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Published on : Jul 20, 2021 | Views : 2707 | Downloads : 6

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Spinal Cord and DRG Stimulation Ausaf A. Bari MD PhD Assistant Professor UCLA Department of Neurosurgery January 30 2019
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Remove the offending agent Microdiscectomy for radicular pain Fusion for instability Release entrapment (carpal tunnel release) MVD for TN Lesional Cordotomy Cingulotomy Myelotomy DREZ Neurectomies, percutaneous rhizotomy for TN Implantable Pain Pumps Intrathecal morphine pump Stimulation Deep brain stimulation (PAG/PVG, Vc Thalamus) Peripheral nerve stimulation (ONS) Spinal Cord Stimulation Dorsal Root Ganglion (DRG) Stimulation Broad Categories of Surgical Pain Procedures
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Affects at least 23.5 million adults in the U.S. $635 billion in cost to society Prevalence of 31% The most common reason people see a physician. Increase in long-term opioid use in the U.S. Back Pain is the most common subtype of chronic pain. The Burden of Chronic Pain
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Gate Control Theory of Pain
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Spinal Cord Stimulation Stimulation for Chronic Pain DRG Stimulation
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Dorsal Column Stimulation at 40-60 Hz Frequency Indications: chronic intractable pain of the trunk and/or limbs, including unilateral or bilateral pain associated with the following: failed back surgery syndrome (FBSS), intractable low back pain, and leg pain Replaces pain with paresthesias Better for extremity pain than for back pain Can develop tolerance to stimulation over time Paresthesias can be affected by postural changes Traditional Low Frequency SCS SCS Paddle
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Percutaneous or through an open laminotomy Use of fluoroscopy Epidural electrode placement between T8-T11 Externalize leads for trial Internalization and placement of pulse generator SCS Placement
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Newer technique 10,000 Hz (vs. 40-60 Hz for regular SCS) No paresthesias - no mapping Some evidence for better outcomes compared to traditional SCS Better outcomes for BACK PAIN Less tolerance to stimulation High Frequency SCS
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HF10 Outcomes RCT HF10 > SCS for Back and Leg Pain At 12 months (50% reduction in pain): 78% (HF10) vs. 53% traditional SCS
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HF10 Outcomes RCT Lack of paresthesias: May allow patients to use stimulation throughout the day including while sleeping (24hrs). Potential disadvantage of HF10? Increase in power consumption. Need for more frequent recharging of pulse generator. Mechanism: Unlike traditional SCS, unknown - possible inhibition of wide dynamic range (WDR) dorsal horn neurons.
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Spinal Cord Stimulation Stimulation for Chronic Pain DRG Stimulation
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DRG Stimulation
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DRG Stimulation More localized dermatomal distribution May be better for more causalgia/CRPS of the lower limb Can be used with or without paresthesias Targets certain anatomical areas that are difficult to treat with SCS: pelvis groin foot buttocks abdominal pain
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DRG vs SCS ACCURATE trial: RCT of DRGS vs SCS for CRPS of the lower extremities. Primary outcome: ≥ 50% reduction in VAS At 12 months: DRG: 74% vs SCS: 53% Less positional variation in perceived paresthesias. (Due to decreased CSF space between DRG and dura). 95% stimulation specificity vs. SCS Reduced power requirements Reduced lead migration
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DRG Lead Placement Percutaneous placement Hairpin strain relief loop Externalized trial period Permanent implant with IPG Up to 4 separate leads possible
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Pearls for DRG Stimulation Steeper learning curve Limitation due to foraminal stenosis Look for neuroforaminal fat on MRI. If no fat - can still proceed but inform patient that it will be more challenging. For patients with good response to trial can consider removing trial within 3 days to prevent epidural fibrosis for permanent placement. DRG may alleviate nociceptive pain unlike SCS
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Peripheral Nerve Stimulation Pain isolated to the distribution of a single peripheral nerve. Examples: Occipital Neuralgia Entrapment (carpal tunnel syndrome) Post-amputation pain CRPS Post-stroke shoulder pain Post-surgical pain (knee, back, inguinal hernia repair)
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Percutaneous vs. open placement Wired or wireless options Trial period followed by permanent placement Evolving technology
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Take Home Points Try to get patient down to at least 90 morphine equivalents before implanting. Leave pharmacotherapy to the pain management specialists. For radicular pain – DRG would be off label. Better to use SCS. For CRPS involving multiple dermatomes (CRPS) - target the level where the injury initially began. Don’t necessarily document “spinal CORD stimulation” in H&P/Consult Note. Dictate “SPINAL stimulation” to allow for flexibility to use either DRG or SCS. Wireless techniques are available now for patients that do not want an IPG. Patient selection is still key: Remove the offending pathology if possible Externalized trial period Psychiatric pre-evaluation