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Neuromodulation for Spine Pain Care

  • Alexandra R. Adler
  • Mark C. Bicket
  • Shihab U. AhmedEmail author
Chapter

Abstract

Electricity has been used as a modality for pain relief since antiquity. Despite early recognition of this analgesic potential, almost two centuries passed before Melzack and Wall published their seminal gate control theory in 1965. The theory, which held that electrical stimulation of the dorsal column of the spinal cord could modulate the transmission of nociceptive signals from the peripheral nervous system, represented a paradigm shift for the treatment of pain. Coupled closely with the first use of an implanted lead that provided electrical stimulation adjacent to the thoracic dorsal column and relieved pain in the chest wall of a cancer patient, these two events ushered in a new era of pain relief from the targeted application of electrical devices. Incremental progress in the field has led to various improvements in hardware design and implantation techniques, which set the stage for spinal cord stimulation (SCS) to serve as an evidence-based treatment for a variety of chronic pain conditions.

Initially, the main indications for SCS were difficult-to-treat pain conditions such as back and leg pain persisting after spine surgery, formerly referred to as failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS). Studies have demonstrated superior outcomes with SCS versus reoperation in patients with persistent leg pain with FBSS. More recently, with the advent of newer SCS technologies, the list of indications with evidence favoring SCS has grown to include axial lower back pain, which did not respond well to the earlier SCS technology.

This chapter will review the mechanisms of action of SCS, the modes of SCS, indications specific to different types of spinal pain, efficacy data, and the implantation process. While clinical trials support the use of SCS for analgesia, the basic science foundation for neurostimulation remains incomplete and an area of active inquiry. Research continues to investigate the ability of SCS to modulate pain through understanding its molecular mechanisms, the role of pain pathways including descending inhibition, and the involvement of spinal cord dorsal horn stimulation to alter pain processing in the cortex. Indeed, clinical and preclinical studies using functional MRI (fMRI) have confirmed that SCS acts at both the spinal and supraspinal level and hint at future breakthroughs that may advance the ability to relieve pain and suffering in the years to come.

Keywords

Spinal cord stimulation Chronic pain Limb pain Back pain Burst stimulation High-frequency stimulation Dorsal root ganglion stimulation 

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Alexandra R. Adler
    • 1
  • Mark C. Bicket
    • 2
  • Shihab U. Ahmed
    • 3
    Email author
  1. 1.Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonUSA
  2. 2.Department of Anesthesiology and Critical Care MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

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