Spinal cord stimulation or “SCS” offers a non-opioid, FDA approved alternative for chronic pain treatments when other therapies such as physical therapy, medication, injections, or surgery have failed.
SCS blocks the pain signals traveling between the spinal cord and the brain. Stimulation is delivered by a neurostimulator energy source that sends impulses from the device to the spine over thin insulated wires called leads. The leads have contacts which deliver mild electrical impulses to an area near your spine to interrupt pain signals between your spinal cord and your brain.
Risks include infection, lead movement, pain at the implant site, and loss of effectiveness.
The trial lasts up to 7 to 10 days. Afterward, you will visit your doctor and have the temporary leads removed to decide if SCS is right for you.
You may experience some discomfort on your back where the leads were placed for up to 24 hours. This is temporary and should go away in the hours and days after the procedure. You might also experience some changes in stimulation intensity with certain activities during the trial stage which can be controlled with your handheld programming device.
The SCS trial lasts anywhere from 5 days to 14 days depending on what your doctor decides is best for you. During the trial, consider doing some of the things you would normally like to do and more.
A complication may occur during the trial. This includes bleeding into the epidural space, an infection, or other side effects. Do not undergo a trial if you have an active infection requiring antibiotics on the day of the procedure.
The implant procedure is similar to the trial procedure except, new leads will be placed in the same location near your spinal cord. In addition, the neurostimulator will be permanently implanted under your skin. The procedure is usually done in a hospital or surgery center as an outpatient. The procedure itself takes about 1-2 hours.
After the surgery, you will have incisional pain for approximately 5-7 days and pain medications will be prescribed for the short duration. Antibiotics will also be prescribed to reduce the risk of infection. During this time, you will be advised that you avoid certain activities, including those that involve lifting, bending, and twisting. You may also experience pain at the neurostimulator implant site for up to 10 days.
Once the procedural pain has subsided, your system will be turned on at the first follow up visit with your doctor to ensure that it’s working correctly. There are many stimulation settings available to help alleviate your pain. Your doctor will help you find the settings that are right for you.
Follow-up appointment after surgery is approximately 7 to 14 days after implant and 4 weeks after that. These are the postoperative visits to inspect incisions, change dressing, and lift the restrictions. Initially the neurostimulation system may require more frequent adjustments to meet the similar results as the trial period. These first few postoperative visits will be to adjust and personalize your therapy to achieve the best pain relief. You are in control of your stimulation, to make sure the therapy is meeting your needs.
The SCS implant process requires surgery which can have complications. Once the neurostimulation system is implanted, it’s possible that device complications may occur. Some of these complications include infection, bleeding into the epidural space, pain after surgery, and a risk of lead migration.
This procedure uses cooled radiofrequency energy through a probe to safely target the sensory nerves responsible for sending pain signals. A radiofrequency generator transmits a small current of RF energy through an insulated electrode, or probe, placed within tissue. Ionic heating, produced by the friction of charged molecules, thermally deactivates the nerves responsible for sending pain signals to the brain. RF energy heats and cools the tissue at the site of pain.
Radiofrequency can help treat pain located in the neck, low back, knee, hip, and shoulder.
PRP stands for platelet rich plasma and BMAC stands for bone marrow aspirate concentration. This therapy may be used to treat various acute and chronic pain conditions such as rotator cuff tear, tendonitis, muscle tears, sprain, trigger points, meniscus tear of the knee, mild to moderate degenerative arthritis of various joints, disorders of the spine especially facet joints. Your own blood is used to promote cellular repair. PRP and BMAC contain growth factors, platelets and other molecules from your own blood which help the body with healing. The natural healing takes place with the help of certain blood products such as platelets, neutrophils, monocyte macrophage, fibroblasts, endothelial cells. For PRP, approximately 15 mL of blood will be taken from your vein, and for BMAC arrproximately 40-60mL of blood is taken from the bone marrow. Blood is placed into a centrifuge to concentrate the healing components. Under sterile technique, local anesthetic will be used to numb the skin and the area of injection, and ultrasound or x-ray imaging will be used to inject the PRP or BMAC. Following needle removal, you will rest for 15 minutes in the exam room.
