Tripolar Spinal Cord Stimulation for the Treatment of Abdominal Pain Associated With Irritable Bowel Syndrome

Objectives: The objective of this case report is to describe the use of transverse tripolar dorsal column stimulation in a patient with a history of irritable bowel syndrome (IBS) associated with abdominal pain resistant to conservative treatments. Method: We report a 36‐year‐old man who presented to the pain clinic with an eight‐year history of IBS (constipation predominant with occasional diarrheal episodes), with “crampy and sharp” abdominal pain. He also had nonradicular thoracic spine pain due to thoracic scoliosis. Both pains were affecting his ability to function as an attorney. Prior conservative therapy, including psychologic treatment, antidepressants, and opioids, was without any benefits. Results: The use of a spinal cord stimulator (SCS) was discussed with the patient. The procedure was performed after Institutional Review Board approval. A tripolar SCS was implanted at the T8 level using one‐eight contact and two‐four contact percutaneous leads based on paresthesia reproduction of patient's areas of discomfort. This tripolar spinal cord stimulation provided relief of abdominal and thoracic pain, and better management of gastrointestinal symptoms. The patient was followed‐up for one year, and his quality of life also was improved via the IBS‐Severity Scoring System quality of life tool. Conclusions: The use of the tripolar SCS in this patient provided relief of abdominal and thoracic spine pain, regulated bowel habits, and improved the patient's quality of life. We believe that the use of SCS should be considered as a treatment option in patients with IBS when all conservative treatments failed.     

Results of neuromodulation for the management of chronic pain

Background and purpose : Neuromodulative treatment of chronic pain syndromes is a modern mode of treatment of neuropathic and ischaemic pain. Its effectiveness is well documented in the literature. The objective of this work is to present the results of treatment of chronic pain syndromes on the basis of eight-year experience in our department. Material and methods : Since 2002, we have conducted 9 operations of motor cortex stimulation (MCS), 2 of deep brain stimulation (DBS), 45 of spinal cord stimulation (SCS) and 5 of sacral root stimulation (SRS) in the treatment of chronic pain. Results : We obtained good long-term results of neuromodulation in the form of clinical improvement (> 50%) in 4 of 9 patients with MCS (44%), in 13 diagnosed with failed back surgery syndrome (FBSS), 8 with other neuropathic pain, and 11 with angina pectoris from a group of 45 treated with SCS. Sacral root stimulation has been successful in 3 of 5 patients with perianal pain. The best treatment results in SCS, although not statistically significant, were observed in patients treated due to FBSS (13 out of 15) and angina pectoris (11 out of 15) (p = 0.12). In patients with neuropathic pain, peripheral and central, improvement was obtained in 8 out of 15 patients. Conclusions : A good indication for spinal cord stimulation is FBSS and angina pectoris. Motor cortex stimulation is helpful in the treatment of chronic central neuropathic pain. Further observations and a larger group of patients are necessary for a reliable assessment of the effectiveness of neuromodulative treatment of chronic pain in our clinic.     

Spinal cord stimulation in refractory angina pectoris -- a case description

Spinal cord stimulation (SCS) is one of the methods for treating angina pectoris and has been used since 1985. Patients with refractory angina pectoris despite optimal medication and revascularisation procedures are suitable for the SCS. This kind of treatment is not common in Poland. This article reports the first case of a patient with ischaemic heart disease treated with spinal cord stimulation in the Clinical Department of Neurosurgery in the Military Clinical Hospital in Bydgoszcz. The procedure was based on epidural implantation of the electrode at the level of Th1-Th2 and connection with the impulse generator located subcutaneously. As a result of the applied stimulation reduction of the anginal pain was achieved.     

Spinal Cord Stimulation for Intractable Visceral Pain due to Chronic Pancreatitis

Pain caused by chronic pancreatitis is medically intractable and resistant to conventional interventional or surgical treatment. We report a case of spinal cord stimulation (SCS) for intractable pain due to chronic pancreatitis. The patient had a history of nonalcoholic chronic pancreatitis and multiple emergency room visits as well as repeated hospitalization including multiple nerve block and morphine injection for 3 years. We implanted surgical lead at T6-8 level on this patient after successful trial of percutaneous electrode. The patient experienced a decreased visual analog scale (VAS) scores for pain intensity and amount of opioid intake. The patient was followed for more than 14 months with good outcome and no further hospitalization. From our clinical case, spinal cord stimulation on intractable pain due to chronic pancreatitis revealed moderate pain control outcome. We suggest that SCS is an effective, noninvasive treatment option for abdominal visceral pain. Further studies and long term follow-up are needed to fully understand the effect of SCS on abdominal visceral pain.     

