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Spinal Cord Stimulators in Neuropathic Pain

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Introduction Chronic pain is very common Immense physical, psychological, societal impact Financial burden

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Neuropathic pain Damage or dysfunction of the nervous system Typical symptoms - burning - shooting - allodynia - hyperalgesia

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Case history (1) Mr X - Referred to the pain clinic PC - Right arm pain Hx PC - Day 1 post medical procedure - Tingling, weakness, numbness of right arm

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Case history (1) Investigations - MRI - Nerve conduction studies - Electromyography Diagnosis - Brachial plexus injury Conservative management strategy EMG

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Case history (1) Follow up at 6 weeks - Burning, painful to touch, skin discolouration Diagnosis - Complex regional pain syndrome (CRPS) Therapies in pain clinic - Neurogenic pain medications - Cervical sympathetic block

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Case history (1) SCS inserted 2013

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Case history (2) Mr FF, 62 yrs - GP referral to pain clinic PC - Back pain radiating to both legs Hx PC - 20 year history of back pain - Physiotherapy/analgesia - Multiple surgical procedures

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Case history (2) Diagnosis - Failed back surgery syndrome Therapies in pain clinic - Neurogenic pain medications - Epidural and facet joint injections - L5/S1 nerve root block

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Case history (2) SCS inserted 2013

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Management of chronic pain

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Neuromodulation Therapeutic alteration of the nervous system Electrical or pharmacological Implanted devices

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Gate control theory of pain

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Gate control theory and spinal cord stimulators

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History of spinal cords stimulators

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Which patients might be suitable for a SCS? Failed back surgery syndrome CRPS Peripheral neuropathy Ischaemic limb pain Angina

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SCS electrodes

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Components of the SCS

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Phases of SCS implantation 1. Assessment phase - appropriate pathology - appropriate patient 2. Trial phase 3. Implantation phase

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Where are the electrodes placed? Upper extremity T1-T2 Low back T8-T10 Lower extremity T10-T12

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Trial phase

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What are the criteria for a successful trial? 50% pain Area of parasthesia = area of pain Parasthesia not unpleasant Functional improvement

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Complications of SCS Additional revision of the device (23%) Hardware malfunction (10%) Infection (4.6%) Complications during insertion

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Some issues for patients.

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NICE Guidelines

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Case history (1) Complex regional pain syndrome 4 months later VAS scores 10 3 Some restoration of hand function Reduction in analgesic medication Improved mood

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Case history (2) Failed back surgery syndrome 2 months later VAS scores 10 2 Improved mobility Reduced analgesic medications Improved mood

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Conclusion Neuropathic pain is common, some patients are refractory to standard therapies Neuromodulation is an alternative method for treating severe, intractable pain Excellent results can be achieved with selected patients

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Thank You