Percutaneous Lumbar Stimulation

  • Lucas W. Campos
  • Eric T. Lee


The technology behind percutaneous lumbar spinal cord stimulation (SCS), a successful therapy used to treat both chronic axial and radicular spinal pain, has been refined over the last 40 years. Globally, approximately 40,000 spinal cord stimulators are implanted each year. Patient outcomes have been rigorously studied, and there is advocacy for the use of SCS earlier in treatment algorithms for chronic pain conditions. The last two decades of research on SCS has demonstrated potential superiority for use in axial and radicular chronic lumbar spine pain compared to traditional spinal surgery and pharmacologic therapy. Among the strongest evidence is for the use of lumbar SCS in treating failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS). FBSS is a well-studied indication for SCS and is responsible for 70% of all implants. Substantial innovation in hardware, software, and novel waveforms has made SCS a viable option for multiple pain conditions. This chapter reviews the most salient topics regarding the indications and evidence for percutaneous lumbar spinal cord stimulation.


Spinal cord stimulation Failed back surgery syndrome Neuropathic pain Burst stimulation High-frequency stimulation 

Recommended Reading

  1. 1.
    Al-Kaisy A, Van Buyten J-P, Smet I, Palmisani S, Pang D, Smith T. Sustained effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with chronic, low back pain: 24-month results of a prospective multicenter study. Pain Med. 2014;15:347–54.CrossRefGoogle Scholar
  2. 2.
    Al-Kaisy A, Palmisani S, Smith T. The use of 10-kilohertz spinal cord stimulation in a cohort of patients with chronic neuropathic limb pain refractory to medical management. Neuromodulation Technol Neural Interface. 2015;18(1):18–23.CrossRefGoogle Scholar
  3. 3.
    Amirdelfan K, McRoberts P, Deer TR. The differential diagnosis of low back pain: a primer on the evolving paradigm. Neuromodulation. 2014;17(Suppl 2):11–7.CrossRefGoogle Scholar
  4. 4.
    Arle JE, Mei L, Carlson KW. High-frequency stimulation of dorsal column axons: potential underlying mechanism of paresthesia-free neuropathic pain relief. Neuromodulation Technol Neural Interface. 2016;19(4):385–97.CrossRefGoogle Scholar
  5. 5.
    Atkinson L, Sundaraj SR, Brooker C, O’Callaghan J, Teddy P, Salmon J, Semple T, Majedi PM. Recommendations for patient selection in spinal cord stimulation. J Clin Neurosci. 2011;18:1295–302.CrossRefGoogle Scholar
  6. 6.
    Bala MM, Riemsma RP, Nixon J, Kleijnen J. Systematic review of the (cost-)effectiveness of spinal cord stimulation for people with failed back surgery syndrome. Clin J Pain. 2008;24:741–56.CrossRefGoogle Scholar
  7. 7.
    Beltrutti D, Lamberto A, Barolat G, et al. The psychological assessment of candidates for spinal cord stimulation for chronic pain management. Pain Pract. 2004;4:204–21.CrossRefGoogle Scholar
  8. 8.
    Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine. 2009;34:1094–109.CrossRefGoogle Scholar
  9. 9.
    Cohen RA, Kaplan RF, Moser DJ, Jenkins MA, Wilkinson H. Impairments of attention after cingulotomy. Neurology. 1999;53:819–24.CrossRefGoogle Scholar
  10. 10.
    De Ridder D, Vanneste S, Plazier M, van der Loo E, Menovsky T. Burst spinal cord stimulation: toward paresthesia-free pain suppression. Neurosurgery. 2010;66:986–90.CrossRefGoogle Scholar
  11. 11.
    De Ridder D, Plazier M, Kamerling N, Menovsky T, Vanneste S. Burst spinal cord stimulation for limb and back pain. World Neurosurg. 2013;80:642–649.e1.CrossRefGoogle Scholar
  12. 12.
    De Ridder D, Vancamp T, Lenders MWPM, De Vos CC, Vanneste S. Is preoperative pain duration important in spinal cord stimulation? A comparison between tonic and burst stimulation. Neuromodulation. 2015;18:13–7; discussion 17.CrossRefGoogle Scholar
  13. 13.
    De Ridder D, Lenders MWPM, De Vos CC, Dijkstra-Scholten C, Wolters R, Vancamp T, Van Looy P, Van Havenbergh T, Vanneste S. A 2-center comparative study on tonic versus burst spinal cord stimulation: amount of responders and amount of pain suppression. Clin J Pain. 2015;31:433–7.CrossRefGoogle Scholar
  14. 14.
