Spi pinal al Co Cord S d Stimul ulator Di Cui MD Emory Spine - - PowerPoint PPT Presentation

Spi pinal al Co Cord S d Stimul ulator

Di Cui MD Emory Spine Center

History and Utilization

• First implantation credited to Dr. Norman Shealy in

1967

• Programmable electrodes by medtronics in 1982
• A therapy that alleviates pain by sending electrical

stimulation via implanted leads to electrodes in the epidural space

• Neurostimulation activates pain-inhibiting

neuronal circuits in the dorsal horn and induces a tingling sensation (paresthesia) that masks the sensations of pain.

Indication

• Failed back surgery syndrome once other causes are excluded
• Multiple sclerosis
• Chronic painful peripheral neuropathy or plexopathy
• Complex Regional Pain syndrome
• Off Label use for Peripheral vascular disease
• Newer High Frequency SCS also provide an alternative for axial low

back pain

The Mechanism

• Segmental, antidromic activation of A-

Beta afferents

• Gate control theory proposed by Melzack

and Wall in 1965

• Blocking of transmission in the

spinothalamic tract

• Activation of central inhibitory

mechanisms influencing sympathetic efferent neurons

The Mechanism

Surgical leads vs Percutaneous leads

Surgical Leads

 More invasive than percutaneous, thus may

cause patient discomfort1

 May have less chance of migration after

encapsulation due to their shape1

Percutaneous Leads

 May reduce patients’ insertion-related

discomfort2

 May improve implanters’ ability to obtain

accurate results during trialing2

 Offer longitudinal access to multiple levels

• f the spine2

 A small amount of silicone elastomer

adhesive between the inner surface of the anchoring sleeve and the outer surface of the lead may reduce lead migration2

• 1. North RB et al. Neurosurgery. 2005;57:990-996. 2. Renard V-M, North RB. Neuromodulation. 2006;9:12-13

SCS vs repeated lumbosacral spine surgery

• 50 patients selected for re-operation randomized to SCS vs

reoperation, 45 available for follow up @ 3 years

• 19 randomized into SCS and 26 for reoperation
• 9/19 in the SCS group reports satisfaction, 3/26 from the surgical

group

• SCS group needed less opioids
• Neurosurgery. 2005; 56 (1): 98-106

SCS vs medical management: 24 month follow up

• 100 patient with failed back surgery
• Randomized to SCS vs conventional medical management (CMM)
• Favorable results at 6 month
• At 24 months, 17/46 randomized SCS group reports >50% relief
• At 24 months, 1/41 randomized CMM group reports > 50% relief
• 34/72 patient who received SCS as final treatment reports >50% pain

relief vs 1/15 for CMM

Neurosurgery, Volume 63, Issue 4, 1 October 2008, Pages 762–770

High Frequency vs traditional

• 11 centers, 198 patient randomized, 171

implantation

• Randomized into traditional SCS vs HF SCS
• Neurosurgery. 2016 Nov; 79(5): 667–677.

24 months Back pain relief >50% Leg pain relief >50%

Traditional 76.5% 49.3% HF 72.9% 49.3%

Complications and disadvantages

• Dural Puncture
• Estimated to be between 0-0.3%
• Infection
• 5180 cases reviewed, mean 4.89% (range 2.5-10%)
• Lead Fractures/ malfunction
• 4602 cases reviewed, mean 6.37% (range 0-10.2%)
• Lead migration w/ change or loss of stimulation+
• 4968 cases reviewed, mean 15.49% (range 2.1-27%)

Pain Medicine, Volume 17, Issue 2, 1 February 2016, Pages 325–336, Pain Pract. 2011;11(2):148-53.

Where does SCS injection stand?

Low High

Safety

Low High

Cost

Low High

Efficacy

Low High

Ease of Admin

Low High

Availability

Thank You