Managing Pain: Spinal Cord Stimulation

When does pain become ‘chronic’?

Chronic pain is any type of continuous and long-term pain, lasting 12 weeks or more.[1] Chronic pain is a widespread problem with 1 in 5 adults—or 95 million people in Europe—affected.[2]Women are more likely to be affected by chronic pain than men.[3]

What is neuropathic pain?

Neuropathic pain is generated by the nervous tissue itself.[4] It is often described as a shooting or burning pain. It can go away on its own but is often chronic. Sometimes it is unrelenting and severe, and sometimes it comes and goes.[5] Common qualities include burning or coldness, ‘pins and needles’ sensations, numbness and itching.[6]

What causes neuropathic chronic pain?

Neuropathic pain is For reasons that are not entirely clear, injury to any part of the nervous system can evoke and maintain pain. Injury to the peripheral body can be caused by conditions such as Sciatica, shingles, carpal tunnel syndrome and other nerve entrapments. Examples of injuries to the central nervous system include spinal cord injury, failed back surgery syndrome, post traumatic or surgical neuropathy (pain after hip, knee, groin, breast, abdominal, pelvic injury or surgery).

What options are available to control and manage pain?

There are three levels of pain, and each may have different forms of treatment. Usually, doctors follow a treatment plan that begins with basic therapies and progresses to more aggressive solutions, depending on the type and severity of pain. The treatment plan also depends on how patients respond to any treatment.

Level 1—Basic Pain Treatments:

• Rest and diet changes
• Exercise and physical therapy
• Anti-inflammatory drugs
• Cognitive and behavioural modification

Level 2—Mid-Level Pain Treatments:

• Transcutaneous electrical nerve stimulation (TENS)
• Opioids (prescription painkillers)
• Nerve blocks (injection of an anaesthetic, steroid, and/or anti-inflammatory into the pained area)
• Thermal procedures (extreme heat or cold delivered through needles or probes)

Level 3—Advanced Pain Treatments:

• Spinal Cord Stimulation (SCS)
• Surgery
• Implantable drug pumps
• Neuroablation (surgical technique that destroys nerves and tissue permanently)[8]

What is spinal cord stimulation?

It is a reversible and well-established treatment in the UK, which is funded by the NHS. During the procedure, a small battery, called implantable pulse generator (IPG), is positioned below the skin surface in the upper buttocks or abdomen. A rechargeable IPG can last up to 12 years and a non-rechargeable, up to 5.2 years. The IPG is connected to thin wires called leads, which are placed in the epidural space of the spinal cord. The IPG sends electrical stimuli to specific nerves in the spinal cord, effectively masking pain signals travelling to the brain.

SCS can be prescribed for the following conditions:

• Failed back surgery syndrome (FBSS). Pain that persists despite spine surgeries and other medical procedures.
• Complex Regional Pain Syndrome (CRPS). Chronic pain affecting one limb—such as an arm or leg—after an injury. This specific condition is believed to be caused by damage to the peripheral and central nervous systems.
• Peripheral Neuropathy (PN). Involves damaged nerves in the body’s extremities, causing tingling, burning or shooting pain in affected areas. This condition can also cause loss of balance, poor coordination and muscle weakness.

How does a spinal cord stimulator work to reduce pain?

Most pain signals travel from the source of the problem or injury via nerve pathways to the spinal cord, and then onto the brain. When the signals reach the brain, they are perceived as pain sensations. To help alleviate pain, the IPG electrically stimulates specific nerves in the spinal cord to mask the perception of pain signals that move along the spinal cord to the brain.

SCS can be used to treat patients with more than one pain area, including back or neuropathic pain. SCS cannot cure pain or eliminate its cause, but it can help relieve it.

What are the benefits of spinal cord stimulation?

SCS therapy can help manage chronic pain, even when other therapies have failed. SCS could also be a more effective alternative to repeat operations or increased opioid use.

SCS is generally considered effective:

• If pain is reduced by at least 50 percent
• If patients are able to get back to their daily activities

• If pain medication is reduced
• If patients are able to relax and sleep better

The vast majority of patients respond to the procedure and can potentially return to work, achieve better pain control and ultimately lead a better quality of life.

What is the procedure for determining whether spinal cord stimulation is a viable option?

The procedure for determining whether SCS is a viable option is usually a four-stage process:

1. Diagnosis

Patients who are considered for SCS generally have had chronic pain for more than a year. Chronic pain has a physical and emotional impact, resulting in complex needs that need to be evaluated. First, the correct medical diagnosis and pain mechanism is understood, and then the psychological impact is evaluated.

2. Treatment plan

The objective of a treatment plan is to determine if the patient is a good candidate and to provide support with health improvement.

3. Trial period

Normally, patients are offered a home trial with implanted leads and an external pulse generator, lasting 4 to 7 days. During this time, the patient and doctor assess if SCS is an effective pain management system.

4. Permanent implant procedure

If the patient and doctor conclude that the SCS system helps manage the pain effectively, the patient is booked in to have the IPG implanted.

What can a patient expect to experience during and after surgery?

The surgery can be divided into five steps. To start with, the areas where the leads and IPG need to be placed are prepped. The patient will be given a light sedation and local anaesthetic will be used to numb the incision sites.

The second step comprises the lead placement with the aid of fluoroscopy (a type of X-ray). After that, patients are usually woken up to help the doctor determine how well the stimulation covers the pain area. Once the leads are in place successfully, the lead wire is passed under the skin to where the IPG will be implanted.

Finally, the IPG is attached to the leads and placed in a surgically created pocket below the skin. The surgery generally takes one to two hours. The IPG is programmed before patients are discharged home. This usually happens the same day or the following morning.

Patients are asked to restrict your physical activity for several weeks after the implant procedure. Once that period is over, SCS systems are designed to help patients lead a healthy and active lifestyle.

How is a spinal cord stimulator controlled after it has been implanted?

Patients are provided with a remote control. This allows them to turn stimulation on and off, increase and decrease the level of stimulation, and target different pain areas using settings or customised programs.

Visit: controlyourpain.co.uk for more information.