Neurostimulation treatment of nerve root pain

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We can treat chronic nerve root back pain, radiating to the limbs, which does not respond to other therapies. We use minimally invasive treatment where pain impulses are blocked by electrical stimulation of the spinal cord. The current generation of stimulators can be implanted through the skin under local anaesthesia.

Benefits:

  • the method is used when other pain management therapies do not work, pain is often eliminated or significantly reduced,
  • the procedure can be performed under local anaesthesia, even in patients with a number of other conditions,
  • after fast and minimally invasive surgical procedures patients can quickly return to work, and day-to-day activities are no longer painful.
  • minimally invasive procedures also carry a smaller risk of complications associated with damage to nerve roots and wound healing.
  • minimally invasive procedures require a shorter hospital stay.
  • after our procedures you will be able to get up and move independently one hour after the surgery.

Types of stimulation:

Low frequency (LF) stimulation

Over the last 30 years Spinal Cord Stimulation (SCS) was a popular treatment for chronic neuropathic pain syndromes and for failed back surgery syndrome (FBSS). For optimum effect the electrode had to be placed in the region of the sensory roots to ensure precise stimulation of the pain region. Instead of pain patients should feel paresthesia (tingling). The therapeutic effect depended on the degree of overlap of electrically induced paresthesia and the pain site: the better the overlap the larger pain relief. In this method, the mapping of pain sites with the use of stimulation was of key importance. The type of the electrode was also important: electrodes with more contacts ensured a larger spinal cord stimulation area. This type of stimulation, called ‘tonic’ stimulation (i.e. when the patient feels tingling instead of pain), was based on the gate controlling theory. According to the theory, by stimulating large diameter fibres we interfere with signals from thin diameter fibres (which transmit pain signals).
An important parameter of electricity: frequency. In tonic stimulation the therapeutic frequency is between 60 Hz and 120 Hz (maximum tonic battery power: up to 1,200 Hz).
Disadvantages of tonic stimulation:
1. Insufficient pain relief: areas not covered with paresthesia still hurt. Effectiveness of about 50% to 70%.
2. Less effective in the case of complex pain syndromes (of mixed pathogenesis).
3. Not all patients tolerated tingling.
4. Pain in the skin pocket for the stimulator.
5. Patients cannot undergo MRI scans.
6. Battery needs to be replaced, so a new surgery is needed.

High frequency stimulation

High frequency stimulationResearch into the improvement of the tonic stimulation followed two paths:
• some manufacturers improved electrodes, adding more contacts to increase the stimulated area
• others were looking into alternative uses of the same current.
It turned out that frequency modulation is more effective: thin diameter fibres (which transmit pain signals) were directly stimulated while large diameter fibres (responsible for paresthesia) were not.
Stimulation in the frequency range between 3,000 Hz and 10,000 Hz yielded the best results.
Currently, high frequency stimulation is understood as stimulation at 10,000 Hz. Lower values can also be used.
In high frequency stimulation we do not need multipolar electrodes. Instead, +/- polarization is used at TH8-TH9 level.
On the first day after the surgery patients start to feel lasting pain relief, without tingling. The pain relief effect is better than in the case of tonic stimulation, with an 80% success rate. HF stimulation is often used when tonic stimulation does not work, or is not sufficient to relieve pain. Clinical studies have demonstrated that HF stimulation is significantly more effective than tonic stimulations.
Disadvantages of HF stimulation:
1. High frequency means higher energy consumption.
2. An expensive rechargeable stimulator is necessary (about 80,000 zł).
3. Pain in the skin pocket for the stimulator.
4. Patients cannot undergo MRI scans.
5. Battery needs to be replaced, so a new surgery is needed.

Burst stimulation

Burst stimulation is a cheaper equivalent of HF stimulation, allowing for the adjustment of tonic stimulators to higher frequencies. Burst stimulation involves frequency containing 5 spikes at 500 Hz per spike lasting for 20 milliseconds. Widely spaced pulses delivered at the above frequency directly activate pain pathways (as in HF), and the space between the pulses saves battery running time.
Burst is more effective than tonic stimulation. Additionally, the patient does not experience paresthesia. Burst stimulation works where tonic stimulation is insufficient.
There were no significant differences between the efficacy of the tonic and burst stimulation. However, there was a significant difference when it comes to patients’ preferences (patients preferred burst over tonic stimulation).

DRG stimulation (dorsal root ganglion)

Stimulation of dorsal root ganglions is very effective in treating nerve root pain limited to parts of limbs, such as a foot, thigh, knee, etc. It ensures high effectiveness without stimulation of the whole limb.

Stimulation of peripheral nerves

Effective pain-relieving actions for pain affecting only small parts of the body, supplied by one nerve branch. The electrode is placed near the peripheral nerve. This is an effective treatment of pain affecting the head, face or other smaller parts.