Rare Side‐effects during Spinal Cord Stimulation: Gastrointestinal Symptoms

In current medical literature, most reported complications during spinal cord stimulation (SCS) concern technical problems, such as malfunction, migration or breakage of the lead, or internal pulse generator dysfunction, while reports about side‐effects caused by SCS are rare. In this clinical report, we describe uncommon and unexplained gastrointestinal (GI) side‐effects of constipation, abdominal pain, and distension during SCS in a patient suffering for chronic neuropathic pain caused by failed back surgery syndrome. These GI symptoms disappeared after suspension of SCS and were reduced if the stimulation settings were reduced below paresthesia threshold. The symptoms experienced by our patient could be related to a functional and reversible block of parasympathetic outflow in the GI system since SCS may involve not only dorsal horn structures but also somatic and visceral sensory afferents to these structures in an unpredictable way.     

Physiology of Spinal Cord Stimulation: Review and Update

Spinal cord stimulation (SCS) was an outgrowth of the well-known gate control theory presented by Melzack and Wall in 1965. Although the method has been used to treat chronic severe pain for more than three decades, very little was known about the physiological and biochemical mechanisms behind the beneficial effects until recently. We now know that SCS activates several different mechanisms to treat different types of pain such as neuropathic and ischemic. In general, these mechanisms seem most dependent on activation of only a few segments of the spinal cord. However, both animal studies and human observations have indicated that supraspinal circuits may contribute as well. In the treatment of neuropathic pain, intermittent SCS may give several hours of pain relief after cessation of the stimulation. This protracted effect indicates long-lasting modulation of neural activity involving changes in the local transmitter systems in the dorsal horns. In ischemic pain, animal experiments demonstrate that inhibition of afferent activity in the spinothalamic tracts, long-term suppression of sympathetic activity, and antidromic effects on peripheral reflex circuits may take part in the pain alleviation. Moderate SCS intensities seem to evoke sympathetic inhibition, but higher stimulation intensities may induce antidromically mediated release of vasoactive substances, eg, the calcitonin gene-related peptide (CGRP), resulting in peripheral vasodilation. The anti-ischemic effect of SCS in angina pectoris due to intermittent coronary ischemia probably occurs because application of SCS appears to result in a redistribution of cardiac blood supply, as well as a decrease in tissue oxygen demand. Recent studies indicate that SCS modulates the activity of cardiac intrinsic neurons thereby restricting the arrythmogenic consequences of intermittent local coronary ischemia. The present state of knowledge is briefly reviewed and recent research directions outlined.     

Attenuation by spinal cord stimulation of a nociceptive reflex generated by colorectal distention in a rat model

The mechanisms underlying the cause and treatment of visceral pain of gastrointestinal origin are poorly understood. Previous clinical studies have shown that spinal cord stimulation (SCS) attenuates neuropathic and ischemic pain, and animal experiments have provided knowledge about probable physiological mechanisms. The goal of the present study was to investigate whether SCS influences colonic sensitivity in a conscious rat. A visceromotor behavioral response (VMR), induced by colorectal distention, was used to quantify the level of colonic sensitivity. Under anesthesia, an electrode (cathode) was placed on the dorsal surface of the spinal cord at L1. One week after implantation of the SCS electrode, the effects of stimulation delivered with different intensities (50 Hz, 0.2 ms for 30 min) on colonic sensitivity were determined. Nociceptive levels of colorectal distention (60 mm Hg for 10 min) induced an enhanced VMR quantified as an increased number of abdominal muscle contractions compared to controls in which the balloon catheter was inserted into the colorectal region but not distended. Colonic sensitization with acetic acid increased the VMR to innocuous levels of colorectal distention (30 mm Hg for 10 min). We found that SCS induced a significant depression of the VMR produced by colorectal distention in both normal rats and those with sensitized colons. The suppressive effect of SCS on colonic sensitivity suggests that SCS may have therapeutic potential for the treatment of visceral pain of gastrointestinal origin associated with abdominal cramping and painful abdominal spasms.     

