- Spinal cord stimulator
- What is Chronic Pain ?
- Managing your chronic back pain 1)
- What is Complex Regional Pain Syndrome ?
Spinal cord stimulator
Spinal cord stimulator is an implanted, rechargeable spinal cord stimulation system. Spinal cord stimulator device is to restore or supplement function of the nervous system lost during disease or injury 2).
Neurostimulator; SCS; Neuromodulation; Dorsal column stimulation; Chronic back pain – spinal stimulation; Complex regional pain – spinal stimulation; CRPS – spinal stimulation; Failed back surgery – spinal stimulation
Spinal cord stimulator is used for:
- Treatment of chronic pain of the trunk and/or limbs that is difficult to manage (intractable) 3).
Spinal cord stimulator is indicated to aid in the management of chronic intractable pain of the trunk and/or limbs 4).
Why the Procedure is Performed ?
Your doctor may recommend this procedure if you have:
- Back pain that continues or gets worse, even after surgery to correct it
- Complex regional pain syndrome (CRPS)
- Long-term (chronic) back pain, with or without arm or leg pain
- Nerve pain or numbness in the arms or legs
- Swelling (inflammation) of the lining of the brain and spinal cord
Spinal cord stimulator is used after you have tried other treatments such as medicines and exercise and they have not worked.
The main components include an implanted signal generator that is connected to one or two implanted leads, and externally worn transmitter that is doctor and patient controlled. The therapy utilizes pulsed electrical current to create an energy field that acts on nerves near the spinal column to block nerve impulses in the spine 5).
Stimulator placement is done in two stages. A trial (test) stage is done to see how well spinal cord stimulation works for you. If the trial stage is a success, the permanent stimulator system is put into place.
Spinal cord stimulator trial
A trial electrode will be put in first to see if it helps your pain.
- Your skin will be numbed with a local anesthetic.
- Wires (leads) will be placed under your skin and stretched into the space on top of your spinal cord (epidural space).
- These wires will be connected to a small current generator outside of your body that you carry like a cell phone.
- The procedure takes about 1 hour. You will be able to go home after the leads are placed.
If the treatment greatly reduces your pain, you will be offered a permanent generator. The generator will be implanted a few weeks later.
- You will be asleep and pain-free with general anesthesia.
- The generator will be inserted under the skin of your abdomen or buttocks through a small surgical cut.
- The procedure takes about 1 to 2 hours.
The generator runs on batteries. Some batteries are rechargeable. Others last 2 to 5 years. You will need another surgery to replace the battery.
Spinal cord stimulator complications
Risks of this surgery include any of the following 6):
- Cerebrospinal fluid (CSF) leakage
- Damage to the nerves that come out of the spine, causing paralysis, weakness, or pain that does not go away
- Infection of the battery or electrode site (if this occurs, the hardware usually needs to be removed)
- Movement of or damage to the generator or leads that requires more surgery
- Pain after surgery
- Problems with how the stimulator works, such as sending too strong of a signal, stopping and starting, or sending a weak signal
- The stimulator may not work
The spinal cord stimulator device may interfere with other devices, such as pacemakers and defibrillators. After the spinal cord stimulator is implanted, you may not be able to get an MRI anymore. Discuss this with your health care provider.
After the Procedure
After the permanent generator is placed, the surgical cut will be closed and covered with a dressing. You will be taken to the recovery room to wake up from the anesthesia.
Most people can go home the same day, but your surgeon may want you to stay overnight in the hospital. You will be taught how to care for your surgical site.
You should avoid heavy lifting, bending, and twisting while you are healing. Light exercise such as walking can be helpful during recovery.
- After the procedure you may have less back pain and will not need to take as much pain medicines. But, the treatment does not cure back pain or treat the source of the pain.
What is Chronic Pain ?
Pain is a signal in your nervous system that something may be wrong. It is an unpleasant feeling, such as a prick, tingle, sting, burn, or ache 7). Pain may be sharp or dull. You may feel pain in one area of your body, or all over.
There are two types: acute pain and chronic pain.
- Acute pain lets you know that you may be injured or a have problem you need to take care of. Acute pain should go away as your body heals 8).
- Chronic pain is different. The pain may last for weeks, months, or even years 9). There may have been an initial mishap — sprained back, serious infection, spinal cord injury or there may be an ongoing cause of pain — arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage. In some cases there is no clear cause. Environmental and psychological factors can make chronic pain worse.
Common chronic pain complaints include headache, low back pain, cancer pain, arthritis pain, neurogenic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself), psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside or outside the nervous system). A person may have two or more co-existing chronic pain conditions. Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.
Depression and stress tend to make pain worse, including chronic pain.
