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National Hospital for Neurology and Neurosurgery National Hospital for Neurology and Neurosurgery Nevro™ spinal cord stimulation Pain Management Centre If you would like this document in another language or format, or require the services of an interpreter, contact us on 020 3448 2380. We will do our best to meet your needs. Contents What is Nevro™ spinal cord stimulation? 3 How can Nevro™ spinal cord stimulation help? What alternative treatments are available? What will happen if I decide not to have this procedure? 4 What are the risks of Nevro™ spinal cord stimulation? 5 Safety and Precautions 6 Short-wave diathermy 7 Asking for your consent 7 How should I prepare for this procedure? 8 Implant programme 8 What happens during this procedure? 9 What should I expect after this procedure? 10 Where can I get more information? 12 Contact details 12 Where to find us 13 2 4 4 This booklet has been written by the Pain Management Team at The National Hospital for Neurology and Neurosurgery. It is intended for patients (or their family or carers) who have been referred to our service and may be offered this procedure. It is not intended to replace discussion with your consultant. If you have any questions about Nevro™ spinal cord stimulation, please do not hesitate to contact a member of our team. They will be happy to answer them for you. What is Nevro™ spinal cord stimulation? Spinal cord stimulation (SCS) systems have been in use for more than 30 years to treat chronic pain. It works by delivering mild electrical impulses that interrupt pain signals to the brain, and replaces them with a tingling sensation that covers the specific areas where pain is perceived. SCS has been used to treat a wide range of chronic pain conditions, such as failed back syndrome, neuropathic (nerve) pain and complex regional pain syndrome. In 2011 Nevro™ SCS system was introduced and is the first SCS system that can treat chronic pain without the need for the patient to feel the tingling sensation. The Nevro™ system has also been shown not only to treat limb pain but to reduce low back pain. 3 How can Nevro™ spinal cord stimulation help? You may experience improvement in your pain symptoms and quality of life. You may feel more able to function and participate in activities of daily living. It may also be possible for you to take less pain medications. What alternative treatments are available? SCS is usually reserved for patients who have severe chronic pain that is limiting their daily activity and who have already tried all reasonable, more conservative therapies. The pain management centre offer treatments which include a variety of injections, psychological approaches, physiotherapy, TENS (transcutaneous electronic nerve stimulation), medicines and acupuncture. We are happy to discuss your options in detail to help you choose the best treatment for you. What will happen if I decide not to have this procedure? The decision to go ahead with this treatment is entirely yours. If you choose not to proceed we will discuss other treatment options and the management of your symptoms with your doctor. This will not affect further treatment in any way. 4 What are the risks of Nevro™ spinal cord stimulation? All treatments and procedures have risks and we will talk to you about the risks of this procedure. We do not have the exact percentages for these risks but we can group them into common, less common and very rare. It is common to feel some minor discomfort after the procedure which may require a short course of pain killers. Less common risks include: Painful battery or connection site. If this is severe, further surgery or removal of system may be advised. Infection. If this happens, the whole system may need to be removed. Bleeding, which may lead to minor bruising and in very rare cases may require further surgery. It is possible to puncture the membrane around the spinal cord during the procedure causing a leak of fluid which can result in severe headaches. These headaches generally get better once the leak is sealed but may require further treatment in rare cases. The leads may move or stop working. This may require another operation to replace the lead. You may feel stimulation outside the area of pain, but this is only a problem if unpleasant. 5 Failure to capture the area of pain, or no pain relief, which may lead to consideration of further surgery to re-site the leads or remove the system. There are other problems which are very rare but more serious. These include: Needle damage to the spinal cord or nerves. Bleeding and compression of the spinal cord. This can result in nerve damage which may be permanent and very difficult to treat effectively. Not everyone responds to SCS in the same way and your experience may vary. It is important to understand that spinal cord stimulation is not a cure for your pain, but may help you to manage your pain more effectively and improve your function. Safety and Precautions You should always carry an ID card that will be provided by the hospital once you have the stimulator implanted. Once you have a stimulator device implanted there are some things you should know about that may affect the device. Some types of body scanners can interfere with your spinal cord stimulator. Generally, you should not have an MRI scan. Normal x-rays and CT (computerised tomography) scans are generally safe. Other scanners in airports and in 6 some shops can also change the settings of a spinal cord stimulator. In general, any sign that gives a warning for people with heart pacemakers also applies to people with spinal cord stimulators. Short-wave diathermy Some health care professionals, such as physiotherapists, use a treatment called ‘short-wave diathermy’. This treatment can be dangerous for people who have a spinal cord stimulator. If at any time you develop a problem with your spinal cord stimulator or have any concerns you should contact the pain management centre. Asking for your consent We want to involve you in all decisions about your care and treatment. If you decide to go ahead with this procedure, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak to a senior member of staff again. 