Thermogram in spinal cord stimulation with complex regional pain syndrome and a review of the literature

Introduction: Spinal cord stimulation (SCS) is an efficient procedure for treatment of intractable pain. Methods: We present a patient who underwent SCS lead placement for severe left lower extremity pain. The patient had experienced good pain. He underwent thermographic imaging before, just after and ten days later of procedure. Results: Thermogram study revealed from blue color (hypothermic) pattern at before procedure to reddish or pink color (hyperthermic) pattern at ten days later. Discussion: SCS may be increase microcirculation and seems to have sympatholytic effects. Conclusion: We experienced that improvement of blood flow as result of SCS in CRPS.     

Spinal Cord Stimulation Has Proven Benefit on Pain and Quality of Life in Patients With Angina Pectoris When Less Invasive Therapies Have Failed

Background. Since 1988, spinal cord stimulation (SCS) has been used at Odense University Hospital for patients with refractory angina pectoris. The aim of our prospective study was to evaluate the long‐term effects of SCS on pain, activities of daily living (ADLs), quality of life (QOL), sleep hygiene, and physical functioning for patients with angina pectoris. Methods. Before and after placement of SCS for patients with intractable angina pectoris, we performed structured telephone interviews questioning for pain relief, ADLs (Nottingham Health Profile), physical functioning (Seattle Angina Questionnaire) and sleep hygiene. Results. Out of 150 patients with SCS over 15 years, 41 patients had died, 46 patients had their devices explanted, and four patients did not participate or could not be reached. Three patients had less than 6 months of follow‐up and were therefore not included in our analysis. The beneficial effects of SCS treatment for intractable angina pectoris were reduction in pain and improvement in QOL. Sleep pattern and physical functioning were not improved to the same extent as reduction in pain or improvement in QOL. Almost all of our SCS‐treated patients did recommend SCS for intractable angina pectoris. About 30% of patients discontinued treatment, the most common cause being electrode displacement and malfunction of the system. Other reasons for discontinued therapy were the evolvement of invasive treatment options such as coronary artery bypass graft and PTCA and use of such options in some patients during our prolonged observation period. Conclusion. This survey shows that SCS leads to a 70–80% improvement in pain, which, in turn, leads to improvement in QOL, whereas, physical condition and sleep pattern did not improve to the same extent.     

Spinal Cord Stimulation Therapy for Patients With Refractory Angina Who Are Not Candidates for Revascularization

Objectives: The aim of this study was to evaluate the safety and efficacy of spinal cord stimulation (SCS) for refractory angina. Materials and Methods: This multicenter, randomized, single‐blind, controlled trial evaluated SCS in two patient groups: high stimulation (HS) (treatment) and low stimulation (LS) (control). The HS group controlled SCS with a programmer for a minimum of two hours four times daily. The LS group received SCS therapy above the paresthesia threshold for one min once daily. The primary efficacy endpoint was number of angina attacks recorded by patients at six months. The primary safety endpoint was the major adverse cardiac event (MACE) rate at six months. Results: Due to slow enrollment, a futility analysis was performed, resulting in early termination of the study. Sixty‐eight patients were randomized after implantation. Mean change in angina attacks per day from baseline to six months was ?1.19 ± 2.13 (HS) and ?1.29 ± 1.66 (LS). The difference from baseline was significant within each group (both p < 0.001) but not between groups (p = 0.45). Total exercise time and time to angina onset increased significantly from baseline to six months within each group (both p = 0.02 and 0.002) but not between groups (p = 0.52 and 0.51). MACE was similar between groups. Conclusion: Although this study was terminated early, the results obtained at six months suggest that SCS (HS) is not more effective than the control (LS) in patients with refractory angina.     