Many older adults have chronic pain. Women also report having more chronic pain than men, and they are at a greater risk for many pain conditions. Some people have two or more chronic pain conditions.
Chronic pain can occur anywhere in the body. People with chronic pain complain of 10):
- back pain
- cancer pain
- arthritis pain
- pain resulting from nerve damage.
The pain can be described as 11):
- a dull ache
Sometimes people with chronic pain have other symptoms. These could include feeling tired, having trouble sleeping, or mood changes. The pain itself often leads to other symptoms. These include low self-esteem, anger, depression, anxiety, or frustration.
Chronic pain is not always curable, but treatments can help. They include 12):
- Pain Relievers and other medicines
- Acupuncture and massage
- Electrical stimulation e.g. spinal cord stimulator, brain stimulation
- Physical therapy
- Relaxation and meditation therapy
- Behavior modification
- Some physicians use placebos, which in some cases has resulted in a lessening or elimination of pain.
Pain Relievers and Medicines
Pain relievers are medicines that reduce or relieve headaches, sore muscles, arthritis, or other aches and pains. There are many different pain medicines, and each one has advantages and risks. Some types of pain respond better to certain medicines than others. Each person may also have a slightly different response to a pain reliever.
Over-the-counter (OTC) medicines are good for many types of pain. There are two main types of OTC pain medicines: acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin, naproxen (Aleve), and ibuprofen (Advil, Motrin) are examples of OTC NSAIDs. If you take OTC pain medicines, make sure you do read and follow the instructions on the box.
If OTC medicines don’t relieve your pain, your doctor may prescribe something stronger or long-acting medicines for constant pain. Many NSAIDs are also available at higher prescription doses. The most powerful pain relievers are opioids. They are very effective, but they can sometimes have serious side effects. There is also a risk of addiction. Because of the risks, you must use them only under a doctor’s supervision.
There are many things you can do to help ease pain. Pain relievers are just one part of a pain treatment plan.
Your doctor might recommend a prescription pain reliever. Be sure to follow his or her instructions for how to take the medicine. Many prescription pain relievers are opioids. Opioids can be very effective when taken as directed. But many people who misuse opioids become addicted. Opioid addiction is a very serious health issue that can lead to death.
Managing your chronic back pain 13)
Managing chronic pain means finding ways to make your back pain tolerable so you can live your life. You may not be able to get rid of your pain completely, but you can change some things that worsen your pain. These things are called stressors. Some of them may be physical, like the chair you sit in at work. Some may be emotional, like a difficult relationship.
Reducing stress can improve your physical and emotional health. It is not always easy to reduce stress, but it’s easier if you are able to ask your friends and family for help.
Make a List
First, make a list of what makes your back pain better and what makes it worse.
Then try to make changes in your home and work to decrease the causes of your pain. For example, if bending to pick up heavy pots sends shooting pain down your back, rearrange your kitchen so that the pots are hanging from above or are stored at waist height.
If your back pain is worse at work, talk to your boss. It may be that your workstation isn’t set up correctly.
- If you sit at a computer, make sure that your chair has a straight back with an adjustable seat and back, armrests, and a swivel seat.
- Ask about having an occupational therapist assess your workspace or movements to see if changes such as a new chair or cushioned mat under your feet would help.
- Try not to stand for long periods. If you must stand at work, rest one foot on a stool, then the other foot. Keep switching the load of your body’s weight between your feet during the day.
Long car rides and getting in and out of the car can be hard on your back. Here are some tips:
- Adjust your car seat to make it easier to enter, sit in, and get out of your car.
- Bring your seat as far forward as possible to avoid leaning forward when you are driving.
- If you drive long distances, stop and walk around every hour.
- DO NOT lift heavy objects right after a long car ride.
These changes around your home could help relieve your back pain:
- Raise your foot up to the edge of a chair or stool to put your socks and shoes on instead of bending over. Also consider wearing shorter socks. They are quicker and easier to put on.
- Use a raised toilet seat or install handrail next to the toilet to help take pressure off your back when you sit on and get up from the toilet. Also make sure the toilet paper is easy to reach.
- DO NOT wear high-heeled shoes. If you must wear them sometimes, consider wearing comfortable shoes with flat soles to and from the event or until you must put on high-heels.
- Wear shoes with cushioned soles.
- Rest your feet on a low stool while you’re sitting so that your knees are higher than your hips.
Rely on Friends and Family
It is important to have strong relationships with family and friends you can depend on when your back pain makes it hard to get through the day.
Take time to build strong friendships at work and outside of work by using caring words and being kind. Give sincere compliments to the people around you. Respect those around you and treat them the way you like to be treated.
