Spinal Cord Stimulation’s Place in the Pain Treatment Continuum and Advancements in Technology

31st Annual Meeting of the North American Spine Society Highlight

The treatment paradigm for chronic pain is shifting, and spine surgeons should consider treatment with spinal cord stimulation (SCS) earlier in the chronic pain treatment continuum, said Steven M. Falowski, MD, at the 31st Annual Meeting of the North American Spine Society (NASS) in Boston, MA.1

SCS has demonstrated high success rates in previous and also recent studies, with findings showing that earlier use are linked to better outcomes, explained Dr. Falowski, who is Director of Functional Neurosurgery at St. Luke’s University Health Network in Bethlehem, PA. In one study, SCS used within 2 years of diagnosis was linked to a 90% success rate; however, the success rate drops to less than 70% at 5 years after diagnosis, which is the average time to SCS implantation.2
Persistent pain wordcloud with related words
The need for increased use of SCS also should be considered in context with current opinion on the risks of opioid use, and the DEA’s decision to reduce production of schedule II opioid agents in the United States by 25% or more in 2017.3 In addition, spine surgery recently has “come under attack,” particularly in light of the recent New York Times article suggesting that surgeries such as spinal fusion are no better than alternative nonsurgical treatments, Dr. Falowski said.4

“I believe fusions and spinal surgeries are right for the right patient, just like I believe SCS is right for the right patient at the right time,” Dr. Falowski said. For example, “I believe that revision spine surgery exists for people with instability or nerve compromise,” Dr. Falowski said. Outside of those indications, Dr. Falowski said he would choose to implement SCS for those patients with the chief complaints of pain.

Partner With Pain Specialists
In terms of integrating SCS into surgical practice, Dr. Falowski said he has a relationship that enables him to send patients who he thinks will benefit from SCS to pain physicians for SCS trial, with the assumption that Dr. Falowski will place the permanent implants in patients with positive results. “It’s a great way to build and maintain relationships with pain physicians in your community who will allow you to offer your patients a continuum of care,” Dr. Falowski said.

Dr. Falowski encouraged spine surgeons to learn how to place percutaneous implants, not just paddle implants. “Certain products are designed to only be placed percutaneously, and surgeons are in a great position to perform these procedures given that they have seen the spinal anatomy with their own eyes,” Dr. Falowski said.

Dr. Falowski also emphasized the benefits of using neuromonitoring when placing SCS paddle leads to eliminate the need to wake the patient during implantation to verify optimal lead placement using patient feedback. With neuromonitoring, electromyography response is used to verify lead placement.

In a recent prospective study trial, neuromonitoring was linked to appropriately lateralized leads in 89% of cases.5 In addition, significant improvements in outcomes on the McGill Pain Questionnaire, Oswestry Disability Index, Pain Catastrophizing Scale, and Visual Analog Scale were found with cases involving neuromonitoring (P<0.05). Lastly, a more recent prospective study directly compared awake to asleep placement with neuromonitoring demonstrating superiority in placement as well as a recent prospective trial directly comparing awake to asleep placement with neuromonitoring, found that time in the operating room and the incidence of adverse events were reduced with neuromonitoring, Dr. Falowski said.6

Advancements in SCS Technology
Neuromodulation is a rapidly growing field with technology “literally changing overnight,” Dr. Falowski said. Future trends in SCS technology revolve around 10-kHz high-frequency stimulation (HF10 SCS), burst stimulation, and expanded indications for dorsal root ganglion (DRG) stimulation.

HF10 Therapy
HF10 therapy is a paresthesia-free therapy that integrates 10 kHz frequency, pulse width amplitude wave shape, consistent lead placement, and a proprietary programming algorithm, Dr. Falowski explained.

This therapy has demonstrated superiority to conventional tonic SCS, with back pain responder rates of 84.3% vs 43.8% and leg pain responder rates of 83.1% vs 55.0% at 3 months (P<0.001 for both comparisons).6 These findings were sustained at 12-month followup.7

Burst Stimulation
Burst stimulation is establishing itself as a denovo therapy, and also may salvage tonic SCS nonresponders and improve response in tonic SCS responders, Dr. Falowski said. This technology typically emits five signals in a short burst to mirror the physiologic firing of the thalamus. In a study of 102 patients, 95% of responders to tonic SCS had further improvement in pain relief with burst stimulation, Dr. Falowski said.7 In addition, of the 24% of patients who did not respond to tonic SCS therapy, 63% did respond to burst stimulation.8

Dorsal Root Ganglion Stimulation
Dorsal root ganglion (DRG) stimulation is currently approved in the United States for treatment of lower extremity pain in complex regional pain syndrome (CRPS) types 1 and 2. Despite this limited indication, DRG is being used in clinical practice to treat a range of chronic pain conditions that have a focal pain pattern, including post-hernia repair pain, post-hip replacement pain, and post-knee replacement pain, Dr. Falowski said.

Conclusion
“The future is here,” Dr. Falowski concluded, stating that physicians who are already implementing SCS are far ahead of the curve. The technology and indications for SCS are growing, and Dr. Falowski, who encouraged the audience members “to think outside of the box.”

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

Updated on: 10/26/17
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Spinal Cord Stimulation for Chronic Pain: What Conditions and Which Patients?
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