Other Neuromodulation Therapies We Provide
1) Spinal Cord Stimulation for Pain management:
What is a spinal cord stimulator and how does it work
⦁ Spinal cord stimulators consist of thin wires (the electrodes) and a small, pacemaker-like battery pack (the generator).
⦁ The electrodes are placed between the spinal cord and the vertebrae (the epidural space), and the generator is placed under the skin, usually near the buttocks or abdomen.
⦁ Spinal cord stimulators allow patients to send the electrical impulses using a remote control when they feel pain. Both the remote control and its antenna are outside the body.
What is spinal cord stimulation used for
Spinal cord stimulation is used most often after nonsurgical pain treatment options have failed to provide sufficient relief. Spinal cord stimulators may be used to treat or manage different types of chronic pain, including:
⦁ Back pain, especially back pain that continues even after surgery (failed back surgery syndrome)
⦁ Post-surgical pain
⦁ Arachnoiditis (painful inflammation of the arachnoid, a thin membrane that covers the brain and spinal cord)
⦁ Injuries to the spinal cord
⦁ Nerve-related pain (such as severe diabetic neuropathy and cancer-related neuropathy from radiation, surgery or chemotherapy)
⦁ Peripheral vascular disease
⦁ Complex regional pain syndrome
⦁ Pain after an amputation
⦁ Visceral abdominal pain and perineal pain
⦁ Spinal cord stimulation can improve overall quality of life and sleep, and reduce the need for pain medicines.
Who should get a spinal cord stimulator
As with all treatments, your doctor will want to make sure spinal cord stimulation is right for you — and that it is likely to provide significant relief from your chronic pain. Each patient is different, but generally, people who benefit the most from spinal cord stimulation are those who:
⦁ Have not experienced sufficient pain relief with medications, less-invasive therapies or prior surgeries
⦁ Do not have psychiatric disorders that would decrease the effectiveness of the procedure
Spinal cord stimulators come in three main types:
⦁ Conventional implantable pulse generator (IPG) is a battery-operated spinal code stimulator. A battery is placed in the spine during an operation. When it runs out, the battery must be replaced with another surgery. This device can be a good choice for people with pain in just one body part because it has a lower electrical output.
⦁ Rechargeable IPG works similarly to the conventional device, with the difference that the battery can be recharged without another surgery. Because the energy source is rechargeable, these stimulators can put out more electricity. This may be a better choice for people with pain in the lower back or in one or both legs, as the electrical signal can reach further.
⦁ Radio-frequency stimulator uses a battery that’s outside the body. This stimulator is rarely used today because of newer designs and better technology. It has rechargeable batteries, and like the rechargeable IPGs, it may be better for people with pain in the lower back and legs because of the device’s power.
Spinal Cord Stimulator Surgery
Spinal cord stimulators require two procedures to test and implant the device: the trial and the implantation.
Spinal Cord Stimulator Trial
⦁ The first step is a trial period. Your surgeon will implant a temporary device for you to test out. Guided by a specific type of X-ray called fluoroscopy, your surgeon will carefully insert the electrodes in the epidural space of the spine. The location of your pain affects where these electrodes will be placed along the spine. Your surgeon may ask for your feedback during the procedure to best position the electrodes.
⦁ This trial procedure typically requires only one incision in your lower back to place the electrodes. The generator/battery will be outside the body, typically on a belt, you’ll wear around your waist.
⦁ For about a week, you will evaluate how well the device reduces your pain. The trial is considered a success if you experience a 50% or greater reduction in pain level.
⦁ If unsuccessful, the wires can easily be removed in the clinic without damage to the spinal cord or nerves. If successful, surgery is scheduled to permanently implant the device.
Spinal Cord Stimulator Implantation
⦁ During the permanent implantation procedure, the generator is placed underneath the skin and the trial electrodes are replaced with sterile electrodes. Unlike the trial electrodes, these will be anchored by sutures to minimise movement.
⦁ The implantation can take about 1-2 hours and is typically performed as an outpatient procedure.