Spinal Cord Stimulation With Hybrid Lead Relieves Pain in Low Back and Legs

Objective: The failed back surgery syndrome (FBSS) is the most common chronic pain syndrome. Whereas it is relatively easy to achieve pain relief in the lower limbs of FBSS patients with spinal cord stimulation (SCS), it is difficult to manage low back pain with SCS. The performance of a paddle‐shaped SCS lead that can be inserted surgically as well as percutaneously (a hybrid lead) was evaluated in a prospective study on the relief of low back pain and leg pain in patients with FBSS. Materials and Methods: Patients with FBSS being eligible for SCS were enrolled in the study, and a hybrid lead was placed surgically. Outcome measures included pain scores for low back and leg pain assessed by visual analog scale (VAS), pain medication, and patient satisfaction. These scores were assessed before and at regular intervals after implantation. Results: It was shown that a single hybrid lead, generally positioned over the physiological midline of the spinal cord, is capable of alleviating both low back and leg pain in patients with FBSS. Forty‐five subjects were eligible for SCS and received trial stimulation. Forty‐two of them had a successful trial period and were converted to a permanent system. Their average VAS score at baseline was 8.0 for lower limb pain and 7.5 for low back pain. After six months of SCS, these average VAS scores were reduced to 3.2 and 3.5, respectively, and also pain medication was reduced significantly. Conclusion: SCS with a hybrid lead in subjects with FBSS is safe, and causes significant pain relief in both the low back and the lower limbs.     

Treatment of Multifocal Pain with Spinal Cord Stimulation

Introduction: We report a retrospective case study of combined treatment of cancer‐related pain and chronic low back and lower extremity pain related to postlaminectomy syndrome (PLS) with one spinal cord stimulation (SCS) system. Methods: The patient underwent an uneventful SCS trial with percutaneous placement of two temporary eight‐electrode leads (Medtronic Inc., Minneapolis, MN) placed at the level of T8‐T9‐T10 and T5‐T6‐T7. Results: After successful trial, he was implanted with permanent leads and generator, reporting sustained pain relief at 12‐month follow‐up visit. Discussion: SCS is a trialable, reversible, and interactive therapy permitting patients to control the level of stimulation they feel based on their degree of pain. Conclusion: SCS provides an effective, alternative treatment for select patients with cancer‐related chest wall pain and pain related to PLS who have failed conservative treatment.     

Prospective,Two-part Study of the Interaction Between Spinal Cord Stimulation and Peripheral Nerve Field Stimulation in Patients with Low Back Pain: Development of a New Spinal-Peripheral Neurostimulation Method

Objective: The goal of the study was to assess the efficacy of interaction between spinal cord stimulation (SCS) and peripheral nerve field stimulation (PNFS) and to evaluate a new spinal‐peripheral neuromodulation method for low back pain. Materials and Methods: The prospective two‐part study included patients with low back pain due to failed back surgery syndrome and/or spinal stenosis. In the first part 20 patients were implanted with SCS and PNFS. They selected the best program out of three: SCS alone, PNFS alone, or both together. In the second part another 20 patients with the same implanted leads were selecting between three programs: SCS and PNFS separately, SCS as anode and PNFS as cathode, or in reverse. Results: In the first part 79% of the patients selected simultaneous use of SCS and PNFS. The overall success of the trials was 85%. In the second part communication between SCS and PNFS provided wider coverage of axial pain. The overall success of the trials was 90%. Conclusion: Simultaneous use of SCS and PNFS increase efficacy of both methods for axial back pain. The new SPN method showed great potential in providing coverage for back pain.     

Multiple Program Spinal Cord Stimulation in the Treatment of Chronic Pain: Follow-Up of Multiple Program SCS

