Spinal Cord Stimulation for Chronic Pain: What Conditions and Which Patients?

31st Annual Meeting of the North American Spine Society Highlight

Spinal cord stimulation is an ideal tool for the right patient, with proper patient selection being key to successful implementation, said Michael B. Furman, MS, MD, at the 31st Annual Meeting of the North American Spine Society in Boston, MA.1

In addition to consideration of specific indications—ie, patients with chronic radicular pain, axial pain who are not surgical candidates, failed back surgery, or complex regional pain syndrome—the patient selection process involves psychologic screening, consideration of medical history, and spinal cord stimulation (SCS) trial, explained Dr. Furman, Partner, Orthopaedic and Spine Specialists at OSS Health, York, PA.
Female Doctor discussing matters with a troubled male patientThe patient selection process involves psychologic screening, consideration of medical history, and spinal cord stimulation trial. Photo Source: 123RF.com.

SCS Trial

The SCS trial is a key step in the patient selection process, Dr. Furman said. He outlined the following decisions that must be weighed during the SCS trial:

  • Placement of 1 or 2 leads: decision may be based on whether the pain is bilateral or unilateral and physician preference
  • Use a SCS system that relieves pain with or without paresthesia (ie, via conventional SCS or using 10-kHz high-frequency stimulation [HF10 SCS])
  • Use percutaneous lead or surgically implanted paddle lead

For percutaneous lead placement, Dr. Furman recommended using the fluoroscopic contralateral oblique (CLO) view, which allows visualization of anatomical locations that should be avoided.2 In addition, he often uses thoracic advanced imaging to rule out possible obstructions that may block lead placement.

Trials should last at least 5 to 7 days to avoid the high placebo response rate found during SCS trials, which may be as high as >40%, Dr. Furman said.

Optimal interpretation of the SCS trial results is crucial, as some patients may report positive findings because they will try anything to feel better. Further questioning may reveal that, in fact, the patient has little symptomatic improvement. Managing patient expectations is important before considering permanent SCS implantation, Dr. Furman said.

“You want to walk away from the trial with both you and the patient convinced that they did well with the procedure,” Dr. Furman told the audience.

Permanent Spinal Cord Stimulator Implantation

In patients with a positive SCS trial, factors to consider before permanent implantation include the battery type of systems. Some patients are not able to follow the instructions for rechargeable batteries and may be better suited to SCS systems with primary cell (nonrechargeable) devices.

Major concerns with SCS include use in anti-coagulated patients, risk for traumatic spinal cord injury, lead migration, and infection.

Options for SCS systems include conventional tonic, high-frequency, and burst SCS, as well as dorsal root ganglion stimulation.

Dr. Furman concluded by introducing session speakers F. Todd Wetzel, MD, and Steven F. Falowski, MD, FACS, who discussed integrating spinal cord stimulation into a surgical practice and advancements in SCS technology, respectively.

To view additional meeting highlights from the 31st Annual Meeting of NASS, click here.

Updated on: 01/02/20
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