Epidural spinal cord stimulation for treatment of chronic pain—some predictors of success. A 15-year experience

doi:10.1016/S0090-3019(98)00012-3

Surgical Neurology

Volume 50, Issue 2, August 1998, Pages 110-121

https://doi.org/10.1016/S0090-3019(98)00012-3 Get rights and content

Abstract

BACKGROUND We have used epidural spinal cord stimulation (SCS) for pain control for the past 15 years. An analysis of our series of 235 patients has clarified the value of specific prognostic parameters in the prediction of successful SCS.

METHODS Patients were followed up for periods ranging from 6 months to 15 years with a mean follow-up of 66 months. The mean age of the 150 men and 85 women in the study was 51.4 years. Indications for SCS included failed back syndrome (114 patients), peripheral vascular disease (39 patients), peripheral neuropathy (30 patients), multiple sclerosis (13 patients), reflex sympathetic dystrophy (13 patients), and other etiologies of chronic intractable pain (26 patients).

RESULTS One hundred and eighty-nine patients received permanent devices; 111 (59%) of these patients continue to receive satisfactory pain relief. Pain attributable to failed back syndrome, reflex sympathetic dystrophy, peripheral vascular disease of lower limbs, multiple sclerosis, and peripheral neuropathy responded favorably to spinal cord stimulation. In contrast, paraplegic pain, cauda equina syndrome, stump pain, phantom limb pain, and primary bone and joint disease pain did not respond as well. Cases of cauda equina injury had promising initial pain relief, but gradually declined after a few years. After long-term follow-up, 47 of the 111 successfully implanted patients were gainfully employed, compared with 22 patients before implantation. The successful patients reported improvements in daily living as well as a decrease in analgesic usage. Multipolar stimulation systems were significantly more reliable (p < 0.001) than unipolar systems. Complications included hardware malfunction, electrode displacement, infection, and tolerance.

CONCLUSION Aside from etiologies of pain syndromes as a prognostic factor, we have identified other parameters of success. In patients who have undergone previous surgical procedures, the shorter the duration of time to implantation, the greater the rate of success (p < 0.001). The diagnosis of failed back syndrome must be considered a confounding factor in our analysis. Those patients whose pain did not follow a surgical procedure had better responses to SCS than patients who had multiple surgical procedures prior to their first implant. The advent of multipolar systems has significantly improved clinical reliability over unipolar systems. Age, sex, and laterality of pain did not prove to be of significance.

Section snippets

Patient selection

The 235 patients in this series were categorized by etiology of pain as shown in Table 1. Forty-one other patients were not included because of inability to contact them or because of patient death (eight cases) unrelated to their SCS. One hundred fifty men and eighty-five women were included, with an age range of 23–85 years and a mean age of 51.4 years. All patients had used narcotic medication for pain relief before SCS. They were treated in a multidisciplinary pain clinic for a minimum of 6

Pain relief

Two hundred and thirty-five patients were included in this study; 189 patients (80%) experienced satisfactory initial pain relief and had their systems internalized. The minimum follow-up period was 6 months and the maximum follow-up period was 179 months. After an average of 5.6 years follow-up, 111 (59%) internalized patients continue to receive satisfactory pain relief. Of the 111 patients considered successful, 48 (43%) reported excellent pain relief, while the other 63 (57%) patients

Discussion

Several reviews of spinal cord stimulation for the control of chronic, intractable pain have been performed over the past two decades. A comprehensive review of long-term studies is provided in Table 5. Most long-term studies (>5 years) with a significantly large patient database (>100 patients) tend to show success rates of 40–60%. These rates are typically calculated by the number of patients receiving implantation and not by the number of patients screened for the procedure.

During the past

Conclusions

Efficacy of spinal cord stimulation for chronic, intractable pain has increased with the introduction of multipolar devices 41, 42. The use of multipolar devices significantly improves results of stimulation-induced pain relief. A better understanding of prognostic factors should lead to better patient selection and therefore, improved results. The low morbidity of SCS when compared with destructive surgery or other pain relief procedures makes SCS an attractive alternative. Further studies

