Spinal cord stimulation for failed back surgery syndrome

It's worth noting that the outcome of spinal cord stimulation will depend on the patient's individual circumstances and the extent of their FBSS. Some patients may experience a significant improvement in their pain and function and return to work, while others may not see as much improvement. Additionally, the patient's occupation, the severity of the condition, and socioeconomic status are also important factors to consider when assessing the return to work.

Repeated surgery was the most prominent significant risk factor for Spinal cord stimulation for persistent or recurrent pain after lumbar spine surgery. The risk of SCS for persistent or recurrent pain after lumbar spine surgery increases significantly along with the number of lumbar spine procedures. When considering repeated lumbar spine surgery, careful evaluation of treatment options should take place to ensure good patient outcomes ¹⁾.

Spinal cord stimulation for failed back surgery syndrome Systematic reviews.

Spinal cord stimulation is a well-established and effective therapy in the treatment of pain. Proper patient selection and accurate lead placement are paramount in its success. Placement is a multifaceted process requiring proper paddle placement, a well thought out generator placement and appropriate means to limit complications and enhance success. Several intraoperative techniques maximize outcomes, including removal of the superior portion of the inferior level's spinous process for paddle access into the epidural space, generator pocket placement in a location that limits patient discomfort, a strain relief loop at the thoracic incision to prevent lead fractures and allow for full spinal flexibility, generator placement parallel to the body and secured in the pocket to prevent unwanted movement, and intraoperative neuromonitoring for patient comfort and more accurate lead placement compared to X-ray alone or awake placement. This case demonstrates these key elements of intraoperative technique in a candidate with the most common indication for spinal cord stimulator placement-postlaminectomy syndrome-underscoring the ease and viability of this procedure in the appropriate patient population in a means that reduces future complications and adverse events while maximizing success. Full patient consent for video-recording and subsequent use for research purposes was attained. All patient identifiers have been removed for the purpose of patient confidentiality ²⁾.

Among 106 patients with FBSS who benefitted from SCS at a single institution in France between September 1999 and March 2010, we retrospectively included 59 who had stopped work at the time of SCS because of disability or sick leave and evaluated the RTW (rate and predictors, estimating odds ratios [ORs] and 95% confidence intervals [CIs]).

Results: The mean (SD) post-surgery follow-up for the 59 patients (34 men; mean [SD] age 46.9 [7.4] years) was 7.5 (3.6) years (range 5-15). The RTW rate was 30.5%, with a median [IQR] recovery time of 5.5 months [3-8.5]. RTW was improved with functional improvement evolution (OR 1.1, 95% CI [1.01-1.1], p=0.02) and was reduced with unemployment > 3 years (OR 0.1, 95% CI [0.01-0.7], p=0.02).

The protocol for SCS for patients with FBSS, including a strict selection of patients and a multidisciplinary approach, led to good results, especially for the RTW. RTW should be a therapeutic goal, directly affecting indirect costs related to FBSS ³⁾.

Burst stimulation is a recently developed stimulation modality that seems to be superior to tonic stimulation.

In a observational multicenter study of the Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, Department of Pathophysiology and Transplantation, University of Milan, Pain Unit, Santa Maria delle Croci Hospital, AUSL Romagna, Ravenna, Neurostimulation Center, Department of Neurosurgery, Macchi Foundation Hospital, Varese, ASST Rhodense, The Hospital of Garbagnate Milanese, Milanese, Pain Managment Unit, S. Antonio Hospital, Padua, Pain Clinic, Ospedale Clinicizzato SS. Annunziata, Chieti, Interventional Pain Unit, G. da Saliceto Hospital, Piacenza, Italy, compared tonic and burst stimulation during a trial period in patients with FBSS or radiculopathy. All the patients enrolled underwent two weeks of tonic stimulation followed by another two weeks of BurstDR stimulation, without randomization. The primary outcome was the reduction of pain in the legs and back. Health-related quality of life (EQ-5D) and the pain catastrophizing scale (PCS) were assessed before and after the trial. Patients were reevaluated after 12 months. RESULTS:

We recruited 23 patients, 57% of whom had FBSS and 43% had radiculopathies. Five patients failed both the tonic and burst stimulation trials. While tonic stimulation reduced leg pain (p < 0.05), the burst mode added an extra pain reduction (ΔNRS 1.2 ± 1.5) (p < 0.01). No significant reduction in back pain was found (p 0.29). Pain on movement was reduced only by BurstDR (p < 0.01). Both stimulation modalities increased EQ-5D and reduced PCS from the baseline (p < 0.0001). At the end of the SCS trial phase, 26% patients chose tonic SCS, while 74% preferred burst. On 12-month follow-up examination, the benefits recorded at the end of the trial were maintained.

Burst stimulation confers a greater reduction in leg pain intensity at rest and on movement. Reducing axial pain is still a challenge. Further studies are needed in order to provide each patient with the most appropriate stimulation paradigm ⁴⁾.

Twenty patients with failed back surgery syndrome (FBSS) and a preexisting SCS system each received three treatment allocations in random order for a period of one week: 500-Hz tonic stimulation, burst stimulation, and placebo stimulation. The primary outcome measure was pain intensity measured on a numerical rating scale (NRS). Secondary outcome measures were pain quality measured using the Short Form McGill Pain Questionnaire (SFMPQ) and safety. Additional data were collected relating to pain-related disability measured using the Oswestry Disability Index (ODI).

The lowest mean NRS and SFMPQ scores were observed under burst stimulation. For the burst stimulation treatment group, mean NRS and SFMPQ scores were significantly decreased compared with the other treatment groups. Mean NRS and SFMPQ scores were not significantly different between 500-Hz tonic stimulation and placebo stimulation. Although the lowest mean ODI score was observed under burst stimulation, no significant differences were found between the ODI categories. No adverse events occurred, and burst stimulation was significantly preferred by 16 patients (80%).

Overall, burst stimulation resulted in significantly better pain relief and improved pain quality in the short term compared with 500-Hz tonic stimulation and placebo stimulation and was preferred by the majority of patients ⁵⁾.

Thirty patients were treated with SCS between December 1992 and January 1998 for low back and radicular pain after multiple failed back surgeries. Permanent systems were implanted if trial stimulation led to > 50% pain reduction. Median long-term follow-up was 34 months (range, 6-66 months). Severity of pain was determined postoperatively by a disinterested third party. Results. Overall, 12 of the 16 patients (75%) who received permanent implants continued to report at least 50% relief of pain at follow-up. All six patients who underwent placement of laminectomy-styled electrode for SCS in the thoracic region had > 50% pain relief at long-term follow-up. Visual analog scores decreased an average of 3.2 (from 8.6 preoperatively to 5.4 postoperatively). Patients undergoing SCS placement via laminectomy in the thoracic region experienced an average decrease of 4.9 in VAS, whereas those who underwent percutaneous placement of thoracic leads had an average decrease of 2.5. Conclusions. SCS is an effective treatment for chronic low back and lower extremity pain which is refractory to conservative therapy and which is not amenable to corrective anatomic surgery. Though our patient population is small, our results imply that the laminectomy-style electrodes in the thoracic region achieve better long-term effectiveness than percutaneous leads ⁶⁾