7 How should I prepare for this procedure? If you and your pain doctor decide that this is the right treatment option for your pain they will enter you onto a care pathway. You will first be seen by a medical doctor who will determine whether your pain is suitable for spinal cord stimulation. Once you have decided you would like to have this treatment you will be entered into an implant patient programme. Implant programme The programme is designed to: Provide you with information on the procedure and potential risks and benefits Increase your understanding of chronic pain and spinal cord stimulation Increase the effectiveness of spinal cord stimulation treatment Work on maximising your physical fitness and function Help you to work to realistic goals Maximise psychological well being Help you meet other patients who have similar experiences Provide support in decision making 8 You will also have the opportunity to learn about the components of the system and what they look like. Once you have completed the implant programme you will be put on the waiting list for the procedure, and you will be contacted when a date becomes available. You will then also be assessed by the Pre – operative Assessment Centre team prior to coming into hospital to prepare you for the procedure. You will be asked to stop any blood thinning medication such as warfarin, aspirin, and clopidogrel. The pain management nursing team will advise you of alternatives to these medications in the event that you need to continue with these treatments. Please do not stop any medications until you have been advised how and when to do so. You will need to fast before this procedure. You should not eat for at least six hours and have nothing to drink for up to two hours beforehand. As this procedure is usually a day case admission you will be asked to bring someone with you to make sure you get home safely. Alternatively you may be admitted into hospital for a stay of one or more nights. What happens during this procedure? The spinal cord stimulator system will be implanted in a theatre environment using x-ray guidance. The procedure can be done under sedation and with local anaesthetic, or under general anaesthetic. A small incision will be made in 9 your back to implant the lead under your skin in the epidural space. Another incision will be made in either your abdomen or buttock depending on which site you choose for your battery to be implanted. The battery will be positioned under your skin. After the procedure you will spend a short time in the recovery room before going back to your ward. When you are fully awake a specialist pain nurse will teach you how to switch your stimulator on and off. The nurse can also use a special computer to programme your lead to deliver the stimulation to the right area of pain. When you are fully recovered you will be allowed to go home. Most patients will be able to go home on the day of the procedure. If the procedure is scheduled for the afternoon you may be required to stay in hospital overnight. What should I expect after this procedure? When you get home after the procedure you should rest for the day. Do not attempt to drive, or go to work. You should aim to limit the amount of bending and twisting you do. This will reduce the risk of the lead moving out of place. It usually takes up to three to six weeks for the lead to be fully secure, but you will be able to move around freely as long as you are careful not to bend to pick things up or turn or twist your back. You should also avoid heavy lifting. 10 Any suture or clips can usually be removed in ten days time following the surgery. This can be done by your GP or practice nurse. If you notice any redness or swelling around the wound site or near to the implant you will need to contact us as soon as possible. This may require further assessment and in some cases a course of antibiotics if an infection is present. You will need to see your GP first and then contact the Pain Management Centre during working hours Monday to Friday, 9am to 5pm. Outside normal working hours you should visit your local accident and emergency (A&E) department. If your stimulator stops working or require advice concerning the stimulator, you can contact one of the specialist nurses who will see you in normal working hours. Ongoing care You will be seen by a specialist nurse in clinic six weeks after the insertion of your stimulator. The first appointment will be to check the wounds have healed and that the spinal cord stimulator is working at an optimal level. Regular follow-up is necessary to ensure that the spinal cord stimulation continues to work effectively and also to measure the battery life. You will also attend the group sessions at three months, six months and 12 months. 11 If your stimulator stops working or require advice concerning the stimulator you can contact one of the specialist nurses who will see you during normal working hours. Where can I get more information? British Pain Society Information about spinal cord stimulation for the management of pain: recommendations for best clinical practice. www.britishpainsociety.org UCL Hospitals cannot accept responsibility for information provided by other organisations. Contact details The Pain Management Centre The National Hospital for Neurology and Neurosurgery at Cleveland Street 25 Cleveland Street London W1T 4JA Direct Line: 020 3448 4776 Switchboard: 0845 155 5000 / 020 3456 7890 Fax: 020 3448 3511 12 Where to find us 13 Space for notes and questions 14 15 Publication date: June 2016 Date last reviewed: June 2016 Date next review due: June 2018 Leaflet code: UCLH/NHNN/PM/NEVRO/1 © University College London Hospitals NHS Foundation Trust 2013 16