Am I a Good Candidate for Spinal Cord Stimulation?

The implantable ‘pacemaker’ device can help to relieve nerve and other types of chronic pain.

If you have chronic pain resulting from back surgery or complex regional pain syndrome (CRPS), you may have considered spinal cord stimulation (SCS) to relieve your pain. Many individuals with these and other types of nerve pain have achieved at least 50% relief in their pain, and experienced better function, from SCS. 

 

Spinal cord stimulation is not for everyone, however. Find out more about what it is and who benefits from it below. Of note, in an online PPM poll, just over 40% of readers said they have tried SCS to manage their pain.

Spinal cord stimulation (SCS) can provide 50% relief of pain when used to treat certain chronic nerve conditions. (Image: 123RF)

What Is Spinal Cord Stimulation?

SCS involves an implanted device, placed under your skin along the spine by an experienced clinician, that sends small electrical currents to specific regions of the spinal cord. It works by changing the way the brain perceives pain. While SCS does not eliminate the source of the pain, says Julie G. Pilitsis MD, PhD, professor of neurosurgery and neuroscience at Albany Medical College in New York, “the device can trick your nervous system into not feeling pain.”

A spinal cord stimulator typically has three parts:

  • a battery that generates electrical pulses, similar to a pacemaker
  • a lead wire with electrodes that deliver the pulses to the spinal cord
  • a hand-held remote control that enables the patient to adjust the pulse settings.

A spinal stimulator is not the same as a TENS unit, which delivers transcutaneous electrical nerve stimulation by using pads placed on the skin over painful parts of the body.

What Types of Pain Does Spinal Cord Stimulation Treat?

The main indications for SCS are low back pain, leg pain, and CRPS, according to Michael S. Leong, MD, clinical associate professor of anesthesiology and perioperative and pain medicine at Stanford University in California. But it can also be used to treat headaches, spinal cord injury, neck pain, arm pain, abdominal pain, and pelvic pain. “You’re basically looking at the gamut of trying to do stimulation for pain anywhere on the body—head to toe,” he says.

SCS is typically considered for these conditions:

  • abdominal and perineal pain
  • arachnoiditis (inflammation and scarring of the spinal nerves) 
  • back and leg pain that continues after back surgery (called failed back surgery syndrome)
  • chemotherapy-induced peripheral neuropathy
  • CRPS, formerly called reflex sympathetic dystrophy syndrome or RSD)
  • diabetic neuropathy
  • heart pain (angina)
  • peripheral vascular disease
  • phantom limb pain 
  • postherpetic neuralgia, a complication of shingles

Will SCS Help Your Pain?

Doctors use a careful selection process to determine which patients will benefit from the treatment. This process includes the types of pain (see above); meeting requirements for the surgery, such as having imaging done and stopping smoking; and managing expectations.

Most patients who are referred for SCS have tried other treatments in the past—and that’s important. Dr. Leong recommends that SCS candidates have tried the four components of comprehensive pain management before considering spinal cord stimulation: medications, such as such as gabapentin, pregabalin, or duloxetine which are indicated for nerve pain; interventional or injection-type pain management therapies, such as trigger point injections, epidurals or medial branch (nerve) blocks; physical therapy; and sessions with a pain psychologist.

The last component acknowledges the mind-body connection. “Pain wears you down and makes you depressed and it can make your world start to shrink,” says Dr. Leong. SCS candidates will attend a few sessions with a pain psychologist—a requirement of insurance companies as part of the SCS approval process. “The pain psychologist is there to coach patients, so they don’t think that there’s only one magic cure or one therapy for their pain,” says Dr. Leong.  

Both Drs. Leong and Pilitsis emphasize that SCS will not eliminate all the pain experienced by an individual—a 50% improvement in pain, quality of life and function is typically the goal.

