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== Medical uses ==
== Medical uses ==
Currently the [[Food and Drug Administration]] (FDA) approved SCS as treatment for [[chronic pain]], pain in the extremities from nerve damage in 1989, or pain from a [[Failed Back Surgery Syndrome|Failed Back Surgery Syndrome.]]<ref>{{Cite journal|last=Song|first=Jason J.|last2=Popescu|first2=Adrian|last3=Bell|first3=Russell L.|date=May 2014|title=Present and potential use of spinal cord stimulation to control chronic pain|url=https://www.ncbi.nlm.nih.gov/pubmed/24850105|journal=Pain Physician|volume=17|issue=3|pages=235–246|issn=2150-1149|pmid=24850105}}</ref>
Currently the [[Food and Drug Administration]] (FDA) approved SCS as treatment for [[chronic pain]], pain in the extremities from nerve damage in 1989, or pain from a [[Failed Back Surgery Syndrome|Failed Back Surgery Syndrome.]]<ref>{{Cite journal|last=Song|first=Jason J.|last2=Popescu|first2=Adrian|last3=Bell|first3=Russell L.|date=May 2014|title=Present and potential use of spinal cord stimulation to control chronic pain|url=https://www.ncbi.nlm.nih.gov/pubmed/24850105|journal=Pain Physician|volume=17|issue=3|pages=235–246|issn=2150-1149|pmid=24850105}}</ref>

CRPS


== Mechanism ==
== Mechanism ==
Line 16: Line 18:


== Contraindications ==
== Contraindications ==
Currently there is no FDA approval for spinal cord stimulation only for lower back pain. <ref name=":0">{{Cite journal|last=Patel|first=Vikram B.|last2=Wasserman|first2=Ronald|last3=Imani|first3=Farnad|date=2015-08-22|title=Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes)|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604560/|journal=Anesthesiology and Pain Medicine|volume=5|issue=4|doi=10.5812/aapm.29716|issn=2228-7523|pmc=PMC4604560|pmid=26484298}}</ref>
Currently there is no FDA approval for the treatment of solely back pain with SCS. <ref name=":0">{{Cite journal|last=Patel|first=Vikram B.|last2=Wasserman|first2=Ronald|last3=Imani|first3=Farnad|date=2015-08-22|title=Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes)|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604560/|journal=Anesthesiology and Pain Medicine|volume=5|issue=4|doi=10.5812/aapm.29716|issn=2228-7523|pmc=PMC4604560|pmid=26484298}}</ref>


