Spinal Cord Stimulation

What is a spinal cord stimulator?

A spinal cord stimulator (SCS) is a small medical device, similar to a pacemaker, that uses electrical impulses to mask pain signals before reaching the brain. A spinal cord stimulator consists of two components: a pulse generator and electrodes. The pulse generator is positioned just beneath the skin of the back and the electrodes are positioned next to the spinal nerves entering the spinal cord. Abnormal pain signals are eliminated by small electrical impulses created by the pulse generator just before entering the spinal cord.

Who’s a candidate for spinal cord stimulation?

Spinal cord stimulation is BEST for patients with chronic back pain after back surgery or back pain that has lasted longer than 3-6 months and failed to resolve with other treatments like physical therapy, medications, and injections.

The two main factors doctors consider when determining if a patient is a “good” candidate for spinal cord stimulation are:

  • Has the patient had back surgery, and
  • Has the pain been present for longer than 6 months after surgery?

If these two criteria are met then you’re likely a good candidate for spinal cord stimulation.

Here are other pain conditions that are likely to respond to spinal cord stimulation:

  • Chronic pain (pain lasting longer than 3-6 months) that radiates down the leg(s).
  • Chronic pain that has failed to respond to other treatments like physical therapy and injections.
  • Pain related to Chronic Regional Pain Syndrome (CRPS).

What is chronic back pain?

Chronic pain is defined as pain that has been present for 3-6 months. It is abnormal for pain to last longer than 3 months; therefore, once pain has become chronic, further evaluation is necessary to understand why the body is still sending pain signals. Chronic pain is less likely to resolve on its own and often requires treatment. Contrary to popular belief, back surgery is usually not required to alleviate chronic pain as minimally invasive treatments like spinal cord stimulation and nerve ablation have dramatically improved over the last 20 years and now provide superior pain relief with fewer risks when compared to back surgery. However, there are still instances where back surgery remains the gold standard treatment option.

What are the benefits of spinal cord stimulation?

The benefit of spinal cord stimulation is the ability to take back some control of your life. Many patients say that pain has significantly impacted their lives because they can no longer participate in simple activities like cooking, cleaning, or walking. Below are the major factors that make spinal cord stimulation different from other back pain treatments.

Effective When Other Treatments Fail

Spinal cord stimulation (SCS) results in meaningful pain relief for 50-70% percent of well-selected patients and has minor rates of complications (1).SCS can provide relief when doctors can’t isolate and treat a single “pain generator.

Trial Before Committing

Before a permanent spinal cord stimulator is inserted, a trial is performed to ensure adequate pain relief. One of the most unique aspects of spinal cord stimulation is the fact that patients can try the device for up to 7 days before committing to a long-term implant. The trial procedure takes place in an outpatient setting, only requires local or twilight anesthesia, and takes anywhere from 30-60 minutes. Patients can then go about their daily lives for up to 7 days. If patients aren’t comfortable with the device, or if the device does not provide adequate relief, the trial device is removed. Recovery from a stimulator trial is comparable to that of a routine epidural steroid injection.

Summary of current spinal cord stimulation research

Nearly 34,000 patients undergo spinal cord stimulator implants each year. In 1989, the Food and Drug Administration (FDA) approved SCS to relieve chronic pain. Since then, SCS technology has been tested in hundreds of studies, across thousands of patients and continues to improve.

Below are the major findings from 3 recent meta-analyses of randomized controlled trials on the efficacy of spinal cord stimulation. A “meta-analysis” is a study where researchers aggregate findings from all previous relevant studies to formulate stronger conclusions. A “randomized controlled trial” is a form of study design that produces the strongest, most reliable results in scientific research.

Increased the odds of reducing pain by 50% (2).

In patients with intractable spine/limb pain, spinal stimulation was associated with better pain reduction than medical therapy. New stimulation technology was likely associated with better pain reduction than conventional stimulation.

Results in a higher prevalence of patients going back to work compared with before treatment (3).

Chronic pain has a substantial negative impact on work‐related outcomes, which underscores the importance of interventions to reduce the burden. This meta-analysis concluded that SCS intervention resulted in a higher prevalence of patients at work compared with before treatment.

Increased odds of reducing pain medication consumption(4).

In patients with intractable spine/limb pain, SCS was associated with increased odds of reducing pain medication consumption.

What is the process of getting a spinal cord stimulator?

The four steps required to receive a spinal cord stimulator are outlined below.

