What is a spinal cord stimulator?
A spinal cord stimulator, or SCS for short, is a device that is implanted around an individual’s spinal cord for chronic pain management purposes. SCS devices may provide pain relief to individuals who are faced with a life of chronic pain either in the neck, back or extremities and dealing with disability, depression and difficulty functioning.
Spinal cord stimulation is not a first-line treatment for pain management. Pain management doctors in Arizona consider a spinal cord stimulator option as a last resort for multiple conditions including failed back surgery syndrome, post laminectomy syndrome, failed neck surgery, RSD, peripheral neuropathy, or other diagnoses involving chronic pain where surgery is no longer an option.
Who benefits from a spinal cord stimulator?
Individuals dealing with chronic pain may benefit from a SCS as a last resort option. The reason it is a last resort is that a spinal cord stimulator implant does not fix the patient’s problem, and it is quite costly to the insurance company. It may simply be an excellent method of “masking” a person’s pain to allow them to function better, have less pain, and need to take fewer pain medication.
In fact, as many as 50,000 SCS implants are placed worldwide annually. Those individuals who have had back or neck surgery and are left with residual intractable pain and have no further surgical options may be excellent candidates for an SCS. Peripheral neuropathy affects millions of Americans, and surgery is not often an option. Diabetic neuropathy is the most common type of peripheral neuropathy, and is seen in 20% of those with diabetes. Spinal Cord stimulation may help tremendously with pain relief in these patients along with restoring some of the sensation that was lost.
In addition, those individuals who have Reflex Sympathetic Dystrophy (also known as Complex Regional Pain Syndrome), may benefit tremendously as well from an SCS.
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What are the Main Benefits of Spinal Cord Stimulation?
There are 3 main benefits of spinal cord stimulation:
1) May relieve pain substantially in the back, neck, legs, and arms.
2) A SCS may be tried with a trial first in a minimally invasive procedure so the patient
knows pretty well if a final implant is going to work. (Sort of like dipping the toes in the water first).
3) A SCS may be turned off or removed if the pain relief is no longer being achieved.
How is a spinal cord stimulator implanted?
There are two phases to obtaining a stimulator. In the first phase, the patient undergoes a trial SCS to see if in fact the implant is going to work well. These devices are expensive (over $15,000 to the insurance company) and there are some risks involved with the final procedure, so doing a trial first is an excellent idea to see if it will provide relief for the chronic pain being experienced.
The trial SCS is placed as an outpatient and typically takes 30 to 90 minutes. General anesthesia is not used, as the pain doctor will need feedback from the patient during the procedure. Patients typically receive IV sedation for the procedure and are placed on their stomachs in the prone position.
If the implant is being used to help relieve back or leg pain, the skin over the lumbar spine is numbed up and a needle is placed into the area around the spinal cord. The trial spinal cord stimulator is a thin catheter lead that is then fed through the needle into the area around the spinal cord. It is delicately manipulated upwards and once satisfactory placement has been achieved it is then connected in a sterile manner with the programming device. The tip of the catheter lead has electrical diodes implanted and it emits slight electrical impulses to the spinal cord area. This alters the way that the brain perceives pain signals and may “exchange” the pain for a tingling sensation.
The pain doctor then begins asking the patient if the tingling sensation covers the area of the pain. The catheter lead is then manipulated until it reaches a point where the patient does say it is providing coverage of where the pain usually resides.
At that point placement is finished and the area where the catheter comes out of the skin is covered with a sterile bandage. The catheter lead portion outside the skin is attached to a programmed unit with a battery pack that stays on the patient’s waist for the next 5 to 7 days.
The patient keeps a log of how much pain relief is being achieved with the various programming possibilities from the device. If the device provides at least 50% pain relief over those 5 to 7 days, that individual is typically considered a candidate for a final spinal cord stimulator implant.
Why is it necessary to have a trial implant prior to the final spinal cord?
There are a few reasons the trial is necessary. The first and biggest is that the spinal cord stimulator final implant is very expensive. The cost is well over $15,000 and insurance companies do not take that lightly. They want to have a very good idea that the final implant is a medically necessary procedure. For this reason often times a psychological evaluation is required for final approval, and the trial implant needs to have at least 50% pain relief according to most insurance companies.
Another reason is that there are some risks associated with having a final implant in place. There is a need for general anesthesia and a larger incision with dissection around the spinal cord, so the trial will at least help identify whether those risks are worth the potential benefits.
Does Insurance Cover a Spinal Cord Stimulator Implant?
Most insurance companies do provide coverage for the implant with provisions for pre-surgical psychological counseling. In addition, the trial SCS implant needs to provide at least 50% pain relief. Check with your insurance provider for specific coverage and prerequisites.
How is the final spinal cord stimulator placed?