Contraindications are conditions or factors that suggest that a particular technique should not be used. In the case of spinal cord stimulation, the most concerning contraindications include coagulopathy<ref>{{Cite journal|last=Narouze|first=Samer|last2=Benzon|first2=Honorio T.|last3=Provenzano|first3=David A.|last4=Buvanendran|first4=Asokumar|last5=De Andres|first5=José|last6=Deer|first6=Timothy R.|last7=Rauck|first7=Richard|last8=Huntoon|first8=Marc A.|date=May 2015|title=Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain|url=https://www.ncbi.nlm.nih.gov/pubmed/25899949|journal=Regional Anesthesia and Pain Medicine|volume=40|issue=3|pages=182–212|doi=10.1097/AAP.0000000000000223|issn=1532-8651|pmid=25899949}}</ref>, infection<ref>{{Cite journal|last=Knezevic|first=Nebojsa N.|last2=Candido|first2=Kenneth D.|last3=Rana|first3=Shalini|last4=Knezevic|first4=Ivana|date=July 2015|title=The Use of Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy|url=https://www.ncbi.nlm.nih.gov/pubmed/26218955|journal=Pain Physician|volume=18|issue=4|pages=E643–650|issn=2150-1149|pmid=26218955}}</ref>, pacemaker<ref>{{Cite journal|last=Deer|first=Timothy R.|last2=Mekhail|first2=Nagy|last3=Provenzano|first3=David|last4=Pope|first4=Jason|last5=Krames|first5=Elliot|last6=Leong|first6=Michael|last7=Levy|first7=Robert M.|last8=Abejon|first8=David|last9=Buchser|first9=Eric|date=August 2014|title=The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee|url=https://www.ncbi.nlm.nih.gov/pubmed/25112889|journal=Neuromodulation: Journal of the International Neuromodulation Society|volume=17|issue=6|pages=515–550; discussion 550|doi=10.1111/ner.12208|issn=1525-1403|pmid=25112889}}</ref>, imaging studies indicating difficulty in placement, or concerns that arise during psychological evaluation.
Contraindications are conditions or factors that suggest that a particular technique should not be used. In the case of spinal cord stimulation, the most concerning contraindications include coagulopathy<ref>{{Cite journal|last=Narouze|first=Samer|last2=Benzon|first2=Honorio T.|last3=Provenzano|first3=David A.|last4=Buvanendran|first4=Asokumar|last5=De Andres|first5=José|last6=Deer|first6=Timothy R.|last7=Rauck|first7=Richard|last8=Huntoon|first8=Marc A.|date=May 2015|title=Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain|url=https://www.ncbi.nlm.nih.gov/pubmed/25899949|journal=Regional Anesthesia and Pain Medicine|volume=40|issue=3|pages=182–212|doi=10.1097/AAP.0000000000000223|issn=1532-8651|pmid=25899949}}</ref>, infection<ref>{{Cite journal|last=Knezevic|first=Nebojsa N.|last2=Candido|first2=Kenneth D.|last3=Rana|first3=Shalini|last4=Knezevic|first4=Ivana|date=July 2015|title=The Use of Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy|url=https://www.ncbi.nlm.nih.gov/pubmed/26218955|journal=Pain Physician|volume=18|issue=4|pages=E643–650|issn=2150-1149|pmid=26218955}}</ref>, pacemaker<ref>{{Cite journal|last=Deer|first=Timothy R.|last2=Mekhail|first2=Nagy|last3=Provenzano|first3=David|last4=Pope|first4=Jason|last5=Krames|first5=Elliot|last6=Leong|first6=Michael|last7=Levy|first7=Robert M.|last8=Abejon|first8=David|last9=Buchser|first9=Eric|date=August 2014|title=The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee|url=https://www.ncbi.nlm.nih.gov/pubmed/25112889|journal=Neuromodulation: Journal of the International Neuromodulation Society|volume=17|issue=6|pages=515–550; discussion 550|doi=10.1111/ner.12208|issn=1525-1403|pmid=25112889}}</ref>, imaging studies indicating difficulty in placement, or concerns that arise during psychological evaluation.


== Risks/Complications ==
== Risks/Complications ==
The most common complications involve hardware related issues and the majority of complications are not life threatening.<ref>{{Cite journal|last=Hayek|first=Salim M.|last2=Veizi|first2=Elias|last3=Hanes|first3=Michael|date=October 2015|title=Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database|url=https://www.ncbi.nlm.nih.gov/pubmed/26053499|journal=Neuromodulation: Journal of the International Neuromodulation Society|volume=18|issue=7|pages=603–608; discussion 608–609|doi=10.1111/ner.12312|issn=1525-1403|pmid=26053499}}</ref>
The most common complications involve hardware related issues and the majority of complications are not life threatening.<ref>{{Cite journal|last=Hayek|first=Salim M.|last2=Veizi|first2=Elias|last3=Hanes|first3=Michael|date=October 2015|title=Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database|url=https://www.ncbi.nlm.nih.gov/pubmed/26053499|journal=Neuromodulation: Journal of the International Neuromodulation Society|volume=18|issue=7|pages=603–608; discussion 608–609|doi=10.1111/ner.12312|issn=1525-1403|pmid=26053499}}</ref>

=== Lead Migration ===
The most common hardware related complication is lead migration, in which the implanted electrodes move from their original placement. With this complication, recapturing paraesthesia coverage can be attempted with reprogramming.<ref>{{Cite journal|last=Eldabe|first=Sam|last2=Buchser|first2=Eric|last3=Duarte|first3=Rui V.|date=2016-02-01|title=Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature|url=https://academic.oup.com/painmedicine/article/17/2/325/2460710/Complications-of-Spinal-Cord-Stimulation-and|journal=Pain Medicine|volume=17|issue=2|pages=325–336|doi=10.1093/pm/pnv025|issn=1526-2375}}</ref> In circumstances involving major lead migration a reoperation may be required to reset the the lead placement.<ref name=":1">{{Cite journal|last=Kumar|first=Krishna|last2=Buchser|first2=Eric|last3=Linderoth|first3=Bengt|last4=Meglio|first4=Mario|last5=Van Buyten|first5=Jean-Pierre|date=January 2007|title=Avoiding complications from spinal cord stimulation: practical recommendations from an international panel of experts|url=https://www.ncbi.nlm.nih.gov/pubmed/22151809|journal=Neuromodulation: Journal of the International Neuromodulation Society|volume=10|issue=1|pages=24–33|doi=10.1111/j.1525-1403.2007.00084.x|issn=1094-7159|pmid=22151809}}</ref> Studies differ greatly in reporting the percentage of patients who have lead migration but the majority of studies report in the range of 10-25% of lead migration for spinal cord stimulation.<ref name=":1" />

Lead migration with a paddle technique is less likely to incur a migration compared to percutaneous leads.