    Deer T, Pope J, Hayek S, Narouze S, Patil P, Foreman R, Sharan A, Levy R. Neurostimulation for the treatment of axial back pain: a review of mechanisms, techniques, outcomes, and future advances. Neuromodulation. 2014;17(Suppl 2):52–68.CrossRefGoogle Scholar
  15. 15.
    Deer TR, Narouze S, Provenzano DA, et al. The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on bleeding and coagulation management in neurostimulation devices. Neuromodulation. 2017;20:51–62.CrossRefGoogle Scholar
  16. 16.
    Deogaonkar M, Sharma M, Oluigbo C, et al. Spinal cord stimulation (SCS) and functional magnetic resonance imaging (fMRI): modulation of cortical connectivity with therapeutic SCS. Neuromodulation. 2016;19:142–53.CrossRefGoogle Scholar
  17. 17.
    Flacco ME, Manzoli L, Boccia S, et al. Head-to-head randomized trials are mostly industry sponsored and almost always favor the industry sponsor. J Clin Epidemiol. 2015;68:811–20.CrossRefGoogle Scholar
  18. 18.
    Frot M, Mauguière F, Magnin M, Garcia-Larrea L. Parallel processing of nociceptive A-delta inputs in SII and midcingulate cortex in humans. J Neurosci. 2008;28:944–52.CrossRefGoogle Scholar
  19. 19.
    Grider JS, Manchikanti L, Carayannopoulos A, et al. Effectiveness of spinal cord stimulation in chronic spinal pain: a systematic review. Pain Physician. 2016;19:E33–54.PubMedGoogle Scholar
  20. 20.
    Guido W, Sherman SM. Response latencies of cells in the cat’s lateral geniculate nucleus are less variable during burst than tonic firing. Vis Neurosci. 1998;15:231–7.CrossRefGoogle Scholar
  21. 21.
    Gybels J, Erdine S, Maeyaert J, et al. Neuromodulation of pain. A consensus statement prepared in Brussels 16–18 January 1998 by the following task force of the European Federation of IASP Chapters (EFIC). Eur J Pain. 1998;2:203–9.CrossRefGoogle Scholar
  22. 22.
    Haider S, Owusu-Sarpong S, Peris Celda M, Wilock M, Prusik J, Youn Y, Pilitsis JG. A single center prospective observational study of outcomes with tonic cervical spinal cord stimulation. Neuromodulation. 2017;20:263–8.CrossRefGoogle Scholar
  23. 23.
    Hayek SM, Veizi E, Hanes M. Treatment-limiting complications of percutaneous spinal cord stimulator implants: a review of eight years of experience from an academic center database. Neuromodulation Technol Neural Interface. 2015;18(7):603–9.CrossRefGoogle Scholar
  24. 24.
    Holsheimer J, Buitenweg JR. Review: bioelectrical mechanisms in spinal cord stimulation. Neuromodulation. 2015;18:161–70; discussion 170.CrossRefGoogle Scholar
  25. 25.
    Hou S, Kemp K, Grabois M. A systematic evaluation of burst spinal cord stimulation for chronic back and limb pain. Neuromodulation. 2016;19:398–405.CrossRefGoogle Scholar
  26. 26.
    Kapural L, Yu C, Doust MW, et al. Novel 10-kHz High-Frequency Therapy (HF10 Therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: The SENZA-RCT randomized controlled trial. Anesthesiology. 2015;123:851–60.CrossRefGoogle Scholar
  27. 27.
    Kapural L, Yu C, Doust MW, et al. Comparison of 10-kHz High-Frequency and Traditional Low-Frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: 24-Month Results From a Multicenter, Randomized, Controlled Pivotal Trial. Neurosurgery. 2016;79:667–77.CrossRefGoogle Scholar
  28. 28.
    Krames ES, Oakley JC, Foster AM, Henderson J, Prager JP, Rashbaum RR, Stamatos J, Weiner RL. Spinal cord stimulation has comparable efficacy in common pain etiologies. Neuromodulation. 2008;11:171–81.CrossRefGoogle Scholar
  29. 29.
    Kreis PG, Fishman S. Spinal cord stimulation: percutaneous implantation techniques: Oxford University Press; 2009.Google Scholar
  30. 30.
    Kulkarni B, Bentley DE, Elliott R, Youell P, Watson A, Derbyshire SWG, Frackowiak RSJ, Friston KJ, Jones AKP. Attention to pain localization and unpleasantness discriminates the functions of the medial and lateral pain systems. Eur J Neurosci. 2005;21:3133–42.CrossRefGoogle Scholar
  31. 31.
    Kumar K, Wilson JR. Factors affecting spinal cord stimulation outcome in chronic benign pain with suggestions to improve success rate. Acta Neurochir Suppl. 2007;97:91–9.PubMedGoogle Scholar
  32. 32.
    Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132:179–88.CrossRefGoogle Scholar
  33. 33.
    Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery. 2008;63:762–70; discussion 770.CrossRefGoogle Scholar
  34. 34.
    Kumar K, Caraway DL, Rizvi S, Bishop S. Current challenges in spinal cord stimulation. Neuromodulation. 2014;17(Suppl 1):22–35.CrossRefGoogle Scholar
  35. 35.
    Lopez-Garcia JA, King AE. Membrane properties of physiologically classified rat dorsal horn neurons in vitro: correlation with cutaneous sensory afferent input. Eur J Neurosci. 1994;6:998–1007.CrossRefGoogle Scholar
  36. 36.
    Manchikanti L, Manchikanti KN, Pampati V, Brandon DE, Giordano J. The prevalence of facet-joint-related chronic neck pain in postsurgical and nonpostsurgical patients: a comparative evaluation. Pain Pract. 2008;8:5–10.CrossRefGoogle Scholar
  37. 37.
    Mekhail NA, Cheng J, Narouze S, Kapural L, Mekhail MN, Deer T. Clinical applications of neurostimulation: forty years later. Pain Pract. 2010;10:103–12.CrossRefGoogle Scholar
  38. 38.
    Mekhail N, Wentzel DL, Freeman R, Quadri H. Counting the costs: case management implications of spinal cord stimulation treatment for failed back surgery syndrome. Prof Case Manag. 2011;16:27–36.CrossRefGoogle Scholar
  39. 39.
    Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150:971–9.CrossRefGoogle Scholar
  40. 40.
    Moayedi M, Davis KD. Theories of pain: from specificity to gate control. J Neurophysiol. 2013;109:5–12.CrossRefGoogle Scholar
  41. 41.
    Nelson DV, Kennington M, Novy DM, Squitieri P. Psychological selection criteria for implantable spinal cord stimulators. Pain Forum. 1996;5:93–103.CrossRefGoogle Scholar
  42. 42.
    Nielson DM, Yang X, Vera-Portocarrero L, Molnar GF. Spinal cord stimulation (SCS) and functional magnetic resonance imaging (fMRI): modulation of cortical connectivity with therapeutic SCS. Scholar
  43. 43.
    North JM, Hong K, Cho PY. Clinical outcomes of 1 kHz subperception spinal cord stimulation in implanted patients with failed paresthesia-based stimulation: results of a prospective randomized controlled trial. Neuromodulation Technol Neural Interface. 2016;19(7):731–7.CrossRefGoogle Scholar
  44. 44.
    Oswald A-MM, Chacron MJ, Doiron B, Bastian J, Maler L. Parallel processing of sensory input by bursts and isolated spikes. J Neurosci. 2004;24:4351–62.CrossRefGoogle Scholar
  45. 45.
    Pai S, Sundaram LJ. Low back pain: an economic assessment in the United States. Orthop Clin North Am. 2004;35:1–5.CrossRefGoogle Scholar
  46. 46.
    Perruchoud C, Eldabe S, Batterham AM, et al. Analgesic efficacy of high-frequency spinal cord stimulation: a randomized double-blind placebo-controlled study. Neuromodulation. 2013;16:363–9; discussion 369.CrossRefGoogle Scholar
  47. 47.
    Pope JE, Falowski S, Deer TR. Advanced waveforms and frequency with spinal cord stimulation: burst and high-frequency energy delivery. Expert Rev Med Devices. 2015;12:431–7.CrossRefGoogle Scholar
  48. 48.
    Price DD. Psychological and neural mechanisms of the affective dimension of pain. Science. 2000;288:1769–72.CrossRefGoogle Scholar
  49. 49.
    Evans C. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press (US); 2012.Google Scholar
  50. 50.
    Rinaldi PC, Young RF, Albe-Fessard D, Chodakiewitz J. Spontaneous neuronal hyperactivity in the medial and intralaminar thalamic nuclei of patients with deafferentation pain. J Neurosurg. 1991;74:415–21.CrossRefGoogle Scholar
  51. 51.
    Rupert MP, Lee M, Manchikanti L, Datta S, Cohen SP. Evaluation of sacroiliac joint interventions: a systematic appraisal of the literature. Pain Physician. 2009;12:399–418.Google Scholar
  52. 52.
    Russo M, Van Buyten J-P. 10-kHz high-frequency SCS therapy: a clinical summary. Pain Med. 2015;16:934–42.CrossRefGoogle Scholar
  53. 53.
    Russo M, Verrills P, Mitchell B, Salmon J, Barnard A, Santarelli D. High frequency spinal cord stimulation at 10 kHz for the treatment of chronic pain: 6-month Australian clinical experience. Pain Physician. 2016;19:267–80.PubMedGoogle Scholar
  54. 54.
