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spinal cord stimulation

Chronic Neuropathic Pain in Primary Care—The Role of Neuromodulation

Teaser: 

Philippe Magown, MD CM, PhD, FRCSC,

Caleo Health, Calgary, Alberta.

CLINICAL TOOLS

Abstract: Neuropathic pain is a severe pain condition characterized by burning, tingling, or lancinating pain in the distribution of a nerve, dermatome, or sclerotome and affects patient function, quality of life, mood, and employment. Neuropathic pain is generally refractory to pain medications but amenable to gabapentinoids and antidepressants. When neuropathic pain is refractory to conservative medical management, neuromodulation is the next strategy. Neuromodulation is the modulation of neural signals, most commonly performed with electrical stimulation, such as spinal cord stimulation. Spinal cord stimulation can provide clinically significant pain relief, improve quality of life and function for neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.
Key Words: Spinal cord stimulation, failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, refractory angina.

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1. Neuromodulation outcomes for neuropathic pain are best if performed early upon confirmation of pain refractoriness to multimodal and multi-pharmacological management.
2. Level 1 and 2 evidences support the use of neuromodulation for neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.
3. Neuromodulation can provide 50% or more pain relief in a significant proportion of patients with neuropathic pain conditions refractory to pharmacotherapy.
1. Neuropathic pain is a severe pain condition along a nerve, dermatome, or sclerotome that is characterized by burning, lancinating, prickling, or shocking-like pain generally refractory to pain medications.
2. Neuropathic pain refractory to four or more pharmacological agents among TCAs, SNRIs, gabapentinoids, and tramadol can benefit from neuromodulation, even more so if performed within two years of onset.
3. Neuromodulation can provide 50% or more pain relief in a significant proportion of patients with failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.
A successful back school educates the patient about the benign nature of back pain and provides the tools to transfer knowledge about back hygiene into practice in the patient's life.
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Related Terms: Back Health, spinal cord stimulation, failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, refractory angina
Disclaimer: 
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Spinal Cord Stimulation: An Under-utilized and Under-recognized Pain Treatment Modality

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

Teaser: 

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.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Pain, chronic pain, spinal cord stimulation, opioids, neuropathic pain, persistent postoperative neuropathic pain
Disclaimer: 
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.