=== Lead Fracture ===

=== Battery Failure ===

=== Pain related to device components. ===

=== Wound Infection ===

=== Device Removal ===

=== Dural Puncture ===


=== Neurological Injury ===
PMID: 28535554,  26814260


== Technique ==
== Technique ==

Revision as of 18:51, 8 August 2017

Spinal Cord Stimulator Sandbox


Khrisfaiss/sandbox
Anterior view X-ray of a spinal cord stimulator (SCS) implanted in the thoracic spine

A Spinal Cord Stimulator (SCS) or Dorsal Column Stimulator (DCS) is a type of implantable neuromodulation device (sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord (dorsal columns) for the treatment of certain pain conditions. SCS has provided therapeutic benefits for otherwise treatment resistant pain disorders. SCS is not effective for all types of pain, and may not be effective for every patient, thus SCS is considered for patients who have chronic pain that have failed conservative therapies. In the United States Failed Back Surgery Syndrome is the most common indication while in Europe the most common indication is peripheral ischemia.[1]

Medical uses

Currently the Food and Drug Administration (FDA) approved SCS as treatment for chronic pain, pain in the extremities from nerve damage in 1989, or pain from a Failed Back Surgery Syndrome.[2]

CRPS

Mechanism

The mechanism by which spinal cord stimulators elicit their action is not well understood, but it is theorized that it is multifactorial. The initial theory behind the analgesia provided from an SCS is Gate Control Theory, but the pain relief is now considered to be more complex.[3] While there are new advances in the types of neuromodulation, the objective of traditional SCS therapy is to "mask" or replace pain sensation with paresthesia or comfortable tingling. In order to do this, a technician or device representative must map the area of stimulation to the areas of nociceptive or neuropathic pain. Based upon the Gate Control Theory, it is theorized that the electrical current from the device alters the pain processing of the Central Nervous System with paresthesias. Although, a significant number of patients report the paresthesias are unpleasant. [4][5]

Contraindications

Currently there is no FDA approval for the treatment of solely back pain with SCS. [6]

Contraindications are conditions or factors that suggest that a particular technique should not be used. In the case of spinal cord stimulation, the most concerning contraindications include coagulopathy[7], infection[8], pacemaker[9], imaging studies indicating difficulty in placement, or concerns that arise during psychological evaluation.

Risks/Complications

The most common complications involve hardware related issues and the majority of complications are not life threatening.[10]

Lead Migration

The most common hardware related complication is lead migration, in which the implanted electrodes move from their original placement. With this complication, recapturing paraesthesia coverage can be attempted with reprogramming.[11] In circumstances involving major lead migration a reoperation may be required to reset the the lead placement.[12] Studies differ greatly in reporting the percentage of patients who have lead migration but the majority of studies report in the range of 10-25% of lead migration for spinal cord stimulation.[12]

Lead migration with a paddle technique is less likely to incur a migration compared to percutaneous leads.

Lead Fracture

Battery Failure

Wound Infection

Device Removal

Dural Puncture

Neurological Injury

Technique

Each patient must be screened to determine candidacy for this procedure. Screening of individuals includes evaluation for a medically indicated diagnosis as well as a history and physical examination to rule out medical conditions that would increase the risk for failure or complications. Often a psychiatric evaluation may be performed to determine appropriate candidates as well.

Spinal Cord Stimulation Trial

For the procedure, patients are under light sedation and are assessed to be wide awake and responsive to commands throughout the entire procedure.

The placement technique traditionally involves placing two leads in the epidural space of the spinal cord at a site lower than the desired position, often beginning at the L1-L2 spinal level. Access to the epidural space is gained with an angulated needle and the leads are then guided into the epidural space and advanced to the desired position. [6]

Spinal Cord Stimulator Implant

Burst

High Frequency

PMI: 27139915 Burst stimulation

Recovery or Rehabilitation

Patients are typically asked to return to clinic within one week of the implantation to ensure the wound is healing well, and to ensure there is no infection. In addition to ruling out surgical complications, the device may often need reprogramming during the first few post-operative follow ups.