Step 1: Evaluation by a Medical Doctor

If you have chronic back pain that has failed multiple therapies or have persistent back pain after spine surgery (failed back surgery syndrome), discuss spinal cord stimulation with your interventional pain doctor. An interventional pain doctor specializes in using non-surgical, minimally invasive procedures to reduce pain. If you are unsure if you’re a candidate for spinal cord stimulation, you can speak with an interventional pain doctor.

Step 2: Psychological Evaluation

Pain has a strong mental component. To ensure the best outcome possible, patients must undergo a psychological evaluation prior to beginning a spinal cord stimulator trial. The intent is to address any underlying issues related to anxiety or depression and make sure patients are comfortable living with an implantable device.

Step 3: Spinal Cord Stimulator Trial

Before a permanent spinal cord stimulator is inserted, a trial is performed to ensure adequate pain relief. Unlike the long-term implant, the temporary leads have an external stimulator device that can be easily disconnected. Over the next 3 to 7 days you will be able to see if the SCS works for managing your pain.

A spinal cord stimulator trial is considered successful if:

  • Your pain is reduced by at least 50%.
  • You’re able to return to activities that matter to you.
  • Your need for pain medication is reduced.
  • You’re able to relax and sleep better.

Step 4: Implantation

If the trial run is successful, a minimally invasive procedure is performed to place a permanent stimulator. During the procedure, the lead wires along the back of the vertebrae are connected to a pulse generator positioned just below the skin near the waistline. Most patients leave the day-of or the morning after their procedure.

Step 5: Recovery

The spinal cord stimulator is programmed before leaving the surgery center. Approximately 10 days after the procedure, the incision is checked to ensure adequate wound healing. Fine tuning of the device also occurs to ensure maximum pain relief.

What is recovery like after spinal cord stimulation?

Full recovery after spinal cord stimulation usually takes somewhere between 6 to 8 weeks. By 6 to 8 weeks the body has had time to heal the small incision where the spinal cord stimulator is inserted and has had time to fix the stimulator leads into place. During the healing process, you can carry out activities; however, don’t over do it. In the first two weeks after the procedure, it’s important to refrain from activities that require lifting objects weighing over 10 pounds, and doing physical activities that require twisting, bending, or climbing.

What are the risks associated with the procedure?

Occasionally patients experience device complications, such as a displaced lead, internally fractured electrode, or device malfunction. Major complications, however, are rare. Complication rates are lower when procedures are performed by an experienced practitioner. The medical problems most often seen are bleeding at the site of the implant, or infection. In such instances, removal of the device and antibiotic treatment are generally required. Infection rates can be as low as 1%, but may rise to 4% in some centers.

Does insurance cover spinal cord stimulation?

The good news is spinal cord stimulation (SCS) is covered by most major health insurers including Medicare, commercial payers, and most workers’ compensation programs. Medicaid coverage for SCS varies based on the state.

Many physicians offer out-of-pocket discounts for patients who do not have insurance but would still like to pursue treatment. Generally, the out-of-pocket cost is significantly lower for patients who do not have insurance.

What’s it like living with a spinal cord stimulator?

Living with a spinal cord stimulator is simple for most patients. Each patient has a remote control that allows easy programming of the stimulator based on your individual needs. Factors such as stimulation strength, duration, and body coverage can be changed.

You and your doctor will work to find your ideal settings for pain relief. Usually, you will have at least 3 different stimulator settings that can be changed throughout the day depending on what you are doing. Back pain often changes based on the activity (sitting versus standing), and the spinal cord stimulator can be programmed to deliver maximum relief based on the activity you are performing. Here are a few additional key points about living with a stimulator.

  1. Microwaves, cell phones, pagers, anti-theft sensors, and the like cannot damage your spinal cord stimulator.
  2. Your doctor will let you know if your type of stimulator is MRI compatible.
  3. Remember to carry your implanted medical device card at airports as the stimulator can be detected at airport security gates.

How do I pick a good doctor for spinal cord stimulation?

If you’re interested in spinal cord stimulation (SCS) try to pick a doctor who performs spinal cord stimulation regularly, i.e., they have significant procedural skill and judgement. When you call the clinic, don’t hesitate to ask the front desk personnel how frequently the doctor performs spinal cord stimulation. Additionally, look for doctors who are fellowship-trained in pain management. These doctors are usually highly skilled in the diagnosis and treatment of pain because they have spent an additional year of training exclusively within the field of pain management.

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