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Download Daniel Kwon, MD - Advanced Interventional Options for Chronic Pain
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Advanced Interventional Options for Chronic Pain October 9, 2105 Daniel Kwon, MD Disclosure No Conflict of Interest Spinal Cord Stimulators (SCS) Implanted medical device that delivers electrical pulses to the nerves in the spinal cord that can interfere with transmission of chronic pain signals and replace them with a paresthesia-like sensation (some devices offer paresthesia free stimulation of the spinal cord) Manufacturers include: Boston Scientific, Medtronic, Nevro, and St. JudeMedical Mechanism of action not completely understood, but theories include: Effect on the dorsal horn level, including suppression of the wide-dynamic-range neurons. Activation of inhibitory GABA-ergic and cholinergic spinal interneurons, while decreasing glutamate at the dorsal horn Stimulation-induced suppression of central excitability Stimulation-induced inhibition of sympathetic nervous system influence Spinal Cord Stimulator Trial Appropriate patient selection. Different manufacturers have slightly different indications but generally the same: FDA approval includes: … “chronic intractable pain of the trunk and/or limbs, including unilateral or bilateral pain associated with the following: failed back surgery syndrome, intractable low back pain and leg pain.” Other indications include complex regional pain syndrome, reflex sympathetic dystrophy or caualgia. Initially spinal cord stimulator trial leads are placed temporarily for several days. If the patient has a positive test (50% or greater relief), then the system may be surgically implanted. Spinal Cord Stimulators (SCS) Procedural Surgically implanted generator in the body, often the hip/gluteal region Electrodes placed into the epidural space Spinal Cord Stimulators (SCS) Spinal Cord Stimulators (SCS) Intrathecal Drug Delivery (IT Pain Pump) This is a device that delivers medications directly to the spinal cord. The pump is generally implanted under the skin at the abdomen or posterior hip/gluteal region with a catheter that is tunneled into the spinal canal. FDA approved medications for IT drug delivery include baclofen, morphine, and ziconitide Manufacturers include Medtronic and Flowonix Intrathecal Drug Delivery (IT Pain Pump) FDA indications include treatment of chronic intractable pain and severe spasticity. Intrathecal Drug Delivery (IT Pain Pump) Conclusions Spinal Cord Stimulators and Intrathecal Pain Pumps have a role in management of chronic pain. However there is a significant risk associated with these interventional options, and a careful assessment of the risks and benefits needs to be performed prior to going forwards with these treatments.
