Spinal Cord Stimulation: An Under-utilized and Under-recognized Pain Treatment Modality

Philip Chan, MD, FRCPC (Anesthesiology, Pain Medicine), FIPP,

Director, Chronic Pain Clinic, Department of Anesthesia/Chronic Pain Clinic, St. Joseph's Healthcare, Hamilton, Ontario, Assistant Clinical Professor, Department of Anaesthesia, Faculty of Health Sciences, McMaster University, Program Director, Pain Medicine Residency Program, McMaster University, Medical Director, Neuromodulation Program, Hamilton Health Sciences Corporation, Hamilton, ON.

CLINICAL TOOLS

Abstract: There is increasing concern in Canada about the overuse and misuse of opioids. While there are no simple answers to this complex societal problem, adequate and timely access to proper multidisciplinary chronic pain care is important in decreasing the reliance on opioids when treating chronic pain in Canada. Neuromodulation therapy, especially spinal cord stimulation (SCS), offers patients the potential for pain relief without repeated injections or ongoing medication use. SCS is effective in the treatment of persistent postoperative neuropathic pain and complex regional pain syndrome. Prospective SCS candidates should undergo a full multidisciplinary assessment to evaluate both physical and psychological factors that may adversely affect results.
Key Words: chronic pain, spinal cord stimulation, opioids, neuropathic pain, persistent postoperative neuropathic pain.

The best studied indications for SCS are persistent postoperative neuropathic pain (so-called failed back surgery syndrome [FBSS]) and complex regional pain syndrome (CRPS).
The key to success with SCS is to generate a pattern of paresthesia that overlaps with the patient’s area of pain while avoiding extraneous paresthesia that may cause discomfort.
SCS is a cost-effective treatment, whereby the long-term savings in terms of diagnostic imaging, physician visits, medications, and rehabilitative services outweighed the higher upfront cost.
Contraindications for SCS implantation include: systemic infection, cognitive impairment, and low platelet counts.
Well-accepted positive predictive factors for long-term success with SCS include: patients whose etiology of pain have a predominately peripheral neuropathic pain component, treatment early in the course of the pain syndrome, and the presence of allodynia and other features suggestive of neuropathic pain. Significantly depressed mood, low energy levels, somatization, anxiety, and poor coping skills are important predictors of poor outcome.
SCS is a non-destructive procedure; the device can be explanted at any point if it no longer provides pain relief, and it does not preclude other treatment modalities, including spinal surgery, in the future.
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This article was published as part of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource. The development of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource was supported by an educational grant from Medtronic Canada.