    Saadé NE, Jabbur SJ. Nociceptive behavior in animal models for peripheral neuropathy: spinal and supraspinal mechanisms. Prog Neurobiol. 2008;86:22–47.CrossRefGoogle Scholar
  55. 55.
    Shealy CN, Taslitz N, Mortimer JT, Becker DP. Electrical inhibition of pain: experimental evaluation. Anesth Analg. 1967a;46:299–305.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anesth Analg. 1967b;46:489–91.Google Scholar
  57. 57.
    Shechter R, Yang F, Xu Q, et al. Conventional and kilohertz-frequency spinal cord stimulation produces intensity-and frequency-dependent inhibition of mechanical hypersensitivity in a rat model of neuropathic pain. J Am Soc Anesthesiol. 2013;119:422–32.CrossRefGoogle Scholar
  58. 58.
    Smith H, Youn Y, Pilitsis JG. Successful use of high-frequency spinal cord stimulation following traditional treatment failure. Stereotact Funct Neurosurg. 2015;93:190–3.CrossRefGoogle Scholar
  59. 59.
    Song Z, Ultenius C, Meyerson BA, Linderoth B. Pain relief by spinal cord stimulation involves serotonergic mechanisms: an experimental study in a rat model of mononeuropathy. Pain. 2009;147:241–8.CrossRefGoogle Scholar
  60. 60.
    Song Z, Viisanen H, Meyerson BA, Pertovaara A, Linderoth B. Efficacy of kilohertz-frequency and conventional spinal cord stimulation in rat models of different pain conditions. Neuromodulation. 2014;17:226–34; discussion 234–5.CrossRefGoogle Scholar
  61. 61.
    Stancák A, Kozák J, Vrba I, Tintera J, Vrána J, Polácek H, Stancák M. Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients. Eur J Pain. 2008;12:137–48.CrossRefGoogle Scholar
  62. 62.
    Swadlow HA, Gusev AG. The impact of “bursting” thalamic impulses at a neocortical synapse. Nat Neurosci. 2001;4:402–8.CrossRefGoogle Scholar
  63. 63.
    Sweet J, Badjatiya A, Tan D. Paresthesia-free high-density spinal cord stimulation for postlaminectomy syndrome in a prescreened population: a prospective case series. Neuromodulation Technol Neural Interface. 2016;19(3):260–7.CrossRefGoogle Scholar
  64. 64.
    Tiede J, Brown L, Gekht G, Vallejo R, Yearwood T, Morgan D. Novel spinal cord stimulation parameters in patients with predominant back pain. Neuromodulation. 2013;16:370–5.CrossRefGoogle Scholar
  65. 65.
    Van Havenbergh T, Vancamp T, Van Looy P, Vanneste S, De Ridder D. Spinal cord stimulation for the treatment of chronic back pain patients: 500-Hz vs. 1000-Hz burst stimulation. Neuromodulation. 2015;18:9–12; discussion 12.CrossRefGoogle Scholar
  66. 66.
    de Vos CC, Bom MJ, Vanneste S, Lenders MWPM, de Ridder D. Burst spinal cord stimulation evaluated in patients with failed back surgery syndrome and painful diabetic neuropathy. Neuromodulation. 2014;17:152–9.CrossRefGoogle Scholar
  67. 67.
    Washburn S, Catlin R, Bethel K, Canlas B. Patient-perceived differences between constant current and constant voltage spinal cord stimulation systems. Neuromodulation. 2014;17:28–35; discussion 35–6.CrossRefGoogle Scholar
  68. 68.
    Wille F, Breel JS, Bakker EWP, Hollmann MW. Altering conventional to high density spinal cord stimulation: an energy dose-response relationship in neuropathic pain therapy. Neuromodulation. 2017;20:71–80.CrossRefGoogle Scholar
  69. 69.
    Wu G, Ringkamp M, Hartke TV, Murinson BB, Campbell JN, Griffin JW, Meyer RA. Early onset of spontaneous activity in uninjured C-fiber nociceptors after injury to neighboring nerve fibers. J Neurosci. 2001;21:RC140.CrossRefGoogle Scholar
  70. 70.
    Youn Y, Smith H, Morris B, Argoff C. The effect of high-frequency stimulation on sensory thresholds in chronic pain patients. Stereotact Funct Neurosurg. 2015;93(5):355–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Lucas W. Campos
    • 1
  • Eric T. Lee
    • 2
  1. 1.Interventional Pain PhysiciansChicoUSA
  2. 2.Musculoskeletal Care and Regenerative Medicine, St Charles Spine InstituteThousand OaksUSA

Personalised recommendations