Korean J Pain.  2020 Apr;33(2):99-107. 10.3344/kjp.2020.33.2.99.

Spinal cord stimulation in chronic pain: technical advances

• Isagulyan E
• Slavin K
• Konovalov N
• Dorochov E
• Tomsky A
• Dekopov A
• Makashova E
• Isagulyan D
• Genov P

• KMID: 2502633
• DOI: http://doi.org/10.3344/kjp.2020.33.2.99

Abstract

Chronic severe pain results in a detrimental effect on the patient’s quality of life. Such patients have to take a large number of medications, including opioids, often without satisfactory effect, sometimes leading to medication abuse and the pain worsening. Spinal cord stimulation (SCS) is one of the most effective technologies that, unlike other interventional pain treatment methods, achieves long-term results in patients suffering from chronic neuropathic pain. The first described mode of SCS was a conventional tonic stimulation, but now the novel modalities (high-frequency and burst), techniques (dorsal root ganglia stimulations), and technical development (wireless and implantable pulse generator-free systems) of SCS are becoming more popular. The improvement of SCS systems, their miniaturization, and the appearance of new mechanisms for anchoring electrodes results in a significant reduction in the rate of complications and revision surgeries, and the appearance of new waves of stimulation allows not only to avoid the phenomenon of addiction, but also to improve the long-term results of chronic SCS. The purpose of this review is to describe the current condition of SCS and up-to-date technical advances.

Keyword

Chronic Pain; Complex Regional Pain Syndromes; Failed Back Surgery Syndrome; Low Back Pain; Neck Pain; Neuralgia; Pain; Pain Management; Spinal Cord Stimulation

Figure

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  Fig. 1 Stimulation patterns in tonic (conventional) and burst stimulations.

Reference

1. Torrance N, Ferguson JA, Afolabi E, Bennett MI, Serpell MG, Dunn KM, et al. 2013; Neuropathic pain in the community: more under-treated than refractory? Pain. 154:690–9. DOI: 10.1016/j.pain.2012.12.022. PMID: 23485369. PMCID: PMC3630326.

2. Shoskes DA, Katz E. 2005; Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep. 6:296–9. DOI: 10.1007/s11934-005-0027-0. PMID: 15978233.

3. Peckham AM, Fairman KA, Sclar DA. 2017; Prevalence of gabapentin abuse: comparison with agents with known abuse potential in a commercially insured US population. Clin Drug Investig. 37:763–73. DOI: 10.1007/s40261-017-0530-3. PMID: 28451875.

4. Melzack R, Wall PD. 1965; Pain mechanisms: a new theory. Science. 150:971–9. DOI: 10.1126/science.150.3699.971. PMID: 5320816.

5. Vannemreddy P, Slavin KV. 2011; Spinal cord stimulation: current applications for treatment of chronic pain. Anesth Essays Res. 5:20–7. DOI: 10.4103/0259-1162.84174. PMID: 25885295. PMCID: PMC4173369.

6. Krames ES, Foreman R. 2007; Spinal cord stimulation modulates visceral nociception and hyperalgesia via the spinothalamic tracts and the postsynaptic dorsal column pathways: a literature review and hypothesis. Neuromodulation. 10:224–37. DOI: 10.1111/j.1525-1403.2007.00112.x. PMID: 22150836.

7. Ultenius C, Song Z, Lin P, Meyerson BA, Linderoth B. 2013; Spinal GABAergic mechanisms in the effects of spinal cord stimulation in a rodent model of neuropathic pain: is GABA synthesis involved? Neuromodulation. 16:114–20. DOI: 10.1111/ner.12007. PMID: 23240579.

8. Jeon YH. 2012; Spinal cord stimulation in pain management: a review. Korean J Pain. 25:143–50. DOI: 10.3344/kjp.2012.25.3.143. PMID: 22787543. PMCID: PMC3389317.