Treatment options:

Pasha® electrode for temporary spinal cord stimulation

This method is recommended for neuropathic pain (chronic, subacute) in lower limbs and spine sections. In this type of stimulation the electrode is not implanted permanently. It is used at the operating theatre to provide electrical stimulation. The electrode is inserted through a Touchy needle, under local anaesthesia, at a safe level (L2-L3). The electrode is inserted into the epidural space and is advanced to the level of the conus or the DREZ region. First, we check the location of the electrode using tonic stimulation and we map pain sites. After that each pain region is supplied with pulsed radiofrequency stimulation for 4 minutes. During one procedure we stimulate between 3 and 4 regions. The method may also be used for permanent implantation of the stimulator. The pain-relieving effect lasts for 6 to 12 months and the procedure can be repeated.

Wireless SCS stimulators (from Stimwave)

This is the most advanced wireless stimulators, where the electrode and the stimulator are integrated in one compact device. Thanks to this solution, the electrode and stimulator can be implanted at the same time (there is no need for a second surgery). Also, the patient does not need any implanted batteries. The battery is outside, worn on a belt close to the stimulator. Energy is not transferred by induction, so there is no heating, and the battery does not have to be close to the implanted stimulator. This cutting-edge patented energy transfer method does not involve heating and the energy source does not have to be in immediate vicinity of the stimulator, it should be placed abut 20 cm away.
The external battery is rechargeable.
The stimulator can deliver all types of stimulation: tonic, burst and high frequency (up to 3,000 Hz). The price ranges from 23,000 to 32,000 złoty.
The stimulator with a frequency of 10,000 Hz costs 45,000 złoty (if the patient has already had a stimulator of up to 3,000 Hz, software may be updated after some time and HF stimulator may be bought, and the surgery is not necessary).
The battery placed outside the patient’s body reduces procedure costs because:
– the procedure is short, under local anaesthesia, without battery implantation within the patient’s body,
– there are no wires under the skin,
– the battery does not have to be replaced when used,
– the lowest cost as compared to other manufacturers.

Eligibility for the procedure:

  • The patient’s eligibility is evaluated on the basis of the whole clinical picture.
  • Diagnostic imaging is necessary: the standard test is a 1.5 or 3-tesla MRI scan. If there are absolute contraindications for an MRI scan (strong claustrophobia, metal implants, others), the patient’s eligibility may be evaluated on the basis of an ‘open’, low-field MRI or computed tomography.
  • For large degenerative lesions a computed tomography examination is recommended in addition to an MRI scan.
  • If there are any doubts as to the diagnosis, an EMG test is performed to precisely determine the level where the pain and other symptoms originate.

Before the procedure:

The basic laboratory tests include blood type and Rh factor, complete blood count, basic biochemistry tests (sodium, potassium, urea, creatinine, glucose), coagulation parameters (APTT, INR), ECG, a general chest x-ray (for patients over 40 or with a history of pulmonological problems). Additional tests or consultations with specialists may be required, depending on the patient’s condition, the underlying disease and other medical conditions (such as a thyroid profile test, urinalysis, consultation with a cardiologist). The meeting with the anaesthetist takes place a few days before the procedure if the neurosurgeon so recommended. Otherwise, the meeting takes place on the day of the procedure, during the admission process.
Please bring to the hospital only the necessary items, such as medical records, neurosurgeon’s consultation documents with the eligibility evaluation, imaging test results (MRI, CT, x-ray) on CDs with descriptions, laboratory test results, routine medications, toiletries, towel, socks, pyjamas and footwear as well as a change of clothes. Please do not bring any jewellery and other valuables. In each hospital room there is a wardrobe and a cupboard for your personal belongings (in two-person rooms each patient has his/her own wardrobe and cupboard).
The final evaluation of your eligibility for the procedure is done on the day of the procedure. You will be asked to give written consent to the surgical procedure and general anaesthesia (you can download samples from our site). You take your blood pressure medications, heart medications and hormonal medications if you take them on a regular basis.

Procedure:

The surgery is performed under general or local anaesthesia. It can be performed as an open or percutaneous procedure. Usually the procedure lasts from 60 to 120 minutes, depending on the procedure used. Subcuticular suturing is used.

After the procedure:

After the procedure you wake up at the recovery room next to the operating theatre. Following your full awakening from anaesthesia you will be transferred either to your room or the recovery room (depending on your condition and the course of anaesthesia/procedure).
After 2 hours we make the first attempt to mobilise you (with a nurse’s or a doctor’s assistance). On the day of the procedure you may walk around your room and go to the bathroom. Activity is slightly limited. On the day after the procedure you get up in the morning and increase your activity level. Before midday you should be able to walk in the corridor or balcony. During that time you will receive advice on post-operative rehabilitation from a qualified physiotherapist. You will be discharged in the afternoon, after a medical examination.
While at home you should avoid effort for 2 to 3 weeks. In the first week after the surgery you should schedule a follow-up appointment to check your wound. The next visit is scheduled 3 weeks after the procedure to evaluate preliminary treatment outcomes. During the whole post-operative period you can call your doctor directly.

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+48 61 62 33 111

Wielkopolskie Centrum Medyczne
Sp z o.o. S.K.A

st. Bolesława Krzywoustego 114
61-144 Poznań, POLAND

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