This procedure is performed under general anesthesia. The surgery involves two different steps. The first step is an incision over the area of the low back for the area where the stimulator is going to be placed. A minimally invasive type of dissection is takien down to the area around the spinal cord and a little bit of bone is then removed so that the larger final implant can be placed. Rather than a tiny catheter used for the trial, the final implant looks like a miniature paddle and has a lot more electrical diodes in it. This allows for an excellent array of electrical stimulation programs. Some programmable devices have well over 100 options!
Once the little bit of bone is removed around the spinal cord, the paddle stimulator implant is delicately fed up over the spinal cord and positioned according to where it looks good on fluoroscopy, which is a real-time form of x-ray. With the patient being under general anesthesia for the final implant, input such as obtained during the trial is not necessary. This is step one and typically the catheter part is sutured into the soft tissues to try and prevent it from moving after the acceptable final placement.
The second phase of the surgery involves placing the catheter underneath the skin subcutaneously to the area for attachment to the battery. This entails “running” the lead as it comes out of the spinal area to where the batttery pack is placed. The catheter lead is then placed into a battery pack which is about the size of a hockey puck. Over the years they have gotten a lot smaller and they also have the ability to be rechargeable outside the skin.
The placement of the battery pack is typically just above the buttock region so that the patient will not be sitting on it. Sometimes the placement is around the front towards the abdomen in the subcutaneous tissues overlying the right or left side of the abdomen area. Once these two phases of the surgery are completed, the stimulator is tested and the soft tissues are closed up with appropriate sterile bandages placed.
Patients able to go home the same day and programming is usually turned on at the first postoperative visit at 5 to 7 days, or it may be done as soon as the patient feels up to it. Your doctor will assist with this decision.
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How well does a spinal cord stimulator implant work?
Numerous studies have been done on the effectiveness of spinal cord stimulation in the low back area. Not as many have been done for stimulators in the neck area. But overall, effectiveness of spinal cord stimulators for back and lower extremity pain have shown approximately 62% good to excellent results.
A study of patients with St. Jude’s Medical SCS implants showed that 84% of patients reported that their quality of life was greatly improved, with 77% receiving good or excellent pain relief. Over 80% of patients decreased their narcotic usage.(references) One study published in the journal Lancet showed that 85% of patients receiving a spinal cord implant for diabetic peripheral neuropathy achieved substantial return of sensory loss, while over half of the patients noticed complete reversal of their sensory loss. Over one third of patients in the study decreased their opiate needs significantly while the average pain reduction on the visual analog scale was over 7 points!
There are some new studies coming out looking at different types of leads used for spinal cord stimulator, including a new type of lead that involves a tripolar tip. There are also stimulators that involve two different paddles, one placed around the spinal cord area and another placed in the soft tissues of the back. This new method may increase the effectiveness of the stimulator providing relief for low back pain as well as leg pain.
For this reason, SCS’s are now showing better results for individuals who have mostly axial low back pain, and not a lot of leg pain. These implants represent cutting edge modern technology now and show immense promise in the field of pain management. Despite the fact that they do not fix the problem, they may be able to mask pain from a problem that cannot be fixed despite the advances in modern medicine.
What are the risks of having the spinal cord stimulator placed?
There are some significant risks associated with placement of a spinal stimulator, but overall the procedure is much lower risk than major spine surgery. These risks are typically not life-threatening, but may involve a need for a repeat surgery.
One significant risk is infection. These implants are considered to be foreign bodies by the patient’s body, and an infection may result. This risk is less than 5%. Another risk would be bleeding from the surgery. If the patient is on anti-clotting medication such as Coumadin, Lovenox or anti-inflammatories such as aspirin, these need to be stopped approximately a week prior to the procedure. Your doctor will be able to tell you the specifics on ceasing those medications.
Another risk is that the implant simply does not provide the pain relief desired. There is also a chance that they may work well for a while but then the effectiveness will wear off. The newest stimulators have a large amount of programming possibilities, so just changing the program may be able to get back to the pain relief that was initially achieved.
Another risk is that the implant may move (migrate). The paddle that is implanted around the spinal cord may shift after satisfactory initial placement. This may happen very soon after the surgery or within a few weeks. Typically after that time frame some scarring will occur around the implant and it becomes much less likely to move. Another unusual risk is nerve damage during placement of the implant. Typically if there is some nerve injury, it is transient and gets better over the ensuing days to weeks.
If you or a loved one is dealing with chronic pain either in the neck, back or extremities, a SCS may be the answer. It has also shown promise for chronic pelvic and abdominal pain and even testicular pain. So if you’re dealing with any of these types of issues, Arizona Pain Specialists may be able to help you.
The pain management doctors at Arizona Pain are Board Certified and Fellowship Trained. They have performed thousands of spinal cord stimulator implants and also provide comprehensive treatment options including chiropractic services, acupuncture, spinal decompression therapy and massage along with medication management.
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