9. Cook AW. 1976; Letter: percutaneous trial for implantable stimulating devices. J Neurosurg. 44:650–1. DOI: 10.3171/jns.1976.44.5.0650.

10. Lind AL, Emami Khoonsari P, Sjödin M, Katila L, Wetterhall M, Gordh T, et al. 2016; Spinal cord stimulation alters protein levels in the cerebrospinal fluid of neuropathic pain patients: a proteomic mass spectrometric analysis. Neuromodulation. 19:549–62. DOI: 10.1111/ner.12473. PMID: 27513633.

11. Slavin KV. 2014; Spinal stimulation for pain: future applications. Neurotherapeutics. 11:535–42. DOI: 10.1007/s13311-014-0273-2. PMID: 24696306. PMCID: PMC4121441.

12. Shim JH. 2013; Spinal cord stimulation: panacea for incurable diseases? Korean J Anesthesiol. 65:103–4. DOI: 10.4097/kjae.2013.65.2.103. PMID: 24023989. PMCID: PMC3766772.

13. Smith BH, Torrance N, Ferguson JA, Bennett MI, Serpell MG, Dunn KM. 2012; Towards a definition of refractory neuropathic pain for epidemiological research. An international Delphi survey of experts. BMC Neurol. 12:29. DOI: 10.1186/1471-2377-12-29. PMID: 22640002. PMCID: PMC3476440.

14. Slangen R, Schaper NC, Faber CG, Joosten EA, Dirksen CD, van Dongen RT, et al. 2014; Spinal cord stimulation and pain relief in painful diabetic peripheral neuropathy: a prospective two-center randomized controlled trial. Diabetes Care. 37:3016–24. DOI: 10.2337/dc14-0684. PMID: 25216508.

15. Zipes DP, Svorkdal N, Berman D, Boortz-Marx R, Henry T, Lerman A, et al. 2012; Spinal cord stimulation therapy for patients with refractory angina who are not candidates for revascularization. Neuromodulation. 15:550–8. DOI: 10.1111/j.1525-1403.2012.00452.x. PMID: 22494013.

16. Özdemir İ, Akbaş M, Yeğin A, Dağıstan G, Erkan DÖ. 2017; [Spinal cord stimulation in 62 patients: retrospective evaluation]. Agri. 29:25–32. Turkish.

17. Kapural L, Nagem H, Tlucek H, Sessler DI. 2010; Spinal cord stimulation for chronic visceral abdominal pain. Pain Med. 11:347–55. DOI: 10.1111/j.1526-4637.2009.00785.x. PMID: 20088856.

18. Kapural L, Cywinski JB, Sparks DA. 2011; Spinal cord stimulation for visceral pain from chronic pancreatitis. Neuromodulation. 14:423–6. DOI: 10.1111/j.1525-1403.2011.00381.x. PMID: 21854493.

19. Isagulyan ED, Shabalov VA. 2014; Chronic electrical stimulation of the spinal cord in the treatment of failed back surgery syndrome. Hir Pozvonoc. 3:41–8. Russian. DOI: 10.14531/ss2014.4.41-48.

20. Taylor RS, Van Buyten JP, Buchser E. 2005; Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: a systematic review and analysis of prognostic factors. Spine (Phila Pa 1976). 30:152–60. DOI: 10.1097/01.brs.0000149199.68381.fe. PMID: 15626996.

21. Kumar K, North R, Taylor R, Sculpher M, Van den Abeele C, Gehring M, et al. 2005; Spinal cord stimulation vs. conventional medical management: a prospective, randomized, controlled, multicenter study of patients with failed back surgery syndrome (PROCESS study). Neuromodulation. 8:213–8. DOI: 10.1111/j.1525-1403.2005.00027.x. PMID: 22151547.

22. Imran TF, Malapero R, Qavi AH, Hasan Z, de la Torre B, Patel YR, et al. 2017; Efficacy of spinal cord stimulation as an adjunct therapy for chronic refractory angina pectoris. Int J Cardiol. 227:535–42. DOI: 10.1016/j.ijcard.2016.10.105. PMID: 27836302.

23. Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Leong M, et al. 2014; The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee. Neuromodulation. 17:515–50. DOI: 10.1111/ner.12208. PMID: 25112889.

24. Slangen R, Faber CG, Schaper NC, Joosten EA, van Dongen RT, Kessels AG, et al. 2017; A trial-based economic evaluation comparing spinal cord stimulation with best medical treatment in painful diabetic peripheral neuropathy. J Pain. 18:405–14. DOI: 10.1016/j.jpain.2016.11.014. PMID: 27965045.

25. Duarte RV, Andronis L, Lenders MW, de Vos CC. 2016; Quality of life increases in patients with painful diabetic neuropathy following treatment with spinal cord stimulation. Qual Life Res. 25:1771–7. DOI: 10.1007/s11136-015-1211-4. PMID: 26694963. PMCID: PMC4893357.

26. van Beek M, Slangen R, Schaper NC, Faber CG, Joosten EA, Dirksen CD, et al. 2015; Sustained treatment effect of spinal cord stimulation in painful diabetic peripheral neuropathy: 24-month follow-up of a prospective two-center randomized controlled trial. Diabetes Care. 38:e132–4. DOI: 10.2337/dc15-0740. PMID: 26116722.

27. Taylor RS, Van Buyten JP, Buchser E. 2006; Spinal cord stimulation for complex regional pain syndrome: a systematic review of the clinical and cost-effectiveness literature and assessment of prognostic factors. Eur J Pain. 10:91–101. DOI: 10.1016/j.ejpain.2005.02.004. PMID: 16310712.

28. Stanton-Hicks M. 2006; Complex regional pain syndrome: manifestations and the role of neurostimulation in its management. J Pain Symptom Manage. 31(4 Suppl):S20–4. DOI: 10.1016/j.jpainsymman.2005.12.011. PMID: 16647591.

29. Barolat G, Oakley JC, Law JD, North RB, Ketcik B, Sharan A. 2001; Epidural spinal cord stimulation with a multiple electrode paddle lead is effective in treating intractable low back pain. Neuromodulation. 4:59–66. DOI: 10.1046/j.1525-1403.2001.00059.x. PMID: 22151612.

30. North RB, Kidd DH, Farrokhi F, Piantadosi SA. 2005; Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 56:98–106. DOI: 10.1227/01.NEU.0000144839.65524.E0. PMID: 15617591.

31. Al-Kaisy A, Van Buyten JP, Smet I, Palmisani S, Pang D, Smith T. 2014; Sustained effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with chronic, low back pain: 24-month results of a prospective multicenter study. Pain Med. 15:347–54. DOI: 10.1111/pme.12294. PMID: 24308759. PMCID: PMC4282782.

32. Deer T, Slavin KV, Amirdelfan K, North RB, Burton AW, Yearwood TL, et al. 2018; Success Using Neuromodulation with BURST (SUNBURST) study: results from a prospective, randomized controlled trial using a novel burst waveform. Neuromodulation. 21:56–66. DOI: 10.1111/ner.12698. PMID: 28961366.

33. Kapural L, Yu C, Doust MW, Gliner BE, Vallejo R, Sitzman BT, et al. 2016; Comparison of 10-kHz high-frequency and traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: 24-month results from a multicenter, randomized, controlled pivotal trial. Neurosurgery. 79:667–77. DOI: 10.1227/NEU.0000000000001418. PMID: 27584814. PMCID: PMC5058646.

34. Thomson SJ, Tavakkolizadeh M, Love-Jones S, Patel NK, Gu JW, Bains A, et al. 2018; Effects of rate on analgesia in kilohertz frequency spinal cord stimulation: results of the PROCO randomized controlled trial. Neuromodulation. 21:67–76. DOI: 10.1111/ner.12746. PMID: 29220121. PMCID: PMC5814855.

