available literatures on HF-SCS, including Nevro's paresthesia-free ultra high-frequency 10 kHz therapy (HF10-SCS). Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary goal is to describe the present developing conceptions of preclinical mechanisms of HF-SCS and to review clinical efficacy on paresthesia-free HF10-SCS for various chronic pain states. Results: HF10-SCS offers a novel pain reduction tool without paresthesia for failed back surgery syndrome and chronic axial back pain. Preclinical findings indicate that potential mechanisms of action for paresthesia-free HF-SCS differ from those of traditional SCS. Conclusions: To fully understand and utilize paresthesia-free HF-SCS, mechanistic study and translational research will be very important, with increasing collaboration between basic science and clinical communities to design better trials and optimize the therapy based on mechanistic findings from effective preclinical models and approaches. Future research in these vital areas may include preclinical and clinical components conducted in parallel to optimize the potential of this technology.