⦁ After the local anesthesia has been administered, your surgeon will make one incision (typically along your lower abdomen or buttocks) to hold the generator and another incision (along your spine) to insert the permanent electrodes. The incisions are about the length of a driver’s license. As in the trial procedure, fluoroscopy is used to determine where the electrodes are placed.
⦁ Once the electrodes and generator are connected and running, your surgeon will close the incisions.
⦁ Your surgeon may provide sedation to keep you comfortable and ask for your feedback during placement of the electrodes.
Spinal Cord Stimulator Recovery
⦁ Most patients leave the same day as their procedure — once the anesthesia has worn off. For several days after surgery, your incisions may be painful. Try not to stretch, twist or reach, which could pull at the incisions.
⦁ Dressings will be placed over the incision sites, which can be removed after about 3 days. In most cases, incisions heal within about 2-4 weeks after surgery.
⦁ Your doctor will discuss your recovery plan, but generally lighter activity is recommended for about 2 weeks after surgery.
2) Vagus Nerve Stimulation:
About one-third of people with epilepsy don’t fully respond to anti-seizure drugs. Vagus nerve stimulation may be an option to reduce the frequency of seizures in people who haven’t achieved control with medications.
Vagus nerve stimulation may also be helpful for people who haven’t responded to intensive depression treatments, such as antidepressant medications, psychological counselling (psychotherapy) and electroconvulsive therapy (ECT).
The Food and Drug Administration (FDA) has approved Vagus nerve stimulation for people who:
⦁ Are 4 years old and older
⦁ Have focal (partial) epilepsy
⦁ Have seizures that aren’t well-controlled with medications
The FDA has also approved Vagus nerve stimulation for the treatment of depression in adults who:
⦁ Have chronic, hard-to-treat depression (treatment-resistant depression)
⦁ Haven’t improved after trying four or more medications or electroconvulsive therapy (ECT), or both
⦁ Continue standard depression treatments along with Vagus nerve stimulation
Implanted Vagus nerve stimulation isn’t a cure for epilepsy. But many will have fewer seizures, up to 20 to 50 percent fewer. Seizure intensity may lessen as well.
It can take months or even a year or longer of stimulation before you notice any significant reduction in seizures. Vagus nerve stimulation may also shorten the recovery time after a seizure. People who’ve had Vagus nerve stimulation to treat epilepsy may also experience improvements in mood and quality of life.
Research is still mixed on the benefits of implanted Vagus nerve stimulation for the treatment of depression. Some studies suggest the benefits of Vagus nerve stimulation for depression accrue over time, and it may take at least several months of treatment before you notice any improvements in your depression symptoms. Implanted Vagus nerve stimulation doesn’t work for everybody, and it isn’t intended to replace traditional treatments.
Studies of implanted Vagus nerve stimulation as a treatment for conditions such as Alzheimer’s disease, headaches and rheumatoid arthritis have been too small to draw any definitive conclusions about how well it may work for those problems. More research is needed.
3) Peripheral Nerve Stimulation
When pain becomes chronic and long-lasting, and medicine and therapy are not helping, our neurosurgeons at the Center for Neuromodulation can provide peripheral nerve stimulation (PNS) to ease your pain. Peripheral nerve simulators work much like spinal cord simulators, except that we send the mild electrical currents directly to nerves outside of the spinal cord. Peripheral nerves run from your spinal cord to the limbs or organs in your body.
We start by conducting a neuropsychological examination. Then, as with spinal cord stimulation, we start with a trial run to test your response to temporary electrodes that we place along the length of the offending peripheral nerve. If your pain does not subside significantly, we remove the electrodes. If it works, then we place permanent electrodes at the nerve site and an internal battery-operated stimulator under the skin. These batteries last for several years and we can replace them easily. Once the stimulator is in place, we customise the electrical pulse settings to provide the highest level of pain relief.
