J Korean Neurosurg Soc.  2022 Mar;65(2):276-286. 10.3340/jkns.2021.0145.

Clinical Outcomes after Spinal Cord Stimulation According to Pain Characteristics

• Ha JH
• Huh R
• Kim SG
• Im SB
• Jeong JH
• Hwang SC
• Shin DS
• Kim BT
• Chung M

• KMID: 2527184
• DOI: http://doi.org/10.3340/jkns.2021.0145

Abstract

Objective
: Spinal cord stimulation (SCS) is an effective treatment for chronic neuropathic pain. However, its clinical efficacy in regard to specific types of pain has not been well studied. The primary objective of this study was to retrospectively analyze the clinical outcomes of paddle-type SCS according to the type of neuropathic pain.
Methods
: Seventeen patients who underwent paddle-lead SCS at our hospital were examined. Clinical outcomes were evaluated pre- and postoperatively (3 months, 1 year, and last follow-up) using the Neuropathic Pain Symptom Inventory (NPSI). The NPSI categorizes pain as superficial, deep, paroxysmal, evoked, or dysesthesia and assess the duration of the pain (pain time score). Changes in NPSI scores were compared with change in Visual analogue scale (VAS) scores.
Results
: After SCS, the pain time score improved by 45% (independent t-test, p=0.0002) and the deep pain score improved by 58% (independent t-test, p=0.001). Improvements in the pain time score significantly correlated with improvements in the VAS score (r=0.667, p=0.003, Spearman correlation). Additionally, the morphine milligram equivalent value was markedly lower after vs. before surgery (~49 mg, pared t-test, p=0.002). No preoperative value was associated with clinical outcome.
Conclusion
: The NPSI is a useful tool for evaluating the therapeutic effects of SCS. Chronic use of a paddle-type spinal cord stimulation improved the deep pain and the pain time scores.

Keyword

Spinal cord stimulation; Chronic pain; Pain management; Pain measurement

Figure

• 

  Fig. 1. Correlation analysis between the Visual analogue scale (VAS) and the Neuropathic Pain Symptom Inventory (NPSI). The change of VAS score after the surgery was correlated to the change of the NPSI score. It shows that the improvement of VAS score was significantly correlated to the improvement of the time score among the NPSI subscores (Spearman correlation, r=0.688, p=0.002). From top left to bottom right, each figure indicates correlation between VAS and improvement of time score (A), superficial pain (B), deep pain (C), paroxysmal pain (D), evoked pain (E), and dysesthesia (F), respectively. *Significant correlation was found between time score and VAS score improvements.

• 

  Fig. 2. Change of morphine milligram equivalent (MME) dose before and after spinal cord stimulation (SCS). In the graph, a bar indicates 95% confidence interval (CI), and a circle in the center of bars indicates mean value of MME. MME dose before surgery (103.7 mg) was reduced after surgery (54.7 mg) examined at the last follow-up. This difference was statistically significant (t-test, p=0.002).

• 

  Fig. 3. Correlation analysis between morphine milligram equivalent (MME) dose reduction and improvement of Neuropathic Pain Symptom Inventory (NPSI) score. Each graph is a scatter plot and regression line showing correlation between MME dose reduction and improvement of time score (A), superficial pain score (B), deep pain score (C), paroxysmal pain score (D), evoked pain score (E), and dysesthesia score (F). Only the deep pain score was shown to be significantly correlated to the MME dose reduction (Spearman correlation analysis, p=0.001). *Significant correlation was found between deep pain improvement and MME dose reduction.

• 

  Fig. 4. Sequential changes of the Neuropathic Pain Symptom Inventory (NPSI) score. This graph shows sequential changes of the total NPSI score in each patient. The most patient in the present study experienced prominent clinical improvement at the 3-months follow-up. These early prominent improvements were maintained throughout follow-up time in some patients (patient No. 1, 3, 4, 5, 6, 8, 11, 14, and 15). However, these initial improvements were partially lost over time in the other patients (patient No. 2, 7, 9, 10, 12, 13, 16, and 17).

• 

  Fig. 5. Sagittal computed tomography image of patients with device related complication. There were two patients whose spinal canal was stenosed due to mass effect of paddle-type electrode and pre-existing spinal stenosis. Patient 3 suffered from loss of proprioception 36 months after implantation of electrode (Penta; St. Jude Medical, Austin, TX, USA) at C3 to C5 level (A). Since patient 3 had gained significant benefits from spinal cord stimulation (SCS), he did not want to remove the device. Anterior interbody fusion with total corpectomy of C4 and partial corpectomy of C5 was performed (B), and his proprioception was recovered. Patient 17 had a loss of proprioception and low motor weakness 6 months after implantation of electrode (Specify 5-6-5; Medtronic Inc., Minneapolis, MN, USA) at T11–12 level (C). Because SCS give prominent pain relief to him, decompressive laminectomy was performed rather than device removal. Laminectomy at T10–12 level with removal of thickened ligamentum flavum was performed (D). After this surgery his proprioception was improved, and mild low motor weakness was improved.

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