35. De Andres J, Monsalve-Dolz V, Fabregat-Cid G, Villanueva-Perez V, Harutyunyan A, Asensio-Samper JM, et al. 2017; Prospective, randomized blind effect-on-outcome study of conventional vs high-frequency spinal cord stimulation in patients with pain and disability due to failed back surgery syndrome. Pain Med. 18:2401–21. DOI: 10.1093/pm/pnx241. PMID: 29126228.

36. Al-Kaisy A, Palmisani S, Smith TE, Pang D, Lam K, Burgoyne W, et al. 2017; 10 kHz high-frequency spinal cord stimulation for chronic axial low back pain in patients with no history of spinal surgery: a preliminary, prospective, open label and proof-of-concept study. Neuromodulation. 20:63–70. DOI: 10.1111/ner.12563. PMID: 28025843.

37. Kinfe TM, Pintea B, Link C, Roeske S, Güresir E, Güresir Á, et al. 2016; High frequency (10 kHz) or burst spinal cord stimulation in failed back surgery syndrome patients with predominant back pain: preliminary data from a prospective observational study. Neuromodulation. 19:268–75. DOI: 10.1111/ner.12379. PMID: 26762585.

38. Muhammad S, Roeske S, Chaudhry SR, Kinfe TM. 2017; Burst or high-frequency (10 kHz) spinal cord stimulation in failed back surgery syndrome patients with predominant back pain: one year comparative data. Neuromodulation. 20:661–7. DOI: 10.1111/ner.12611. PMID: 28544182.

39. Lambru G, Trimboli M, Palmisani S, Smith T, Al-Kaisy A. 2016; Safety and efficacy of cervical 10 kHz spinal cord stimulation in chronic refractory primary headaches: a retrospective case series. J Headache Pain. 17:66. DOI: 10.1186/s10194-016-0657-2. PMID: 27393015. PMCID: PMC4938814.

40. Arcioni R, Palmisani S, Mercieri M, Vano V, Tigano S, Smith T, et al. 2016; Cervical 10 kHz spinal cord stimulation in the management of chronic, medically refractory migraine: a prospective, open-label, exploratory study. Eur J Pain. 20:70–8. DOI: 10.1002/ejp.692. PMID: 25828556.

41. Arle JE, Mei L, Carlson KW, Shils JL. 2016; High-frequency stimulation of dorsal column axons: potential underlying mechanism of paresthesia-free neuropathic pain relief. Neuromodulation. 19:385–97. DOI: 10.1111/ner.12436. PMID: 27145196.

42. Cuellar JM, Alataris K, Walker A, Yeomans DC, Antognini JF. 2013; Effect of high-frequency alternating current on spinal afferent nociceptive transmission. Neuromodulation. 16:318–27. DOI: 10.1111/ner.12015. PMID: 23252766.

43. Russo M, Verrills P, Mitchell B, Salmon J, Barnard A, Santarelli D. 2016; High frequency spinal cord stimulation at 10 kHz for the treatment of chronic pain: 6-month Australian clinical experience. Pain Physician. 19:267–80.

44. Hou S, Kemp K, Grabois M. 2016; A systematic evaluation of burst spinal cord stimulation for chronic back and limb pain. Neuromodulation. 19:398–405. DOI: 10.1111/ner.12440. PMID: 27139915.

45. Kriek N, Groeneweg G, Huygen FJ. 2015; Burst spinal cord stimulation in a patient with complex regional pain syndrome: a 2-year follow-up. Pain Pract. 15:E59–64. DOI: 10.1111/papr.12295. PMID: 25858033.

46. De Ridder D, Plazier M, Kamerling N, Menovsky T, Vanneste S. 2013; Burst spinal cord stimulation for limb and back pain. World Neurosurg. 80:642–9. DOI: 10.1016/j.wneu.2013.01.040. PMID: 23321375.