Peripheral Nerve Stimulation provides long lasting pain relief by blocking pain signals from reaching the brain. Nerve related pain is blocked by delivering a week electrical pulse through a small electrode which is placed with ultrasound guidance over the affected nerve. This therapy can be used to treat CRPS, occipital neuralgia, peripheral neuropathy, and other painful nerve injuries.
Targeted drug delivery is a safe and effective way to manage chronic pain or cancer pain with fewer side effects and lower drug doses compared to oral pain medications. Effective pain control is achieved by delivering medication directly to the surrounding spinal cord by means of a programmable drug reservoir. After a successful trial, the drug pump and catheter are implanted beneath the skin. Medication doses are adjusted through a programming device and patients can deliver medications when programmed by your doctor.
Lumbar spinal stenosis is when there is narrowing of the spinal canal due to degenerative changes of the spine. Narrowing may cause pain, numbness, tingling, weakness, and difficulty walking. Indirect spinal decompression, or the vertiflex procedure is the placement of a spacer device that is implanted in between the spinous processes of the lumbar spine to relieve the pressure on the nerves and to reduce the pain. This procedure is performed in an outpatient setting and the patient goes home the same day of the procedure.
Ketamine – Effects
The action of ketamine involves multiple mechanisms with multiple receptors. Ketamine is noncompetitive, reversible N-methyl-D-aspartate (NMDA) channel blocker which blocks the excited nerves, potentiates delta and mu opioid agonism and opioid potentiation, alters the nitric oxide guanosine monophosphate system, changes in cholinergic activity, and central dopamine and noradrenaline release. The NMDA channel blockade is especially unique to the mechanism of action of ketamine. This leads to quick onset of action (less than 5 minutes) and a short duration of activity when given in a single shot.
Indications of ketamine include anesthetic induction, maintenance, and perioperative pain management especially in patients with opioid tolerance, dependence or patients at risk of opioid related respiratory depression. Subanesthetic ketamine infusion are routinely used to treat complex regional pain syndrome and other causes of neuropathic pain. Ketamine has multiple systemic effects including central nervous system, cardiovascular system pulmonary system including the airways, and hepatic system. Side effects include nausea, headache, fatigue, dysphoria as well as dissociative experiences such as hallucination, delusion, or out of body experiences. These central nervous system side effects may be mitigated with use of benzodiazepine prior to ketamine use.
Phantom Limb Pain: Treatment
Post amputation pain (PAP) is a challenging constellation of painful disease states caused by the surgical or traumatic removal of a limb or appendage. The most common causes are vascular disease and trauma. The two most common causes of PAP are residual limb pain and phantom limb pain. Residual limb pain is often referred to as stump pain. This is pain which can be localized to the residual appendage after an amputation. There are multiple causes which include infections, soft tissue injuries, bony injuries, nerve lesions or neuromas, hematomas, and even local ischemia or poor healing. The treatment for stump pain is often treating the underlying cause. When identifiable anatomic pathology is identified, surgical exploration can be helpful. Also, neuroma injections have shown anecdotal benefit. Often times, this pain can be resolved by reviewing the fit of a prosthesis or through exercise based physical therapy. Often times, musculoskeletal issues can arise due to gait changes and prosthetic devices can cause irritation at the stump site which can be extremely uncomfortable.
While over 90% of patients do experience phantom sensations after an amputation, only about 80% experience phantom limb pain. This is described as dysesthesia in the absent part of the affected limb. While phantom limb pain is extremely common in this population, it is also extremely difficult to treat. While examination can rule out stump pain causes, it is rarely helpful in pointing to a cure of this disease. Many neuropathic pain medications such as tricyclic antidepressants, gabapentinoids, NMDA antagonists, and calcitonin have shown promise in the treatment for this disease.
Psychologic therapies such as cognitive behavioral therapy (CBT), hypnosis, and mirror therapy have shown some benefit for patients with this condition. TENS therapy has also been found to be effective. When conservative treatment have failed, interventional procedures like neuromodulation can be effective. Dorsal column stimulation has been shown effective in case series and other anecdotal data. More recently, dorsal root ganglion stimulation and peripheral stim is being studied specifically for phantom limb pain. While these technologies are exciting, we are still awaiting true, concrete evidence.