spinal cord stimulators. fda-approved therapy to treat chronic pain of the trunk and/or limbs used...
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Spinal Cord Stimulators
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FDA-approved therapy to treat chronic pain of the trunk and/or limbs
Used to treat patients with neuropathic pain
SCS is considered a third tier pain therapy
SCS is not a cure
Spinal Cord Stimulation Therapy
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Pain Nociceptive Pain
Harmful stimulus is applied to skin, joints, muscles and nociceptive nerve endings are activated
Sharp shooting/ dull aching pain Typically lessens over time Responds well to traditional treatments
Neuropathic Pain Arise spontaneously without activation of
nociceptors Typically Chronic pain Does not respond well to traditional treatments Tactile Hypersensitivity- allodynia and
hyperalgesia
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How does SCS Therapy work?
Stimulator leads placed along the dorsal column of the spinal cord produce paresthesia sensation to help mask pain signals
There are 3 types of SCS systems that can be used depending on the patient’s pain Conventional IPG system Rechargeable IPG System Radiofrequency (RF) system
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Spinal Cord Stimulator Procedure
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Theories Behind SCS Therapy Gate Control Theory
By stimulating the large A beta blocks the transmission of pain signals via the small C fibers
Stimulating supraspinal pathways sends signals up the dorsal column to the brain stem and is then returned to spinal cord via dorsal Longitudinal fasciculus to mediate the pain pathways
Descending Inhibition of Pain pathways Stimulation of the adrenergic sympathetic
neurons close the gate Stimulation of Dorsal Nerve root fibers
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Benefits of SCS
Pain reliefReduction in pain medication intakeImprovement of depression symptomsReturn to workReturn to daily activitiesIncrease quality of life
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SCS Candidates
SCS is a last resort treatment of chronic pain when other therapies have failed
Patients must have a multidisciplinary screening to determine if they would be a good candidate
Successful Trial PlacementPatients must be motivated and willing
to try the treatment
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Successful SCS treatments SCS has been used since 1967 for the
treatment of chronic pain SCS has successfully treated numerous
painful disorders Failed Back Surgery Syndrome/ Arachnoiditis Reflex Sympathetic Dystrophy (Complex
Regional Pain Syndrome Angina Stump Pain/ Phantom Limb Pain Peripheral neuropathies Radiculopathies Peripheral Vascular Disease/ Ischemic Pain
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Failed Back Surgery Syndrome
Pain that persists after one or more surgical procedure on the lumbo-sacral spine
Most common diagnosis for patients who receive SCS
Etiology is difficult to pinpoint Most common cause of FBSS- improper
patient selection 1-10% of patients will be worse after
surgery Characteristics: back/ leg pain,
numbness/tingling & weakness in legs, stabbing burning and shooting pain
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FBSS Results
Leveque, J et al. Randomized Controlled Trial of 16
patients with FBSSANS St. Jude Medical Company Case
Study Case Study of a patient with FBSS
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Complex Regional Pain Syndrome
AKA: Reflex Sympathetic DystrophyMulti-symptom/ Multi-system Characteristics:
Soft tissue injury/ immobilization Temperature difference between affected
and unaffected extremity of at least 1°C Tactile hypersensitivity Cutaneous changes
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CRPS and SCS Research Results
Kemler, M et al. Randomized Control Trial of patients with
Chronic Reflex Sympathetic DystrophyHarney, D et al.
Review of case studies with patients with CRPS treated with SCS
Overall all SCS groups had a 60-70% success rate, narcotic intake was reduced and improvement in activity and quality of life
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SCS and Angina Number 1 Reason for Spinal Cord
Stimulator implantation in Europe Main Clinical Symptoms are related to
ischemic heart pain Pain in chest, arms, throat and neck Results:
Improved Coronary blood flow but no increase in totally flow
Altered sympathetic/ parasympathetic balance Research- Ferrero, P et al., De Jongste et al.
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Leg painCharacteristics
Pain in leg when walking Numbeness/tingling in leg Burning pain that is worse at night Phantom limb sensation- uncontrollable
movements Sensitive Pain
Research Jivegard et al. Raina, et al.
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Questions??
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ReferencesANS: St. Jude Medical Company. (n.d.). Spinal Cord
Stimulation: A Promising Treatment Option for Your Patients With Chronic Pain [Pamphlet].
Boston Scientific. (2007). Taking Control of Your Pain: The First Step [Pamphlet]. USA: Precision Plus.
Cameron, T., Ph.D. (2004, March). Safety and Efficacy of Spinal Cord Stimulation for the Treatment of Chronic Pain: a 20-year Literature Review. Journal of Neurosurgery: Spine, 100, 254-267.
Ferrero, P., MD., Grimaldi, R., MD., Massa, R., MD., & Chiribri, A., MD. (2007, January). Spinal Cord Stimulation for Refractory ANgina in a Patient Implanted with a Cardioverter Defibrillator. PACE, 30, 143-146.
Greenwald, T., RN., & Ryan, B., RN. (2004, June). Spinal Cord Stimulation Overview. In Mayfield Clinic. Retrieved January 15, 2009, from http://www.mayfieldclinic.com/PE-STIM.htm
Harney, D., Magner, J. J., & O’Keeffe, D. (2004, June). Complex Regional Pain Syndrome: the case for Spinal Cord Stimulation (a Brief Review). Injury: International Journal of the Care of the Injured, (36), 357-362.
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References Continued…Kemler, M. A., MD., Barendse, G. A., MD., & Van Kleef,
M., M.D., Ph.D. (2000, August). Spinal Cord Stimulation in Patients with Chronic Reflex Sympathetic Dystrophy. The New England Journal of Medicine, 618-624.
Leveque, J.-C., Villicencio, A. T., & Bulsara, K. R., MD. (2008, October). Spinal Cord Stimulation for Failed Back Surgery Syndrome. Neuromodulation, 4(1), 1-9.
North, R., MD. (2007). Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Chronic Neuropathic Pain. American Academy of Pain Medicine, 8(S4), S20-S275.
Raina, G. B., Piedimonte, F., & Micheli, F. (2007). Posterior Spinal Cord Stimulation in a Case of Painful Legs and Moving Toes. Stereotactic and Functional Neurosurgery, (85), 307-309.