This last week I spent time at a huge convention on “Neuromodulation.” This is the technical name for anything and everything that can affect the nervous system, whether in the extremities, spine or brain. It covered everything from drugs to brain implants and everything in between. It included a variety of things that were interesting to pain physicians. Most interesting was the amount of different things that are available for pain patients and the why this is important. The biggest topic is opioid abuse and how we can possibly use stimulation to lower the amount of drugs used. Secondly, the next big topic was whether research shows one form of spinal stimulation to be better than others.
Stimulation For Chronic Pain
Up until the last three or four years, only one type of stimulation was available for pain patients. All the manufacturers made similar units and there were only differences in the quality of the battery. Then one company came up with a new high frequency type of spinal stimulator that involved placing the leads midline at T9 in the spine. That caused all the other companies to try to find better systems to relieve pain and to learn more about critical features that patients want to help take care of their pain symptoms. We now are actually learning new things about stimulation, what works and what makes a pain patient happy.
Improving pain control and patient comfort as well as making the experience as easy as possible seems critical. Beyond making the patient experience better, a lot of the science does not appear to be well proven. There are things being done by all of the major companies, but what works for the most patients and the medical problems is what is important. One thing that I realized is doctors seem to project mostly what they think is good for the patient. What is really needed now is trying to find what really does work for patients, and more research and data is needed.
The first thing patients want is that their pain is less intense and more manageable. There is no solution that will make the pain gone, but realistic goals of being able to do more activities like standing, walking and doing stuff around the house. Further, the equipment should be easy to use, comfortable, work right, and not constantly reminding you that for pain relief you have to make adjustments to the equipment. It also should be probably keep itself up-to-date and not fail quickly. In reality, all these things are quite hard to do and none of the systems available are perfect. Patients also need their doctors to better explain what any of the systems can do for them.
Improving Systems
There is a lot of hype now being given to doctors about each of the systems available. What the doctor hears is how can the big device manufacturers partner with their practice. They want to show us how the product is better than everyone else’s design. The reality is in the final run there are few things necessary for the patient. First off, the system needs to be able to control pain reliably. That takes units that will not fail to soon, and produce a signal that hopefully will control pain. The best way to determine this is to do a trial of the whatever system may be a good fit. These days trials should be 7-10 days and after 2-3 days the system should be reprogrammed to make sure everything is working. The patient needs to have less pain and improved function that is helpful to them. Taking less medication and sleeping better is also a good goal.
The biggest challenge is trying to pick the best product for each patient. The general choices come down to system flexibility to provide different signals to cover the pain, whether the system needs recharging of the battery (and how well does that work), what complications may happen with trial or implant and what may be the best system for the specific pain problem. The worst problem to deal with is obtaining insurance coverage for any of the systems.
The major manufacturers all have different batteries, some last longer, are rechargeable, and fast to recharge. There are systems with batteries that are not rechargeable and some batteries only last 2-3 years if the system is being fully used. The degree of MRI compatibility is also variable, some of the systems are only partially able to be in a scanner since they may heat up in the magnet of the scanner. Lastly, they all seem to be able to deliver signals where the patient does not feel the stimulation but gets pain relief. The treating doctor should understand the advantages of each of the systems, but unfortunately the manufacturers seem to heavily influence physicians implant decisions. The best implant should be what fits best for a particular patient. Personally after years of working with these units, a good rechargeable system is best for most people.
New developments are for isolated nerve issues and specific pain problems especially complex regional pain syndrome below the waist level. For these patients with absolutely no back issues, a dorsal root ganglia spinal cord stimulator has had excellent results. However, they do have a significantly higher rate of complications due to the unit location right on top of the nerve as it exits the spine. Nerve trauma can occur with these units when implanted.
The other very interesting development is the approval of peripheral nerve stimulators. When blocking a single nerve relieves symptoms (and this should be done with ultrasound guidance), then a trial of this type of stimulation could be beneficial. These units involve a wire placed next to the nerve and then a special small stimulator placed on the skin above the end of the wire that drives a small current that then blocks pain signals.
The options with electrical stimulation to control pain appear to be improving. Technical advances in the last five years have been significant in providing a patient with options to control pain much better. The new systems may be able to decrease some patient’s pain by at least 50 percent and greatly improve ability to do activities and sleep. If traditional treatments are not effective, contacting an interventional pain physician for new options is a great idea.