47. Schu S, Slotty PJ, Bara G, von Knop M, Edgar D, Vesper J. 2014; A prospective, randomised, double-blind, placebo-controlled study to examine the effectiveness of burst spinal cord stimulation patterns for the treatment of failed back surgery syndrome. Neuromodulation. 17:443–50. DOI: 10.1111/ner.12197. PMID: 24945621.

48. Julius D, Basbaum AI. 2001; Molecular mechanisms of nociception. Nature. 413:203–10. DOI: 10.1038/35093019. PMID: 11557989.

49. Scholz J, Woolf CJ. 2007; The neuropathic pain triad: neurons, immune cells and glia. Nat Neurosci. 10:1361–8. DOI: 10.1038/nn1992. PMID: 17965656.

50. Deer TR, Levy RM, Kramer J, Poree L, Amirdelfan K, Grigsby E, et al. 2017; Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial. Pain. 158:669–81. DOI: 10.1097/j.pain.0000000000000814. PMID: 28030470. PMCID: PMC5359787.

51. Eldabe S, Burger K, Moser H, Klase D, Schu S, Wahlstedt A, et al. 2015; Dorsal root ganglion (DRG) stimulation in the treatment of phantom limb pain (PLP). Neuromodulation. 18:610–6. DOI: 10.1111/ner.12338. PMID: 26268453.

52. Weiner RL, Yeung A, Montes Garcia C, Tyler Perryman L, Speck B. 2016; Treatment of FBSS low back pain with a novel percutaneous DRG wireless stimulator: pilot and feasibility study. Pain Med. 17:1911–6. DOI: 10.1093/pm/pnw075. PMID: 27125284.

53. Russo M, Cousins MJ, Brooker C, Taylor N, Boesel T, Sullivan R, et al. 2018; Effective relief of pain and associated symptoms with closed-loop spinal cord stimulation system: preliminary results of the Avalon study. Neuromodulation. 21:38–47. DOI: 10.1111/ner.12684. PMID: 28922517.

54. Bolash R, Creamer M, Rauck R, Vahedifar P, Calodney A, Fox I, et al. 2019; Wireless high-frequency spinal cord stimulation (10 kHz) compared with multiwaveform low-frequency spinal cord stimulation in the management of chronic pain in failed back surgery syndrome subjects: preliminary results of a multicenter, prospective randomized controlled study. Pain Med. 20:1971–9. DOI: 10.1093/pm/pnz019. PMID: 30908577.

55. Duarte RV, Nevitt S, McNicol E, Taylor RS, Buchser E, North RB, et al. 2020; Systematic review and meta-analysis of placebo/sham controlled randomised trials of spinal cord stimulation for neuropathic pain. Pain. 161:24–35. DOI: 10.1097/j.pain.0000000000001689. PMID: 31453983.

56. Deer TR, Lamer TJ, Pope JE, Falowski SM, Provenzano DA, Slavin K, et al. 2017; The Neurostimulation Appropriateness Consensus Committee (NACC) safety guidelines for the reduction of severe neurological injury. Neuromodulation. 20:15–30. DOI: 10.1111/ner.12564. PMID: 28042918.

57. Deer TR, Provenzano DA, Hanes M, Pope JE, Thomson SJ, Russo MA, et al. 2017; The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management. Neuromodulation. 20:31–50. DOI: 10.1111/ner.12565. PMID: 28042909.

58. Deer TR, Narouze S, Provenzano DA, Pope JE, Falowski SM, Russo MA, et al. 2017; The Neurostimulation Appropriateness Consensus Committee (NACC): recommendations on bleeding and coagulation management in neurostimulation devices. Neuromodulation. 20:51–62. DOI: 10.1111/ner.12542. PMID: 28042905.

59. Roth SG, Lange S, De La Cruz P, Haller J, Kumar V, Wilock M, et al. 2015; A prospective study of the intra- and postoperative efficacy of intraoperative neuromonitoring in spinal cord stimulation. Stereotact Funct Neurosurg. 93:348–54. DOI: 10.1159/000437388. PMID: 26444517.