Pain struck 50-year-old Dawn Tavener as she strolled down a mountainside in France a few years ago. At the bottom of the slope, she could barely walk. Back home in California, she was diagnosed with a herniated disc that would require surgery. Sadly, what was supposed to be a three-hour procedure caused further nerve damage and turned into a two-week nightmare with one complication after another. Worst of all, the pain persisted after she left the hospital, making it impossible to work, drive, or sit comfortably.
Anthony Torres, a 36-year-old crane operator at a cargo port, was critically injured in an on-the-job accident. He had severe spinal, brain, and foot injuries, partial paralysis, balance issues, and unbearable back, leg, and foot pain.
Torres had numerous procedures to alleviate the pain, including the insertion of 10 screws and two rods, a titanium cage, L5-S1 vertebrae fusion, and 23 epidural injections. Nothing was successful in remedying the agonizing pain throughout his body.
In the past, most patients like Tavener and Torres could not foresee an end to their pain, but over the last 50 years, advances in spinal cord stimulation therapy have enabled people with chronic pain to return to everyday activities.
Neel Mehta, MD, director of the Weill Cornell Pain Medicine Center in New York City, is an advocate for spinal cord stimulation (SCS). “It is important to formulate a treatment plan that doesn’t simply rely on opioids,” he says. “We’re trying to give people a second chance at life.”
Spinal cord stimulation has proven effective for many chronic pain conditions. Previously recommended only after traditional first-line treatments (medication, chiropractic or physical therapy, and corrective surgery) had been ineffective, spinal cord stimulation is more often considered a primary option.
Timothy Deer, MD, president and CEO of the Center for Pain Relief in Charleston, West Virginia, identifies three situations in which surgeons may recommend spinal cord stimulation: when surgery has a 50/50 chance of success, when insurance companies deny spinal fusion for discogenic pain because they see better outcomes with spinal cord stimulation, or when spinal cord stimulation is believed to provide a better alternative to opioids.
Laura Tyler Perryman, chair and CEO of the medical device company Stimwave, says spinal cord stimulation systems have the potential to significantly reduce the lifetime cost of care for chronic pain patients, making the devices feasible and effective alternatives to pain medications.
What is spinal cord stimulation?
According to the International Neuromodulation Society, SCS, or neuromodulation, is “therapeutic interaction with the central, peripheral, or autonomic nervous system for therapeutic effect by means of targeted electrical stimulation or pharmacological delivery from implanted devices.”
Most spinal cord stimulation devices are small paddle-like pulse generators that are implanted through a minimally invasive surgical procedure into the opening between the spine and the spinal cord, in the area where the pain occurs. In some spinal cord stimulation models, electrical contacts connect the paddle to a battery implanted under the skin. However, more recent devices are wireless. A clinician initially programs the device, and patients then use a wireless remote to control the level of stimulation being delivered by the pulse generator.
Michael Kaplitt, MD, PhD, associate professor of neurological surgery and associate attending neurosurgeon at New York’s Memorial Sloan-Kettering Cancer Center and New York-Presbyterian/Weill Cornell, says the idea behind spinal cord stimulation is to trick the brain into feeling an alternate sensation to pain and ultimately to block the electrical signal of the pain neuron to the spine and brain. Here’s how it works.
The nervous system is made up of the central nervous system, which is comprised of the brain and the spinal cord, and the peripheral nervous system, which includes all the nerves that branch out from the spinal cord.
The thalamus, in the lower part of the brain, relays sensory impulses from receptors in different parts of the body to the higher part of the brain (the central cortex within the central nervous system). It is in the central cortex where sensations are interpreted as touch, pain, or temperature. The thalamus serves as a “gateway” of sorts, filtering which information is relayed for processing. Therefore, by stimulating the thalamus, the brain can be tricked into feeling an alternative sensation to pain.
Older spinal cord stimulation devices would send low levels of electrical energy to nerve fibers, replacing pain with a tingling or warm sensation, therefore preventing pain signals from reaching the brain. The most recent spinal cord stimulation devices operate at high frequencies that are not felt by patients at all, and yet they provide the same relief as when patients are distracted by alternative sensations.
Within the peripheral nervous system, special nerve cell clusters called dorsal root ganglion (DRG) help transmit the sensory messages of pain and touch. The DRG, lying at the base of individual branching spinal nerves, very close to the spinal cord itself, transmit sensory information from the skin to the spinal cord. In 2016, the U.S. Food and Drug Administration approved the first spinal cord stimulation system, Axium from St. Jude Medical, to treat pain from the DRG. (See “Five Spinal Cord Stimulators.”)
When to opt for spinal cord stimulation
People who have back surgery but don’t experience quick relief should give themselves time to heal, says Mehta, but they shouldn’t wait too long to consider spinal cord stimulation if they continue to have chronic pain.
One study found that family physicians treat patients for an average of 3.13 years before referring them for spinal cord stimulation. The time lag allows pain to become ingrained in the body and causes many physiological changes.
“If the body is used to being in pain, it gets used to sending pain signals and in fact becomes more efficient at doing so,” says Mehta. “It’s just like if your house keeps getting robbed: You install an alarm system and you become more alert. Things like muscles and joints that would usually not hurt begin to hurt.”
This unrelieved pain can also lead to psychological damage such as depression, anger, and frustration, since the patient can see no end to the pain. Mehta explains that the longer the pain is left to wreak havoc on the body, the harder it is to resolve. In fact, research shows that spinal cord stimulation is far more effective when it’s started between six months to a year after conventional treatments failed.
Fortunately, people who endure long battles with chronic pain can benefit from spinal cord stimulation. For instance, Deer recalls a 54-year-old man who had a laminectomy (an operation to remove the back of one or more vertebrae to relieve pressure on the spinal cord or nerves) in 2003.
His back and leg pain persisted, and he agreed to spinal fusion surgery in 2014 and again in 2015. Frustrated with unrelieved pain and the side effects of opioids, he met with Deer and was offered a trial spinal cord stimulation implant. Less than a week after receiving the device, his pain was reduced 70%. After 12 weeks with a permanent implant, he achieved an 80% reduction in pain. The man was soon able to gradually reduce his pain medications and has resumed his active lifestyle.
After Dawn Tavener, who injured her back in France, had an spinal cord stimulation device implanted, the relief from her pain was almost immediate. When Mehta came to check on her the morning following the procedure, he found her dressed and sitting in a chair — something she had been unable to do for almost two years. Later, she and her husband returned to the mountains in France, leaving a painful ordeal behind her.
In November 2015, Anthony Torres had a successful spinal cord stimulation device trial for the relief of his injury-induced chronic pain. “The best thing is that it gave me relief from the pain and allowed me to get off the pain medications,” he says.
Spinal cord stimulation may be the answer for people whose lives have been seriously inhibited by pain. Although not a cure or panacea, it offers many advantages: cost-effective treatment at lower lifetime health-care cost; better long-term outcomes; a minimally invasive procedure that is fully reversible; and the ability to reduce the need for strong, addictive pain medication.
In addition, according to Mehta, the scope of spinal cord stimulation is continuing to grow. Recent trials are exploring its use in control of the bladder or anal sphincter and in producing movement in people with spinal cord injuries. With such clear benefits, spinal cord stimulation holds much promise and hope for people struggling with life-limiting pain.
Want to learn more about technology that can help to reduce pain? Read “How Technology Helps More People Live Pain Free.”