SCS Is a Two-Part Process

A patient who has met the requirements for SCS will undergo Part 1: a trial of the stimulator. You can think of the trial as taking the device for a test drive for several days. The trial stimulation is an out-patient procedure performed by a specialist, such as a neurosurgeon, anesthesiologist, or physiatrist.

Dr. Leong likens the beginning of the trial procedure to receiving epidural injections, something many pain patients are familiar with. After numbing the skin with an anesthetic, a clinician will insert the SCS needle into the skin of the back. Then a wire, called a lead, will be inserted through the hollow needle into the epidural space between the backbone and the spinal cord. The lead has several tiny electrodes, which are positioned over specific nerves. The doctor uses x-ray imaging to guide the electrodes to the sites.

You may have heard of patients experiencing a tingling feeling with spinal cord stimulation. In recent years, newer devices have been developed that deliver different waveforms of stimulation—such as high-frequency stimulation and burst stimulation—which eliminate the tingling sensation.

The patient leaves the procedure with tape over the incision and small wires leading from the incision to a battery back, which the patient wears on a belt. It can take a day or two for the stimulation to begin working on the nerves, says Dr. Pilitsis. The next 3 to 5 days will determine whether the SCS will work for the patient.

If undergoing a trial, you may be asked to keep a log of your activities and pain level during the trial to compare against how you felt and what your did before the trial. For instance, says Dr. Leong, patients may note that they had better sleep, are taking fewer pain pills, or moving around more easily.

Dr. Pilitsis stresses the importance of the trial: “The best pain relief you’re going to get with the device is what you get in that trial.” As noted, success is considered a 50% improvement in pain, quality of life and functionality.

At the end of the trial, patients can decide if they want to pursue Part 2: the permanent implantation of the SCS system. In this procedure, the battery pack—which had been worn on a belt outside the body during the trial—will be surgically implanted under the patient’s skin. The battery pack is about the size of a silver dollar, and is not visible under the skin.

As with any surgery, there are risks for infection or bleeding, but these tend to be quite low, says Dr. Leong. Quitting smoking for several months before the trial lowers these risks.

Your doctor will perform a trial of the device before permanent implantation on your spine. (Image: iStock)

What Happens After the SCS Device Is Permanently Implanted?

Although 50% pain improvement is the goal, some patients do even better. “I have some successes where people are almost in pain remission, which I define as greater than 80% improvement,” says Dr. Pilitsis. “It seems like about 20% of patients can reach that.”

Patients will be given detailed instructions about caring for themselves after the implantation. For instance, during the first few weeks after surgery patients can shower but not soak in a tub and will have to restrict many activities such as lifting, driving, and strenuous housework.

You will be instructed how to adjust the pulse settings using the remote-control device. This will be an ongoing process as you work with their doctor to find the best settings for your pain and activities.

Many patients can live with the SCS device forever, with replacement of the battery every eight to 10 years. Some choose to have the device removed, called an explant. The two main reasons for explantation are because the device is no longer providing the initial pain relief or because patients find the implant irritating, says Dr. Pilitsis.

“There have been a couple of studies where women have the devices explanted more commonly than men,” notes Dr. Pilitsis. “We’re not sure why that is, it could be a difference in the way women perceive pain, sex hormones, or that the devices are just too big for women.”

With older devices, some patients have developed a tolerance to the stimulation and no longer feel pain relief. This experience has improved with newer devices. “The thought is that now since we have these new waveforms that we can choose between, we can trick the nervous system for longer,” says Dr. Pilitsis.

More technology is on the horizon. For one, the battery packs are getting smallerwhich should make them more comfortable. The latest advance is a device that uses closed-loop stimulation, which directly measures the spinal cord stimulation and then uses this information in a feedback mechanism to deliver better and more stable stimulation to the spinal cord.

Some patients receiving spinal cord stimulation might be able to reduce or eliminate their pain medications—after consulting with their doctor. All patients should follow the advice of their pain specialist about medications, exercise, and other treatments that might reduce their pain further.

 

 
Updated on: 10/04/19
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