If a relationship is causing stress, consider working with a counselor to find ways to resolve conflict and strengthen the relationship
Establish Life Routines
Set up good life habits and routines such as:
- Exercise a little every day. Walking is a good way to keep your heart healthy and your muscles strong. If walking is too hard for you, work with a physical therapist to develop an exercise plan that you can do and maintain.
- Eat foods that are low in fats and sugar. Healthy foods make your body feel better, and they decrease your risk of being overweight, which can cause back pain.
- Reduce demands on your time. Learn how to say yes to things that are important and no to those that are not.
- Prevent pain from starting. Figure out what causes your back pain, and find other ways to get the job done.
- Take medicines as needed.
- Make time for activities that make you feel relaxed and calm.
- Give yourself extra time to get things done or to get where you need to go.
- Do things that make you laugh. Laughter can really help reduce stress.
- Getting regular sleep at night and not taking daytime naps should help.
- Stopping smoking also helps, because the nicotine in cigarettes can make some medicines less effective. Smokers also tend to have more pain than nonsmokers 14).
What is Complex Regional Pain Syndrome ?
Complex regional pain syndrome is an uncommon form of chronic pain that usually affects an arm or a leg 15). It causes intense pain, usually in the arms, hands, legs, or feet. It may happen after an injury, surgery, stroke or heart attack, but the pain is out of proportion to the severity of the initial injury. Rest and time may only make it worse. Treatment is likely to be most effective when started early in the course of the illness.
Symptoms in the affected area are 16):
- Dramatic changes in skin temperature, color, or texture. It often turns red, blue, purple, or blotchy.
- Change in skin texture. The skin over the affected area may become thin or shiny.
- Changes in hair and nail growth.
- Intense burning pain: a painful, burning feeling in the affected area usually an arm, leg, hand, or foot. It often occurs long past the time when your injury should have healed.
- Extreme skin sensitivity: the affected skin may be tender to the touch. It could be swollen and very sensitive to hot or cold temperatures.
- Swelling and stiffness in affected joints.
- Muscle spasms, pain and weakness.
- Decreased ability to move the affected body part
Symptoms may change over time and vary from person to person. Most commonly, pain, swelling, redness, noticeable changes in temperature and hypersensitivity (particularly to cold and touch) occur first. Some people’s symptoms are mild and eventually go away. For others, symptoms can be severe and cause long-term disability.
Over time, the affected limb can become cold and pale and undergo skin and nail changes as well as muscle spasms and tightening. Once these changes occur, the condition is often irreversible.
Complex regional pain syndrome occasionally may spread from its source to elsewhere in your body, such as the opposite limb. The pain may be worsened by emotional stress.
Complex regional pain syndrome occurs in two types, with similar signs and symptoms, but different causes 17):
- Type 1. Also known as reflex sympathetic dystrophy syndrome, this type occurs after an illness or injury that didn’t directly damage the nerves in your affected limb. About 90 percent of people with complex regional pain syndrome have type 1.
- Type 2. Once referred to as causalgia, this type follows a distinct nerve injury.
What causes complex regional pain syndrome ?
The cause of complex regional pain syndrome is unknown 18). However, it is believed that complex regional pain syndrome happens because of damage to the nervous system. It may happen if the nervous system malfunctions. In most cases, it is triggered by an injury or trauma. These could include:
- fractures or amputation
- burns, cuts, or bruises
- crush injury
- heart attacks
- minor procedures, such as a needle stick.
Anyone at any age can get complex regional pain syndrome. Many cases of complex regional pain syndrome occur after a forceful trauma to an arm or a leg, such as a crush injury, fracture or amputation. Other major and minor traumas — such as surgery, heart attacks, infections and even sprained ankles — also can lead to complex regional pain syndrome. Emotional stress may be a precipitating factor, as well.
It is more common in women. It seems to peak at around age 40. It is uncommon in children and rare in the elderly.
It’s not well-understood why these injuries can trigger complex regional pain syndrome, but it may be due to a dysfunctional interaction between your central and peripheral nervous systems and inappropriate inflammatory responses.
Complex regional pain syndrome is not predictable. The only way to prevent or avoid it is to try to avoid being injured.
The following measures may help you reduce the risk of developing complex regional pain syndrome:
- Taking vitamin C after a wrist fracture. Studies have shown that people who took a daily minimum dose of 500 milligrams (mg) of vitamin C after a wrist fracture had a lower risk of complex regional pain syndrome compared with those who didn’t take vitamin C.
- Early mobilization after a stroke. Some research suggests that people who get out of bed and walk around soon after a stroke (early mobilization) lower their risk of complex regional pain syndrome.
Complications of complex regional pain syndrome
If complex regional pain syndrome isn’t diagnosed and treated early, the disease may progress to more disabling signs and symptoms. These may include:
- Tissue wasting (atrophy). If you avoid moving an arm or a leg because of pain or if you have trouble moving a limb because of stiffness, your skin, bones and muscles may begin to deteriorate and weaken.