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To examine if the use of an antibacterial envelope (TYRX) decreases the rate of postoperative infection in chronic pain patients undergoing treatment with spinal cord stimulation (SCS) involving device implantation.
Single-center retrospective cohort study comparing postoperative infections rates in non-TYRX recipients from 2018 to 2020 with recipients of a TYRX antibacterial envelope from 2020 to 2021. Infection was registered if a patient received any form of antibiotic treatment after hospital discharge within a follow-up period of 100 days.
A total of 198 patients were included: 100 in the TYRX group and 98 in the non-TYRX group. There were no significant differences between the 2 groups regarding age, body mass index (BMI), smoking, diabetes, and use of immunosuppression. The overall infection rate was 5.6%. The infection rate was 4% in the TYRX group and 7.1% in the non-TYRX group (P = 0.6). However, the 4 cases of postoperative infection in the TYRX group could be effectively managed with oral antibiotics alone, whereas 6 out of the 7 patients in the non-TYRX group required intravenous antibiotics. Moreover, device explantation was necessary in 3 of these patients suggesting the event of more severe infections in the non-TYRX group (P = 0.014).
The TYRX antibacterial envelope displayed infection rates reducing capabilities, along with a clear tendency to reduce revision surgeries and system removals due to infections.
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Spinal cord stimulation (SCS) has been used as a minimally invasive and effective treatment modality for various chronic pain disorders, with the main target being stimulation of the dorsal columns; however, certain neuropathic pain areas involve dermatomes that are suboptimally covered by SCS. Stimulation of the spinal nerve roots has the advantage of targeting one or several dermatomes at the same time. The aim of this systematic review is to investigate the efficacy of spinal nerve root stimulation (SNRS) for chronic pain disorders.
A detailed literature review was performed through the Ovid Embase and MEDLINE data bases in addition to reference searching. Gray literature was included by searching through common search engines using a simplified search strategy. Studies included were focused on adult patients (aged >18 years), diagnosis of chronic pain syndrome (including but not limited to complex regional pain syndrome, persistent spinal pain syndrome, neuropathic pain secondary to trauma or infection, postherpetic pain, and cancer pain). Patients must have undergone SNRS insertion, with ≥six months of documented pain intensity scores on follow-up.
A total of 40 studies underwent full text review, and 13 articles were included in final analysis. Mean preoperative pain intensity was 8.14 ± 0.74 on the visual analog scale, whereas mean postoperative pain intensity at one year was 3.18 ± 1.44. Of 119 patients, 83 (70%) achieved ≥50% reduction in pain intensity after SNRS, whereas 36 (30%) achieved <50% reduction in pain intensity. Only three studies assessed changes in analgesia medication dose and reported morphine equivalent doses varied by case series. Overall, there was a trend toward a reduction in analgesia medications in the postoperative period.
SNRS led to a mean 44% reduction in pain intensity, with a low level of certainty. In addition, there is some evidence to suggest that using SNRS is associated with reduced use of analgesics, including morphine and gabapentin.
A Bibliometric Analysis of Top-Cited Journal Articles Related to Neuromodulation for Chronic Pain
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Since its foundation in the 1960s, neuromodulation has become an increasingly used treatment option for chronic pain. This bibliometric analysis examines the most cited research in this field with the aim of uncovering existing trends and future directions.
Clarivate’s Web of Science data base was searched for the top 25 most cited studies focusing on neuromodulation for chronic pain. Various bibliometric parameters were then extracted and analyzed. Randomized controlled trials (RCTs) were compared with non-RCTs.
The top 25 articles had a mean of 347 citations and 22.2 citations per year, with more recent articles having a higher citation rate. Most were published in the last two decades and predominantly originated from the United States. There were 13 RCTs, which were significantly more recent (p = 0.004) and more cited per year (p = 0.001) than the 12 non-RCTs. Sources included 15 journals with a mean impact factor of 13.896. The most studied modality was spinal cord stimulation with 20 articles (76.9%), followed by intrathecal drug delivery (15.4%), dorsal root ganglion stimulation (3.8%), and peripheral nerve stimulation (3.8%).
Analysis of the most cited articles on neuromodulation reveals a focal shift from historical reports to innovative RCTs that have increasingly guided pain practice in the recent years. As novel techniques and technologies continue to develop, high-quality evidence coupled with broadening indications will likely direct further expansion of this field.
Systematic Review to Identify Predictors of Treatment Response to Neuromodulation in Patients With Neuropathic Pain—Protocol
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Patients who suffer from long-term, neuropathic pain that proves refractory to conventional medical management are high consumers of health care resources and experience poorer physical and mental health than people with other forms of pain. Pharmacologic treatments have adverse effects; nonpharmacologic interventions have limitations. Spinal cord stimulation (SCS) is an effective treatment for neuropathic pain, although 30% to 40% of patients fail to achieve acceptable levels of pain relief. There are currently no objective methods to predict the success of SCS to treat neuropathic pain, and therefore, it is important to understand which patient factors may be predictive of a lack of response to SCS, to inform future patient treatment options. This study proposes a protocol for a systematic review and meta-analysis of published studies to examine these predictive factors.
Several bibliographic databases will be searched to identify relevant studies published since 2012 that provide data on patient characteristics (eg, age, gender, pain severity) as predictors of SCS outcomes of pain, function, and health-related quality of life. Two independent reviewers will screen citations; data will be extracted after full-text screening. Risk of bias will be assessed using the Quality In Prognosis Studies tool.
A formal quantitative synthesis is planned in which data from studies with the same predictive factors are available; this will be considered for pooling into separate meta-analyses. In cases of high heterogeneity or inconsistency in the data, subgroup analysis will be conducted.
This study seeks to provide a contemporary review of patient predictors of success of neuromodulation for neuropathic pain. We anticipate that findings may guide the use of neuromodulation in patient subgroups and the design and reporting of future clinical studies in this field.
Neuropathic pain questionnaires for back pain, what do we know?
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Low back pain is a global public health concern, with an estimated lifetime prevalence of 84%. Axial low back pain refers to pain confined to an area in the low back and is different to radicular pain which radiates to extremities. Axial low back pain has traditionally been considered as nociceptive. However, research suggests it may have neuropathic components. Neuropathic axial low back pain is an unresolved, hotly contested topic due to controversies surrounding its aetiology, diagnosis, clinical course, prognosis and treatment options.
The reference standard for diagnosing neuropathic pain is by medical history and clinical assessment (i.e., sensory testing), with optional neuropathic screening tools and selective, further diagnostic tests when clinically needed. Neuropathic screening tools are not always specific for neuropathic radiating low back pain, let alone neuropathic axial low back pain. Additionally, not all have been validated for the English language (e.g., PainDETECT). Research also suggests the percentage of patients identified as having neuropathic radiating low back pain may be dependent on the combination of reference standards used.
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The sympathetic nervous system (SNS) is important in the regulation of perfusion. Dorsal root ganglion stimulation (DRG-S) modulates sympathetic tone and is approved to treat complex regional pain syndrome, a disorder related to SNS dysfunction. We herein present 3 cases of DRG-S therapy to improve blood flow and symptoms of ischemia in peripheral arterial disease (PAD).
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PainEpidural spinal cord stimulation for treatment of chronic pain—some predictors of success. A 15-year experience

