Pain

In general, SCS is much more effective in treating radicular pain, or pain that radiates down one’s arm or leg, than it is at treating axial pain, or pain that is only in the neck or back.  One of the first and most frequent uses of SCS has been for the treatment of post-laminectomy syndrome (PLS) which is also called failed back surgery syndrome (FBSS).  Post-laminectomy syndrome is recurrent pain, usually involving the lower back and/or legs, following spinal surgery.  Imaging must first prove that surgically correctable lesions are absent since PLS is considered a diagnosis of exclusion.  A multicenter study confirmed that majority of patients with PLS reported fair to excellent pain relief in both the low back (68.8%) and legs (88.2%) with a spinal cord stimulator device (1).  When compared to repeat spine surgery for PLS, spinal cord stimulation was found to be superior for pain relief (2).  Spinal cord stimulation is also more effective in providing leg and back pain relief in the setting of neuropathic pain secondary to PLS when compared to conservative medical treatment (3).

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lowerbackpainComplex regional pain syndrome (CRPS), which is also called reflex sympathetic dystrophy (RSD), is a neuropathic pain syndrome that involves severe pain, swelling, and skin changes.  CRPS can be a severe disabling condition and is difficult to treat with most conservative care.  CRPS is the second most common indication for spinal cord stimulation in the U.S.  Research has shown that SCS provides pain relief in over 73% of CRPS patients, as well as significantly reducing the associated edema (4, 5).  In addition, a European study found that, "the functional status and the quality of life could be significantly improved in sympathetically maintained CRPS I" when SCS was combined with physiotherapy (6).

 

Peripheral vascular disease (PVD), in which narrowing of blood vessels can lead to tissue ischemia, pain, and limb damage, is a serious condition that has the potential to result in debilitating pain or even amputation.  A study from the mid 1980s demonstrated that SCS is a "valid alternative treatment for moderate peripheral arterial disorders when direct arterial surgery is not possible or has been unsuccessful" (7).  Later in the 1990s, another study found similar results for pain relief (62%) and concluded that SCS is most effective in patients without hypertension (8).  SCS has also been utilized for the treatment of intractable pain due to angina, or chest pain.  Chronic angina that cannot be adequately controlled by a combination of advanced medical, interventional, and surgical therapies may respond to the effects of spinal cord stimulation.  Research has found that SCS "significantly improves exercise capacity and quality of life.” The beneficial effects of SCS for chronic angina "may be related to improved oxygen supply to the heart combined with an analgesic effect" (9).  In Europe, SCS has been utilized to a much greater extend for chronic peripheral vascular disease and for chronic angina. 

SCS is also an effective therapy for pain syndromes associated with peripheral neuropathies.  Peripheral neuropathy is defined as an abnormality of the peripheral nerves.  Peripheral nerves transmit pain, sensory, vibratory, and movement signals to the spinal cord.  The information is then transmitted to the brain.  The most common types of neuropathies are diabetic peripheral neuropathy and idiopathic neuropathy.  Spinal cord stimulation has been used to treat many of these painful peripheral neuropathies.  Some research indicates that pain associated with diabetic peripheral neuropathy is more responsive to SCS than post-herpetic neuropathy pain (10).

Recently, SCS has been reported to successfully treat visceral, or internal organ, pain.  One case reported SCS as a novel treatment of refractory neuropathic mediastinal pain, or pain from the front of the central chest, following surgery (11). In general, spinal cord stimulation offers many desirable benefits for those with severe debilitating chronic pain.  Some of the benefits of SCS include being easily adjustable, testable, reversible and/or removable if necessary.  For many pain conditions, SCS can be less invasive and more effective than surgery.  Ultimately, SCS may permit an individual to return to their daily activities, enjoy recreational activities, and overall increase quality-of-life with less pain.

 

 

REFERENCES:

1) Burchiel KJ, Anderson VC, Brown FD, Fessler RG, Friedman WA, Pelofsky S, Weiner RL, Oakley J, Shatin D. Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine 1996; 21:2786-2794.

2) North RB, Ewend MG, Lawton MT, Kidd DH, Piantadosi S. Failed back surgery syndrome: 5-year follow-up after spinal cord stimulator implantation. Neurosurgery 1991;28:692-9.

3) Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain 2007;132:179-88.

4) Barolat G, Schwartzmann R, Woo R. Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy. Neurophysiology 1987;50:442-3.

5) Robaina FJ, Rodriguez JL, de Vera JA, Martin MA. Transcutaneous electrical nerve stimulation and spinal cord stimulation for pain relief in reflex sympathetic dystrophy. Stereotact Funct Neurosurg 1989;52:53-62.

6) Harke H, Gretenkort P, Ladleif HU, Rahman S. Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe disability. A prospective clinical study. Eur J Pain 2005; 9:363-373.

7) Broseta J, Barbera J, de Vera JA, Barcia- Salorio JL, Garcia-March G, González-Darder J, Rovaina F, Joanes V. Spinal cord stimulation in peripheral arterial disease. A cooperative study. J Neurosurg 1986; 64:71-80.

8) Jivegard LE, Augustinsson LE, Holm J, Risberg B, Ortenwall P. Effects of spinal cord stimulation (SCS) in patients with inoperable severe lower limb ischaemia: A prospective randomized controlled study. J Vasc Endovasc Surg 1995; 9:421-425.

9) De Jongste MJL, Hautvast RWM, Hillege HL, Lie KI; Working Group on Neuroradiology. Efficacy of spinal cord stimulation as adjuvant therapy for intractable angina pectoris: A prospective, randomized clinical study. J Am Coll Cardiol 1994; 23:1592-1597.

10) Kumar K, Toth C, Nath RK. Spinal cord stimulation for chronic pain in peripheral neuropathy. Surg Neurol. 1996 Oct;46(4):363-9.

11) Guttman OT, Hammer A, Korsharskyy B. Spinal cord stimulation as a novel approach to the treatment of refractory neuropathic mediastinal pain. Pain Pract. 2009 Jul-Aug;9(4):308-11.

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