Neurostimulation and Pain Management: Could It Be Right for You?
Practical Pain Management spoke with chronic pain experts C. Norman Shealy, MD, PhD, Founder and CEO of the National Institute of Holistic Medicine, editor of the Journal of Comprehensive Integrative Medicine, and professor emeritus of energy medicine at Holos University Graduate Seminary and Christopher Gay, MD, president and interventional pain physician at the Alaska Center for Pain Relief Inc. in Anchorage, Alaska and diplomat of the American Board of Anesthesiology. Dr. Gay is board certified in both anesthesiology and pain management.
Dr. Gay: Approved by the FDA in 1989, neurostimulation uses modern technology and electrical pulses to help manage an age-old problem: chronic pain. Specifically, it treats pain that is neuropathic in origin, or that results from nerves that are damaged or functioning improperly. The abnormal sensations produced by these nerves can at times be overcome by providing a different electrical stimulus or impulse, which ideally is more pleasant than the original sensation (patients report feeling a tingling sensation).
The technique involves implanting a small device into the thoracic spine (for pain in the lower back and legs) or the neck (for pain in the upper back and arms). The patient controls the pain using a hand-held programmer. Many patients are able to wean off or significantly reduce their use of opioid medications through the use of neurostimulators.
Depending on where in the body the stimulus is applied, this technique may be referred to as spinal cord stimulation (SCS) or peripheral nerve stimulation, both of which are a form of neuromodulation/neurostimulation. Commonly treated conditions are complex regional pain syndrome (CRPS), post-laminectomy or failed-back surgery syndrome, as well as various peripheral nerve applications, such as headaches, among others.
Dr. Shealy: Neurostimulation can also be effective for treating depression, improving mood, and sympathetic dystrophy (a syndrome that causes pain and swelling).
Q: Am I a candidate for spinal cord stimulators (SCS)?
Dr Gay: To determine if you are a good candidate, discuss your case with a spine and pain specialist. Generally speaking, individuals with chronic neuropathic pain syndromes are often good candidates, especially if there is pain in the arms or legs, in the case of spinal cord stimulation. Neurostimulators aren’t effective for patients whose primary symptoms are numbness and weakness.
Q: What do I need to do to prepare for a consultation with a specialist?
Dr Gay: Bring a list of previous treatments and details regarding when they occurred, where they occurred, for what duration, and whether they were helpful. Treatments of interest are: surgery, physical therapy, chiropractic treatments, diagnostic and steroid injections, neuropathic pain medications, anti-inflammatories, opioid pain medications, and complementary alternative medical (CAM) therapies. Also very useful to take to a consultation are the results of any diagnostic studies and imaging such as EMG/nerve conduction studies, x-rays, and MRIs.
Dr. Shealy: Be sure the physician has extensive experience in neurostimulation.
Q: What happens during the SCS trial period? Will I have pain relief right away?
Dr. Gay: I always say that stimulation is one of the few areas of medicine where you get to “try it before you buy it.” The trial is a relatively minor procedure that can be performed in an office setting or at a surgery center. During a trial, one or several trial leads are placed, under fluoroscopic guidance, into the epidural space of the back or neck and connected to an external pulse generator.
The generator is then activated and adequate coverage of the painful area is confirmed. Several programs are then set, which can be used during the trial to determine whether the device makes life better for the patient. Antibiotics are typically administered in an IV or intramuscularly before the trial begins and many physicians will prescribe oral antibiotics as long as the trial device is in, to reduce the risk of infection near the implant site, as it is a direct connection into the spinal canal.
Dr. Shealy: If you do not receive pain relief almost instantly, the spinal cord stimulator needs to be adjusted or it may not work. You may use it as much of the time as you need it.
Q: How long does it take to put in the SCS, and will I be under anesthesia?
Dr. Gay: With preparation and positioning for the procedure and programming of the device, one should plan to spend about an hour or less in the procedural suite or operating room during the trial. As “audience participation” from the patient is needed to confirm adequate placement and coverage of the painful area, it is not common to have general anesthesia or heavy sedation during a trial. Intravenous sedatives, which may be quickly titrated down, are ideal if heavier sedation is needed, so that appropriate and useful responses can be obtained when confirming proper lead placement.
Q: What happens if I need to change my battery or something goes wrong with the SCS leads? Will I need more surgery?
Dr. Gay: If a permanent device has been placed and there is an irreparable issue with the leads or generator/battery, revision surgery may be required. Changes of the pulse generator are usually quick and relatively minor, whereas replacing the leads is a bit more involved, by virtue of the fact that they are buried deep in the spine and usually anchored in place so that they have a lower likelihood of migrating.
Q: How long can I expect to have the SCS?
Dr. Gay: If the trial is successful and a permanent device is placed, it is usually with the expectation that it is for life. As this can be a rather significant change, most insurers require a psychological screening prior to trial and permanent placement.
Historically, stimulator devices have had contraindications related to MRIs and use around other strong magnets and electrical fields. However, innovations are constantly being developed that increasingly allow more compatibility with these settings. It is best to look at the recommendations for the particular device for which one is being considered.
Q: Are there any restriction as far as travel, medical tests, etc.?
Dr. Gay: There are no travel restrictions related to SCS therapy. However, security personnel may not be familiar with the device if is appears on a scanner or activates a metal detector. It is recommended that a patient identification card be carried when traveling. Additionally, the device should be turned off while driving or operating a vehicle or heavy machinery.