We typically perform this procedure under local anesthesia. PNS is an extremely safe procedure and has been used since the 1960s to treat various neurological symptoms. Some of the conditions we treat with PNS are:
⦁ Trigeminal neuropathic pain
⦁ Nerve injuries: Foot Drop Syndromes
⦁ Complex regional pain syndrome
⦁ Peripheral neuropathy
⦁ Post amputation pain syndrome
4) Intrathecal Baclofen Pump:
⦁ Baclofen is a muscle relaxant medicine commonly used to decrease spasticity related to multiple sclerosis, spinal cord injuries, or other neurological diseases. An intrathecal delivery system, which provides the baclofen right to the target site in the spinal cord, is an effective way to deliver the medicine.
What is spasticity?
⦁ Spasticity is a movement disorder that can occur in conditions which affect the brain or the spinal cord, such as multiple sclerosis, stroke, cerebral palsy, spinal cord injury, or brain injury. Spasticity is caused by an imbalance between signals that inhibit or stimulate the spinal cord. This results in hyper excitable stretch reflexes, increased muscle tone, and involuntary movements.
What are the symptoms of spasticity?
⦁ Spasticity causes muscle stiffness and tightness, which interferes with voluntary movements. Spasticity can also cause muscle spasms (jerky involuntary movements) or clonus (repetitive involuntary movement). Stiffness and spasms are often bothersome and sometimes painful, and they interfere with the ability to carry out daily activities. Spasms may also disrupt sleep and increase daytime fatigue. When spasticity is severe, contracture (fixed limitations of range of motion) may develop.
How can spasticity be treated
⦁ Stretching, exercise, and rehabilitation are the first line of interventions for
spasticity. Oral medications are often effective, but may cause side effects such as drowsiness. When spasticity affects only a few muscles, local injections of botulinum toxin can be helpful. When spasticity is diffuse and severe, intrathecal baclofen (Lioresal®) (ITB) may be a good treatment option.
What are the advantages of ITB compared to taking baclofen by mouth
⦁ ITB is usually much more effective in controlling the symptoms of spasticity, because the medication is brought directly in contact with the spinal cord.
⦁ With ITB, the medication is delivered continuously, day and night, giving a more steady relief of symptoms.
⦁ ITB, in most cases, causes less side effects than oral baclofen, particularly when high doses are needed to treat severe spasticity.
⦁ ITB programming is very flexible, allows more precise dosing of baclofen, and gives the ability to deliver different doses at different times of the day.
⦁ Compared to other surgical treatments, ITB is reversible, as the pump can be stopped and removed if needed
What are the potential risks and adverse effects of ITB
⦁ The baclofen pump system needs to be surgically implanted under anesthesia, leading to the usual risks of surgery.
⦁ Complications more specific to ITB include the risk of infection around the device, and the risk of device malfunction.
⦁ Baclofen withdrawal (from abrupt interruption of the delivery of baclofen via the pump) and baclofen overdose (usually as a result of human error) have also occurred with ITB.
⦁ Serious complications from ITB are infrequent, and in most cases reversible as long as they are diagnosed and treated in a timely fashion.
5) Sacral Nerve Stimulation:
The Interstim® neuromodulation (Sacral nerve stimulation) device is a unique innovation in the treatment of bladder dysfunction. By providing an electronic impulse to the irregular firing of the nerves to the bladder it can improve incontinence as well as restoring normal emptying to a non-emptying bladder.
It consists of three components:
⦁ Lead – this is a fine wire, containing four separate electrodes, that can each be stimulated individually or in various combinations to tailor the Neuromodulation to your individual needs.
⦁ Pulse generator – this is the small “battery” that drives the system. It generally needs replacement every 6-7 years.
⦁ Programmer – this is the small remote control (like the one for your TV) that allows you to adjust the InterStim device yourself.
What happens during the procedure?
⦁ You will receive a local anaesthetic.
⦁ You will not be paralysed.
⦁ You will be placed in the prone (face-down) position.
⦁ You will be given intravenous antibiotics before and after the procedure.
⦁ You will have a small incisions made in your lower back.
⦁ A second incision is made just above your buttock.
⦁ The correct position of the electrode will be confirmed by X-ray and test stimulation.