Neurostimulator: The chronic pain eliminator
BACKGROUND: Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally incapacitating. With chronic pain, signals of pain remain active in the nervous system for weeks, months, or even years. This can take both a physical and emotional toll on a person. The most common sources of pain stem from headaches, joint pain, pain from injury, and backaches. Other kinds of chronic pain include tendinitis, sinus pain, carpal tunnel syndrome, and pain affecting specific parts of the body, such as the shoulders, pelvis, and neck. Generalized muscle or nerve pain can also develop into a chronic condition. Because of the mind-body links associated with chronic pain, effective treatment requires addressing psychological as well as physical aspects of the condition. ( Source: WebMD)
SYMPTOMS: The symptoms of chronic pain include mild to severe pain that does not go away, pain that may be described as shooting, burning, aching, or electrical, and feeling of discomfort, soreness, tightness, or stiffness. Pain is not a symptom that exists alone. Other problems associated with pain include fatigue, sleeplessness, withdrawal from activity and increased need to rest, weakened immune system, changes in mood including hopelessness, fear, depression, irritability, anxiety, and stress, and disability. (Source: www.webmd.com)
TREATMENT: Medications, acupuncture, local electrical stimulation, and brain stimulation, as well as surgery, are some treatments for chronic pain. Some physicians use placebos, which in some cases has resulted in a lessening or elimination of pain. Psychotherapy, relaxation and medication therapies, biofeedback, and behavior modification may also be employed to treat chronic pain. (Source: http://www.ninds.nih.gov)
NEW TECHNOLOGY: A neurostimulator is a surgically placed device about the size of a stopwatch. It delivers mild electrical signals to the epidural space near your spine through one or more thin wires, called leads. The electrical signals cause a tingling sensation in the area of your chronic pain. Neurostimulation provides pain relief by blocking the pain messages before they reach the brain. In other words, it outsmarts your pain. Instead of pain, you feel a tingling sensation.
You can adjust the strength and location of stimulation using a handheld programmer. For example, you can regulate different levels of stimulation at different times of the day or for various activities – such as walking, sleeping, or sitting. If your neurostimulator features AdaptiveStim™ technology, then it will automatically adjust stimulation when you are upright (sitting or standing), lying down, or active while in an upright position.
A complete neurostimulation system includes several components:
Neurostimulator: The device that generates the electrical impulses (usually placed under the skin in your abdomen or upper buttock).
Leads: Thin, insulated medical wires that deliver electrical pulses to the epidural space near the spine.
Physician's programmer: A computer at your doctor's office that lets your doctor adjust the neurostimulation system and its settings
Patient's programmer: A handheld device you can use at home to customize the stimulation
The neurostimulation system does not make any noise. It may be felt as a small bump under your skin, but does not normally show through your clothes. (Source: http://www.medtronic.com)
Neel Mehta, M.D., Administrative Director at Weill Cornell College of Medicine, department of anesthesia at New York Presbyterian Hospital, talks about stimulating away pain.
When you first met Catherine, can you tell me what she was like?
Dr. Mehta: Kathryn was a very interesting story. She came to me because she had been traveling all across the country trying to get care. She had a doctor just down the street from here who I often receive patients from. He said, there’s a woman I know and if there’s something you can do for her please let me know. Then we got to talking and she was actually going out to California and meeting somebody that used to work here many, many years ago. I said, wow you traveled all across the country because of your pain and she said, you would too if this is all that could help you. She was a very dynamic woman, but very nervous because she had just seen and heard a lot and was very scared about trying new things because she was almost sure that it wasn’t going to work.
What was wrong with her?
Dr. Mehta: She came to me with a long list of pain. We broke it down and said, alright, if we could target two or three things, which would be the ones that you want to target the most? For her it was her back pain going down in to her legs and her neck pain, which was also shooting up towards her scalp and into both arms. That was really debilitating for her. She is a very successful interior designer and was not able to work anymore. Also, regarding her interaction with her husband she said it’s just not the same marriage because she was emotionally distressed and also just the pain was so severe.
Was it caused by anything?
Dr. Mehta: She had the type of pain that we call neuropathic pain. One subset of that being radicular pain, which is the pain that goes down into her extremities, into her arms and into her legs. She was not a surgical candidate. She had been seen by many neurosurgeons and then been turned away rightfully so, because they did not think that they would be able to help her. Thankfully no one chose to operate on her, which could have possibly made her pain worse.
Can this kind of pain just happen to anybody at any time?
