Several Scoliosis Operations and Still Pain – Spinal Cord Stimulation May Help

I have one gentleman with multiple surgical procedures including fusions and Harrington rod placements who is left with chronic pain. He has to stand up most of the time. I’m presuming there is a pseudoarthrosis at one level but there is got to be another way then surgery there. Spinal Cord Stimulation (SCS)  may help – but the paddles are placed higher than you would think.

SPINAL CORD STIMULATION FOR CONTROL OF LOW BACK PAIN AFTER MULTIPLE CORRECTIVE SURGERIES FOR SEVERE SCOLIOSIS: REPORT OF A CASE
Bernard R. Canlas MD1,2, Antonio N.B. Yap MD1, Berlin Y. Fernando MD1, Jose Martin S. Paiso MD1
Pain Practice Volume 9, Issue 5, pages 404–405, September/October 2009
ref here – no abstract

• 48 yr old  – 4 prior operations – some Harrington rods  un-removable.
• Pain low lumbar and left thigh
• Treatments included most things:
  • opioids
  • anti-seizure meds – probably gabapentin
  • NSAID’s – anti-inflammatory
  • Muscle relaxants
  • anti-depressant analgesics
  • caudal blocks
  • selective nerve blocks
  • trigger point injections
  • facet injections
• Used Medtronic SCS –  position at T7  gave 20% relief, but at T8 gave 60% relief

Another article is:
Effective Cervical Spinal Cord Stimulation for Bilateral Lower Extremities Pain: Technical Report
Leonardo Kapural, Jacek Cywinski, Paulina Zovkic and Michael Stanton-Hicks
Pain Practice, Volume 8, Issue 2, 2008 117–119  ref here – no abstract

Complex case:

• severe scoliosis
• multiple lumbar surgeries age 12 on
• decompressive surgery for the lumbar canal stenosis
• kyphoplasty for accident-related compressive fracture in lumbar spine

electromyogram confirmed  peripheral lower extremity sensory polyneuropathy

Treatments:

• opioids,
• topical lidocaine patches,
• pregabaline,
• duloxetine,
• gabapentin
• venlafaxine
• oxacarbamezepine
• levetiracetam
• epidural steroid injections

Minimal effect

Two octrodes leads used “from the entry point at T4 to C5 lead tip position”. “His setting during the trial and after the implant was pulse width 500, frequency of 60, amplitude using four different programs varied from 1.8 to 3.2 mA.”

“Although patient complained of significant but tolerable upper extremity paresthesias,
his pain relief was so profound that he opted for the permanent implant.”

This article was meant primarily as a treatment for”four extremity pains” which can be achieve through bilateral stimulation in the neck.

They refer to another articles

“Hagen et al. found in 2005 that eight out of 10 patients suffering from neuropathic pain in all four extremities reported greater than 90% pain relief when SCS was used
through cervical lead placement. However, he found that the four-extremity coverage is achieved only when the leads are placed with their rostral electrode tips at the high C2 region with the leads positioned over the physiological midline.2
Three other reports (two abstracts and one case report1,3,4) suggested a different
“sweet spot” area of four-extremity stimulation. in which 4 extremity pain relief was achieved”
1. Hayek S. Four extremity spinal cord stimulation using dual lower-cervical epidural octapolar neuroelectrodes.
Anesthesiology. 2006;105:A1577.
2. Hagen JE, Bennett DS.
Successful Treatment of 4-Extremity Complex Regional Pain Syndrome Type 1 with Dual Octapolar Percutaneous Leads and Closely Spaced Electrodes.
Abstracts of the 7th Congress of the International
Neuromodulation Society; Rome, Italy, June 10–13, 2005.
3. Rauck R, Wages J, North J. Four Extremity Paresthesias with Cervical Spinal Cord Stimulation. 26th Annual Meeting of the American Pain Society; Washington, DC, May
2007: A735.

Comment- there has been no confirmation of top study. It might be technically more difficult to place leads.