Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Spinal Cord Stimulation: Spinal Cord Stimulation:
Indications and Patient SelectionIndications and Patient Selection
Joshua M. Rosenow, MD, FACSJoshua M. Rosenow, MD, FACSAssociate Professor of Neurosurgery
Director, Functional Neurosurgery
Northwestern Memorial Hospital
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
DisclosuresDisclosures
Consultant:
Boston Scientific Neuromodulation
Medtronic Navigation
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
FBSS EtiologiesFBSS Etiologies
Poor patient selection Abnormal psychometrics Chronic pain behavior Unreachable expectations
Incorrect diagnosis Wrong procedure
Wrong level or site Poor technique
Nerve root injury Iatrogenic instability or flat back syndrome Pseudarthrosis Incomplete decompression or incomplete correction of deformity
Progressive disease Recurrent disk herniation or spinal stenosis Transition syndrome
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Indications for SurgeryIndications for Surgery
Compressive lesion
Associated radiculopathy
Demonstrable neurologic deficit
Clear instability / deformity
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
CRPS Diagnostic CriteriaCRPS Diagnostic Criteria
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Revised Diagnostic CriteriaRevised Diagnostic Criteria
Pain and sensory changes disproportionate to the injury in magnitude or duration
At least 1 symptom in 3 or more categories and 1 sign in 2 or more categories
Sensory Vasomotor Sudomotor/edema Motor/trophic
Harden RN and Bruehl SP. Introduction and diagnostic considerations. Harden RN and Bruehl SP. Introduction and diagnostic considerations. Complex Regional Pain Complex Regional Pain Syndrome: Treatment Guidelines.Syndrome: Treatment Guidelines. RSDSA press. 2006:1-11 RSDSA press. 2006:1-11..
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Surgical ContraindicationsSurgical Contraindications
Thecal sac compression by tumor
Significant spinal deformity
Severe emaciation
Significantly low WBC, plt
Coagulopathy
Ongoing infection
Unsuccessful trial
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
SCS: Patient SelectionSCS: Patient Selection
Pain syndrome amenable to stimulation Radicular preferable to axial Neuropathic preferable to nociceptive
Failed reasonable medical management Several pharmacologic classes Dose titration until adverse side effects or lack of response noted
Surgical disease ruled out Reoperation vs. stim? Not surgical candidate?
Pain psychological evaluation
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Patient FactorsPatient Factors
Set appropriate expectations!!!! Takes time, but will be worth the investment
They need to understand this is not a cure!
Seeing the patient multiple times before moving to a trial helps gauge their goals of therapy and probable compliance level
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Patient FactorsPatient Factors
Can they be a reliable partner with a subjective therapy?
Can they give appropriate feedback in the OR?
Can they manage the device? Rechargeable vs primary cell IPG
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Other TreatmentsOther Treatments
Should proceed in parallel Psychological counseling Behavioral treatments Physical therapy and conditioning Vocational counseling and rehab Implantables can’t fix everything!
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Psychosocial FactorsPsychosocial Factors
Present in ALL chronic pain patients Can include:
Depression Personality disorders Drug and alcohol problems Return to work issues Social and family discord Many others
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Pain Psychology Pain Psychology
Spine surgery success in the presence of:Spine surgery success in the presence of:Childhood physical or sexual abuse,Childhood physical or sexual abuse,Emotional neglect/abuseEmotional neglect/abuseAbandonmentAbandonmentChemically dependent parents:Chemically dependent parents:
# Factors# Factors Surgical SuccessSurgical Success
11 95%95%
1-2 1-2 73%73%
3 or more 3 or more 15%15%
Spine surgery success in the presence of:Spine surgery success in the presence of:Childhood physical or sexual abuse,Childhood physical or sexual abuse,Emotional neglect/abuseEmotional neglect/abuseAbandonmentAbandonmentChemically dependent parents:Chemically dependent parents:
# Factors# Factors Surgical SuccessSurgical Success
11 95%95%
1-2 1-2 73%73%
3 or more 3 or more 15%15%
(Shofferman et al., 1992)(Shofferman et al., 1992)
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Predictive value of psychological testingPredictive value of psychological testing
Many studies have examined the value of psychological testing in predicting success with SCS
Daniel et al calculated an 80% accuracy rate using the MMPI and BDI for predicting success.
Burchiel et al. found that the BDI score and mania scale on the MMPI emerged as predictors. Less helpful in a subsequent study.
Long et al reported a 33% success rate in unscreened patients compared with 70% in screened patients.
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Trial TechniquesTrial Techniques
Trial implant Easiest Fastest Remove electrode in office Low prob candidates If multiple choices or procedures
debated If location not suitable for trial
extension Requires reimplant of electrode
at permanent implant
“Permanent Trial” Permanent implant easier Remove electrode in OR If finding therapeutic location 2nd
time will be difficult If implant technique difficult or
invasive If general anes needed for
permanent system
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Paddle TrialsPaddle Trials
Lumbar fusion or laminectomy precluding
percutaneous insertion
Inability to access the epidural space
percutaneously
Bony anatomy
Obesity
Prior procedure in the region of the implant
Tumor resection, etc.
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Preop imaging is essentialPreop imaging is essential
You would never do any other spine case without adequate preop imaging – DON’T START NOW
Preop imaging makes sure something asymptomatic doesn’t become symptomatic
Aids in counseling patient preop if procedure needs to be altered to deal with anatomic issue
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
Preop imaging is essentialPreop imaging is essential
Where is the cord???
The cord may not respect the spinal column midline
Paddle may look great on fluoro and not provide adequate coverage
Department of Neurosurgery, Feinberg School of Medicine,Department of Neurosurgery, Feinberg School of Medicine, Northwestern UniversityNorthwestern University
E-mail: E-mail: [email protected]@nmff.org
Thank you for coming!Thank you for coming!
Phone: Phone: 312-695-0495312-695-0495