Dr. Mehta: The sad reality is that it can. It’s not common, so we’re fortunate for that. But unfortunately some patients do have these kind of stories and it’s pretty catastrophic and with no warning sign. It can be from accidents, it can be from things as simple as a daily chore that just somehow something went wrong. The important thing is she was very aggressive about getting treatment once she started to notice that this wasn’t just going away on its own or with routine medication.
Is there a cure?
Dr. Mehta: That’s a hard thing to answer because often we are managing pain when we’re not successful in curing the pain. The injections may have been helping her with any inflammation of the nerves that she may have had, but eventually as you know that stopped working for her. Then we start to say, okay if we can’t find a cure how do we at least make her be able to be relatively pain free and have her functional ability back? This is not a cure as it’s not an antibiotic, but it has given her, her life back and that’s the most important thing that she wanted.
Why does it work?
Dr. Mehta: The easiest way to explain is that it is a wire that kind of distracts the nerve. The nerve is sending pain signals to the brain saying something is sharp, something is stabbing or burning. That’s what she was describing, that type of pain in her arms and her legs and in her back and so forth. This wire changes that signal, not so much that it takes away the pain but it changes that signal to a much more pleasant feeling that is much more tolerable. In fact, almost anybody could tolerate that sensation and that pain that sharp, stabbing, burning, all that disappears.
What were the results from the trial?
Dr. Mehta: She came in with ten out of ten pain pretty much all the time—severe, debilitating, life-changing. She was on heavy doses of medications because she was not tolerating lower doses. Just to make her pain relatively under control. The problem was that it was making her very sedated, nauseous and so forth. It really changed her mood. With the trial, once the stimulator was in and once we had it programmed, she was able to actually cut back on the doses of her medications while still having a reduction in pain and she actually chose to go to the office and see what it would be like at work. She was very, very pleased. During the trial it’s about a seven day process we communicated by phone every day and then had her come back on the seventh day to remove the trial wire and she told me all the things that she was able to do, including going out to eat, which she was not able to do before with her husband.
How is she different now then when you last saw her?
Dr. Mehta: When I saw her first she was very nervous sitting in her chair, not moving very much and actually a couple times looked like she was going to doze off because of the dose of medication. This is not somebody that is addicted to pain medication and so forth, this is someone that unfortunately needs a dose of medication to help her pain but is now reaching her side effects.
What kind of medications?
Dr. Mehta: Things like morphine and other morphine based pain medications. These are medications that when used in the right way can be helpful.
Who would this be helpful for and who would it not be helpful for?
Dr. Metha: The best candidate would be somebody that has pain going in to the extremities. So in the arms, in the legs, back pain with and neck pain. What has been studied are people who had surgery and still have residual pain. People who have something called complex regional pain syndrome--where the nervous system now actually is false alarming in simple terms and causing pain signals to fire even though nothing is really going on. Now, there are many pain physicians across the country that are actively studying using this for other things, such as chest pain when you’re already had stents and bypasses and still have residual chest pain, abdominal pain from pancreatitis, or having pain in the legs from poor circulation. These are things that are still very experimental and not been FDA approved. But again our hope is that somewhere down the road that these will prove to be effective.
Is this FDA approved?
Dr. Metha: For the type of pain she has ,yes.
How does the procedure work?
Dr. Metha: It is very simple to do. It’s like having an injection but instead of putting medication we put a wire. There are no incisions and there are no scars. If for some reason the trial was not effective, they come in to our office and we pull the wire out and put a Band-Aid on it and there’s no lasting effect. The point I’m trying to get across is that there really isn’t a lot of downside to trying this.
How many people have you been involved with that have come in and it had no effect?
Dr. Metha: usually I‘d say about ten, anywhere from ten to twenty percent of patients will not have a response that’s favorable. Meaning it didn’t address their pain or they didn’t like that sensation. Again as we talked about, it changes from one sensation to another. But for the rest they’ve all gone on, eighty percent of patients go on and have a permanent implant.
Is it immediate relief?
Dr. Metha: It’s like a TV remote, you’re given a box and you turn it on and you can increase the intensity or decrease. Depending on the position you may change how much you need. There are companies out there like Medtronic, who currently is working on something that can actually sense position changes and they are using that for people who change when they’re seated versus standing up. The technology is ever evolving and we think that this is only going to grow in terms of the number of people that can actually benefit from it.
How about Kathryn?
Dr. Metha: She’s honest that her pain is not zero, but it was enough for her to get back to what she wanted to do in life. That’s the most important thing. We talk about pain scores ten out of ten versus five, everybody has their own subjective pain. But what I look at is what she’s able to do. Is she able to walk? Is she able to have her life back? That’s the most important thing and for her the answer is yes.
FOR MORE INFORMATION, PLEASE CONTACT:
Neel Metha, MD
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