History

Society and culture

Special populations

Other animals

  1. ^ Eldabe, Sam; Kumar, Krishna; Buchser, Eric; Taylor, Rod S. (July 2010). "An analysis of the components of pain, function, and health-related quality of life in patients with failed back surgery syndrome treated with spinal cord stimulation or conventional medical management". Neuromodulation: Journal of the International Neuromodulation Society. 13 (3): 201–209. doi:10.1111/j.1525-1403.2009.00271.x. ISSN 1525-1403. PMID 21992833.
  2. ^ Song, Jason J.; Popescu, Adrian; Bell, Russell L. (May 2014). "Present and potential use of spinal cord stimulation to control chronic pain". Pain Physician. 17 (3): 235–246. ISSN 2150-1149. PMID 24850105.
  3. ^ Melzack, R.; Wall, P. D. (1965-11-19). "Pain mechanisms: a new theory". Science (New York, N.Y.). 150 (3699): 971–979. ISSN 0036-8075. PMID 5320816.
  4. ^ Deer, Timothy R.; Krames, Elliot; Mekhail, Nagy; Pope, Jason; Leong, Michael; Stanton-Hicks, Michael; Golovac, Stan; Kapural, Leo; Alo, Ken (August 2014). "The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states. Neuromodulation Appropriateness Consensus Committee". Neuromodulation: Journal of the International Neuromodulation Society. 17 (6): 599–615, discussion 615. doi:10.1111/ner.12204. ISSN 1525-1403. PMID 25112892.
  5. ^ Sinclair, Chantelle; Verrills, Paul; Barnard, Adele (2016-07-01). "A review of spinal cord stimulation systems for chronic pain". Journal of Pain Research. Volume 9: 481–492. doi:10.2147/jpr.s108884. {{cite journal}}: |volume= has extra text (help)CS1 maint: unflagged free DOI (link)
  6. ^ a b Patel, Vikram B.; Wasserman, Ronald; Imani, Farnad (2015-08-22). "Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes)". Anesthesiology and Pain Medicine. 5 (4). doi:10.5812/aapm.29716. ISSN 2228-7523. PMC 4604560. PMID 26484298.{{cite journal}}: CS1 maint: PMC format (link)
  7. ^ Narouze, Samer; Benzon, Honorio T.; Provenzano, David A.; Buvanendran, Asokumar; De Andres, José; Deer, Timothy R.; Rauck, Richard; Huntoon, Marc A. (May 2015). "Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain". Regional Anesthesia and Pain Medicine. 40 (3): 182–212. doi:10.1097/AAP.0000000000000223. ISSN 1532-8651. PMID 25899949.
  8. ^ Knezevic, Nebojsa N.; Candido, Kenneth D.; Rana, Shalini; Knezevic, Ivana (July 2015). "The Use of Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy". Pain Physician. 18 (4): E643–650. ISSN 2150-1149. PMID 26218955.
  9. ^ Deer, Timothy R.; Mekhail, Nagy; Provenzano, David; Pope, Jason; Krames, Elliot; Leong, Michael; Levy, Robert M.; Abejon, David; Buchser, Eric (August 2014). "The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee". Neuromodulation: Journal of the International Neuromodulation Society. 17 (6): 515–550, discussion 550. doi:10.1111/ner.12208. ISSN 1525-1403. PMID 25112889.
  10. ^ Hayek, Salim M.; Veizi, Elias; Hanes, Michael (October 2015). "Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database". Neuromodulation: Journal of the International Neuromodulation Society. 18 (7): 603–608, discussion 608–609. doi:10.1111/ner.12312. ISSN 1525-1403. PMID 26053499.
  11. ^ Eldabe, Sam; Buchser, Eric; Duarte, Rui V. (2016-02-01). "Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature". Pain Medicine. 17 (2): 325–336. doi:10.1093/pm/pnv025. ISSN 1526-2375.
  12. ^ a b Kumar, Krishna; Buchser, Eric; Linderoth, Bengt; Meglio, Mario; Van Buyten, Jean-Pierre (January 2007). "Avoiding complications from spinal cord stimulation: practical recommendations from an international panel of experts". Neuromodulation: Journal of the International Neuromodulation Society. 10 (1): 24–33. doi:10.1111/j.1525-1403.2007.00084.x. ISSN 1094-7159. PMID 22151809.
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