Objective. Follow-up of 80 patients using multiple program spinal cord stimulation (SCS). Methods. For 30 months, we followed 80 chronic pain patients who had undergone SCS implantations at our center. Thirty-six patients had Failed Back Surgery Syndrome (FBSS). Patients were evaluated in patient-controlled stimulation mode (patients can select one of several specific programs in response to their activities and pain level). We collected visual analog pain scores, patient satisfaction scores, pain maps, and paresthesia maps. Results. We previously reported our preliminary findings (Neuromodulation 1998;1 :30–45). At 24 months all patients were using more than one program. At 30 months, 62 patients (76%) were using more than two programs as their preferred stimulation mode and three patients (4%) were satisfied with only one stimulation program. At 30 months all patients chose patient-controlled stimulation as their preferred mode of stimulation. A total of 18 patients (23%) were explanted. Mean pain scores declined from 8.2 at baseline to 4.8 (p < 0.05, n= 79). Paresthesia overlap was 91% (n= 79). Of the patients with FBSS, 81% reported that they were using their SCS daily. Conclusions. In spinal cord stimulation the use of multiple electrodes and multiple stimulation programs, together with advanced programmability, increases paresthesia overlap, reduces pain scores, and may improve patient satisfaction with SCS therapy. This study indicates a significant patient preference for multiple program SCS, if patients are given the option to choose between a single program SCS system or a multiple program SCS system.     

Spontaneous Resolution of Nausea Induced by Spinal Cord Stimulation for Failed Back Surgery Syndrome

Introduction: Spinal cord stimulation (SCS) is used for treatment of pain arising from a variety of pathologies. Reported side‐effects related to SCS are most commonly technical complications including malfunction, lead migration, or severance. Up to date, only a few cases of gastrointestinal side‐effects have been reported. Materials and Methods: A 54‐year‐old man with a 20‐year history of low back pain developed persistent and refractory nausea following spinal cord stimulator implantation. Results: The nausea resolved spontaneously within eight weeks allowing continued use of the spinal cord stimulator. Conclusions: In this case report, we described the uncommon side‐effect of nausea because of SCS that resolved over time allowing continued neurostimulation therapy in a patient with arachnoiditis and failed lumbar back surgery syndrome. We encourage other providers to report similar cases to help elucidate the mechanism of these seemingly underreported side‐effects to allow continuation of the therapeutic effects of SCS.     

High-Level Cervical Spinal Cord Stimulation Used to Treat Intractable Pain Arising from Transverse Myelitis Caused by Schistosomiasis

The efficacy of spinal cord stimulation (SCS) for treatment of various chronic painful conditions is well established. Very few reports have documented the use of SCS for treatment of chronic pain after spinal cord injury. We present a case showing a good outcome after such treatment, and suggest that high cervical stimulation may be efficacious. A 53-year-old male underwent SCS on the C1-3 level for treatment of intractable neuropathic pain below the T3 level, and in the upper extremities, arising from spinal cord injury resulting from transverse myelitis caused by schistosomiasis. High cervical SCS significantly improved the pain in the upper extremities and at the T3-T10 dermatome level. The patient continues to report excellent pain relief 9 months later. The present case suggests that high cervical stimulation may improve chronic pain in the upper extremities and the T3-T10 dermatome level arising from spinal cord injury.     

Lumbar and Sacral Nerve Root Stimulation (NRS) in the Treatment of Chronic Pain: A Novel Anatomic Approach and Neuro Stimulation Technique

Objective. The conventional technique used to stimulate the lumbar dermatomes is by stimulation of the dorsal columns of the spinal cord. Until recently, stimulation of nerve roots had not been successfully accomplished. We had performed selective nerve root cannulations for the placement of temporary catheters at cervical, thoracic, lumbar, and sacral levels in chronic pain patients using a caudad rather than craniad approach. We hypothesized that by stimulating the nerve roots we could improve paresthesia coverage in areas which cannot be covered effectively by spinal cord stimulation (SCS). To test this hypothesis, we have performed trials of nerve root stimulation (NRS) in patients who had failed SCS, or who were not candidates for SCS because their pain was otherwise inaccessible to stimulation. Methods. Five patients who had been unresponsive to conservative treatment, surgery, or SCS underwent 7-day trials with NRS. The diagnoses included: ilioinguinal neuralgia, discogenic low back pain, failed back syndrome, vulvodynia, and interstitial cystitis. We collected paresthesia maps, pain maps, pain visual analog scale (VAS) scores, and patient satisfaction ratings. Results. Paresthesia coverage was above 75% in all patients. VAS scores declined from a mean of 9 ± 1.0 to 2.4 ± 2.1 (p < 0.05, n= 5), all 5 patients requested permanent implantation, and 4 have been implanted so far. Conclusions. Lumbar and sacral NRS trials resulted in adequate paresthesia coverage and effective pain relief in all 5 patients. Further clinical trials to evaluate long-term success rates and safety are indicated. Detailed mapping studies are needed to evaluate the relationship between electrode placement and paresthesia patterns as well as the optimal stimulation parameters.     