Abstract

Section snippets

Patient selection

Pain relief

Discussion

Conclusions

Pain

Pain

Pain

Surg Neurol

Pain

Pain

Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy

Stereotact Funct Neurosurg

Clinical manifestations of reflex sympathetic dystrophy and sympathetically maintained pain

Spinal cord stimulation in peripheral arterial disease

J Neurosurg

Session on spinal cord stimulationSafety and clinical efficacy

Neurosurgery

Spinal cord stimulation in chronic pain therapy

Clin J Pain

Central acute pain mechanisms

Ann Med

Spinal cord stimulation (SCS) in peripheral ischemic pain

PACE

Phantom-limb pain as a perceptual correlate of cortical reorganization following arm amputation

Nature

Clinical use of nociceptive flexion reflex recording in the evaluation of functional neurosurgical procedures

Acta Neurochir Suppl (Wien)

Nociceptive flexor reflexes during analgesic neurostimulation in man

Pain

Spinal electrical stimulation. Current indications and results in a series of 46 patients

Rev Esp Anestesiol Reanim

Visual analogue scales

Epidural spinal cord electrical stimulation improves microvascular blood flow in severe limb ischemia

Ann Surg

Plasticity in human somatosensory thalamus as a result of deafferentation

Stereotact Funct Neurosurg

Spinal cord stimulation and the relief of chronic pain

J Neurol Neurosurg Psychiatry

Long term results of spinal cord stimulation in amputees

Pain reduction in amputees by long term spinal cord stimulation. Long-term follow-up study over 5 years

J Neurosurg

Dorsal column stimulation

Improvement of limb circulation in peripheral vascular disease using epidural spinal cord stimulationa prospective study

J Neurosurg

Spinal cord stimulation is effective in reflex sympathetic dystrophy

Neurosurgery

Deep brain stimulation for intractable paina 15-year experience

Neurosurgery

Treatment of chronic pain by epidural spinal cord stimulationa ten-year experience

J Neurosurg

Epidural spinal cord stimulation for relief of chronic pain

The Pain Clinic

Importance and documentation of an epidural stimulating position

Appl Neurophysiol

Pain
Epidural spinal cord stimulation for treatment of chronic pain—some predictors of success. A 15-year experience