- Muscle tightening (contracture). You also may experience tightening of your muscles. This may lead to a condition in which your hand and fingers or your foot and toes contract into a fixed position.
How is complex regional pain syndrome diagnosed ?
There is not one specific test that can diagnose complex regional pain syndrome 19). Your doctor will diagnose complex regional pain syndrome based on your signs and symptoms. Some tests may be done to rule out another cause to your symptoms. An MRI can show changes in the tissue of the affected limb.
Complex regional pain syndrome treatment
There is no cure. It can get worse over time, and may spread to other parts of the body. Occasionally it goes away, either temporarily or for good. Treatment focuses on relieving the pain, and can include medicines, physical therapy, and nerve blocks.
A variety of therapies are commonly used to treat complex regional pain syndrome:
- Physical therapy. Keeping the body part moving increases circulation and promotes healing.
- Psychotherapy. People in chronic pain may develop mental health disorders. These include depression or anxiety. They can heighten pain. Psychotherapy helps you cope with the pain. It also helps you cope with any conditions that develop.
- Medicine. Your doctor may suggest that you take a nonsteroidal anti-inflammatory drug (NSAID). This can help with pain and inflammation. These medicines include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve). They are available over the counter. Talk to your doctor before using NSAIDs.
If your pain is severe, your doctor may prescribe medicines that block certain nerves. Sometimes steroids help swelling and pain. Some medicines used for depression and seizures also help chronic pain. Narcotics and other pain medicines may not control the pain of complex regional pain syndrome. Sometimes a combination of medicine is necessary.
Antidepressants and anticonvulsants. Sometimes antidepressants, such as amitriptyline, and anticonvulsants, such as gabapentin (Gralise, Neurontin), are used to treat pain that originates from a damaged nerve (neuropathic pain).
Corticosteroids. Steroid medications, such as prednisone, may reduce inflammation and improve mobility in the affected limb.
Bone-loss medications. Your doctor may suggest medications to prevent or stall bone loss, such as alendronate (Fosamax) and calcitonin (Miacalcin).
Intravenous ketamine. Studies show that low doses of intravenous ketamine, a strong anesthetic, may substantially alleviate pain. However, despite pain relief, there was no improvement in function.
Sympathetic nerve block. This is an injection of an anesthetic (pain reliever) to block pain fibers in your affected nerves may relieve pain in some people. This blocks the pain signals. If the injection relieves the pain, it may be repeated. It is not a cure.
Sympathectomy of the injured nerve. A surgeon will cut or clamp the nerve chain. This has been reported to improve pain caused by complex regional pain syndrome.
Applying heat and cold. Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.
Topical analgesics. Various topical treatments are available that may reduce hypersensitivity, such as capsaicin cream (Capsin, Capsagel, Zostrix) or lidocaine patches (Lidoderm, others).
Physical therapy. Gentle, guided exercising of the affected limbs may help decrease pain and improve range of motion and strength. The earlier the disease is diagnosed, the more effective exercises may be.
Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.
Biofeedback. In some cases, learning biofeedback techniques may help. In biofeedback, you learn to become more aware of your body so that you can relax your body and relieve pain.
Spinal cord stimulation. Your doctor inserts tiny electrodes along your spinal cord. A small electrical current delivered to the spinal cord results in pain relief.
Recurrences of complex regional pain syndrome do occur, sometimes due to a trigger such as exposure to cold or an intense emotional stressor. Recurrences may be treated with small doses of antidepressant or other medication.
A treatment that works for one person may not work for another. An individual treatment plan must be made for each person.
Living with complex regional pain syndrome
With early treatment, you may keep complex regional pain syndrome from getting worse. Sometimes the condition improves. If treatment is started early enough, the symptoms may completely go away. People with long-lasting, more severe symptoms often don’t respond to treatment. These people may benefit from a pain management program aimed specifically at dealing with chronic pain.
Take care of your physical and mental health by following these suggestions:
- Maintain normal daily activities as best you can.
- Pace yourself and be sure to get the rest that you need.
- Stay connected with friends and family.
- Continue to pursue hobbies that you enjoy and are able to do.
If complex regional pain syndrome makes it difficult for you to do things you enjoy, ask your doctor about ways to get around the obstacles.
Keep in mind that your physical health can directly affect your mental health. Denial, anger and frustration are common with chronic illnesses.
At times, you may need more tools to deal with your emotions. A therapist, behavioral psychologist or other professional may be able to help you put things in perspective. They also may be able to teach you coping skills, such as relaxation or meditation techniques.
Sometimes joining a support group, where you can share experiences and feelings with other people, is a good approach. Ask your doctor what support groups are available in your community.
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