Spinal Cord Stimulation Reverses Pain and Diarrheal Episodes of Irritable Bowel Syndrome: A Case Report

Irritable Bowel Syndrome (IBS) is a functional gastrointestinal (GI) disorder, characterized by abdominal pain, altered bowel habit (diarrhea and/or constipation), and bloating in the absence of demonstrable organic pathology. It is the most common GI disorder seen in primary care and gastroenterology practices. Conservative therapies for IBS are directed at both pain and correction of altered GI motility. A small proportion of patients with IBS have severe or refractory symptoms and report constant pain. IBS is no longer considered solely a disorder of motility, but rather its clinical expression is viewed as dysregulation of CNS‐enteric function. Symptoms of IBS cannot be explained entirely by changes in motility alone and may also arise from complex feedback and feed–forward interactions between supraspinal circuits, the spinal cord, and the periphery, in effect, a neuropathic process, that might be amenable to neuromodulation, that is, spinal cord stimulation. We present here a single case report of a patient with IBS who responded positively to SCS after failing all conservative therapies to alleviate or manage her abdominal pain and diarrheal episodes. Our discussion is focused on the reasons why SCS might work in patients with IBS.     

Combined Spinal Cord and Peripheral Nerve Field Stimulation for Persistent Post‐Herniorrhaphy Pain

Objectives: Chronic post‐hernia pain is a common complication after inguinal herniorrhaphies. Peripheral nerve field stimulation (PNFS) and spinal cord stimulation (SCS) are two new promising treatment modalities. Four patients with persistent neuropathic post‐hernia pain were recruited for this prospective study. Materials and Methods: Electrodes were inserted into the epidural space of the spinal canal and into the subcutaneous tissue in the inguinal region during a single surgical procedure. During a 14‐day trial, double‐blind stimulation was performed via an external stimulator: three days using the spinal electrode (SCS), three days using the inguinal electrode (PNFS), three days using both (SCS + PNFS), and five days off, with an alternating order from patient to patient. During the trial, pain intensity was assessed thrice daily by the visual analog scale. Additionally, pain intensity and quality of life (QOL) were assessed before and after surgical intervention by the Brief Pain Inventory, SF36 scale, and Pain Disability Index. Results: All patients had a marked pain reduction during the trial phase, and this reduction was more prominent when both electrodes were activated simultaneously (p < 0.001). At the late follow‐up, a significant pain reduction and improvement of QOL was observed in three patients. Conclusions: Both SCS and PNFS are effective in treating post‐hernia pain, but the magnitude of pain reduction was more prominent with concomitant stimulation. Combined PNFS and SCS should be considered for patients with a less than optimal response to either SCS or PNFS. More studies are necessary to address the cost‐effect issues of this new approach to treatment.     

Spinal Cord Stimulation Has Comparable Efficacy in Common Pain Etiologies

Objectives. The probability of success with spinal cord stimulation (SCS) depends largely on appropriate patient selection. Here, we have assessed the predictive value of pain etiology as it relates to pain relief with SCS as part of a prospective multicenter clinical trial. Methods. Sixty‐five subjects with chronic and intractable pain tested an epidural SCS system. Subjects reported pain ratings (visual analog scale) with stimulation off and stimulation on at scheduled follow‐up visits for up to 18 months after activation of the system. Visual analog scale scores were averaged and stratified by dominant pain etiologies, comprising failed back surgery syndrome, complex regional pain syndrome, and a subgroup of subjects with miscellaneous other pain etiologies. Results. More than 70% of subjects in each subgroup had successful outcomes during the temporary trial period and similar percentages of subjects from each etiology subgroup subsequently went on to permanent implantation. After permanent implantation, all subgroups reported more than 50% pain relief, on average, at each follow‐up time point. No predictive value of pain etiology was observed. Conclusions. Spinal cord stimulation is an effective therapy for neuropathic pain arising from a variety of causes. Failed back surgery syndrome, complex regional pain syndrome, and pain of other etiologies responded equally well to SCS.