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Does Spinal Cord Stimulation work?
#11
CASE REPORT
A 32-year-old police woman while on duty was chasing two criminals. One of the criminals was obviously an
expert in shooting, and shot the police woman in both legs. She developed severe CRPS because of this incident. A small
fragment of the bullet in the left leg was not able to be removed surgically because it was too close to the sciatic nerve
that the surgeon decided not to disrupt the circulation in that area.
Because of the severity of the pain, four months after the injury, the patient had received an SCS implant. Every
time the SCS was turned on, the patient would develop a moderate edema of the left lower extremity, edema and water
retention (serous fluid) under the scar of the SCS insertion, and she would have severe electric shock feeling in the left
lower extremity in the area of the bullet scar. The patient complained of severe chest pain and dizziness. Her blood
pressure would rise from 130-140 systolic up to 210-220 systolic until the current of the stimulator was turned off.
This complication which was obviously due to spread of the electrode stimulation to the metallic body of the
bullet fragment and echoing back to the spinal cord canal and to the cardiac plexus, and was mistaken for “infection”
due to the surgical procedure. Obviously, there was no infection, and no infectious agent would grow from the serous
fluid accumulation area. This was obviously a classical neurogenic inflammation(2). The stimulator was removed,
replaced and the electrodes were repositioned for quite a few months, and all along the patient was kept on unnecessary
and on large doses of antibiotics. An infectious disease consultant kept claiming that this was because of some sort of
infectious agent even though nothing could be grown on culture.
The patient continued to run a temperature of 101.6-102.4/F every time the SCS was on.
The temperature would go back to 99- 100/F after the SCS was turned off. As soon as the stimulator was
turned off, the tachycardia and hypertension would partially subside, but the stress of the SCS electrical stimulation
would leave the patient with a baseline hypertension significant enough that she had to be on two different types of
alpha blocker and calcium channel blocker medications.
The doctors who were treating her did not understand that the sympathetic system has three main functions.
(i). Control of vital signs, in this case in the form of hypertension and tachycardia. (ii). Modulation of the body
temperature, in this case a significant degree of fever. (iii). Modulation of the immune system which is the main
domain of the sympathetic system function (2). I also discussed all of these phenomena in the book that I wrote in
1993 titled Chronic Pain: Reflex Sympathetic Dystrophy, Prevention and Management, published by CRC Press in
Boca Raton, Florida(4).
The patient received treatment of IV Mannitol for the problem of neuro-inflammation and water retention,
and that eliminated the neuro-inflammation and the areas of inflammation that were mistaken for abscesses.
TREATMENT
The main goal of treatment for CRPS is reversal of the course, amelioration of suffering, return to work if at
all possible, avoiding surgical procedures such as SCS and amputation, and improvement of quality of life. The key to
success is early diagnosis and early assertive treatment. Lack of proper understanding and proper diagnosis leads to
improper treatment with poor outcome. There is a desperate need for future research in the treatment of CRPS. Delay
in diagnosis is a factor in therapeutic failure. According to Poplawski, et al, treatment, and its results, are hampered by
delay in diagnosis (5). Early diagnosis (up to 2 years) is essential for achieving the goal of successful treatment results.
Simple monotherapy with only nerve block, only Gabapentin, or otherwise, is not sufficient for management of CRPS.
Treatment should be multidisciplinary and simultaneous: effective analgesia, proper antidepressants to prevent pain and
insomnia, physiotherapy, nerve blocks, proper diet, when indicated channel blockers, and anticonvulsant therapy should
be applied early and simultaneously. Administration of piece-meal, minimal treatments is apt to fail (2).
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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#12
Table I. Average Course of Treatment
Course of Treatment Duration of Treatment
1. No ice, no surgery 3.8 Days
2. Ice, no surgery 5.9 Days
3. Surgery
3A. Single Procedure
Sympathectomy 9.2 Days
Cryosurgery 14.5 Days
Rotator Cuff Surgery 12.8 Days
Spinal Cord Stimulator (SCS) Surgery 11.2 Days
Amputation Surgery 18 Days
3B. Multiple Procedures
e.g.: Spinal Cord Stimulator (SCS) Surgery
and Carpal Tunnel Surgery
16.1Days
COMPLICATIONS OF SPINAL CORD STIMULATOR (SCS) IN CRPS
As the condition of CRPS becomes chronic, the SCS can lead to spread of pain from the original site to other
parts of the body (1,2).
This foreign body can cause disturbance of the immune system resulting in skin rash, dermatitis, skin lesions,
and allergic reactions to SCS (1,3).
In rare cases, there are other complications noted with SCS application. These complications consist of the
following:
(i). Epidural abscess or blood clots.
(ii). In occasional cases, the sensitization of the spinal cord by the SCS causes spinal cord sensitization in the
form of myoclonic akinetic seizures(2). This sensitization is due to prolonged electrical stimulation causing exhaustion
of the inhibitory nerve cells. Treatment with Klonopin ®, and removal of the SCS prevents the sensitization.
Such attacks of myoclonic seizures originating from the spinal cord due to the spinal cord sensitization are not
limited to the SCS. They are also seen in other spinal procedures(9). The diagnosis of spinal cord originated myoclonic
seizures is quite difficult, and usually these patients are labeled as "functional" or "hysterical." Such patients respond
very nicely to treatment with Klonopin®, brand name rather than generic.
The removal of SCS, as well as multidisciplinary treatments, aiming at desensitizing the spinal cord, help this
condition.
Another problem with the SCS is the tendency for electrode movement due to improper anchoring, and the
necessity for the surgeon try to correct the position of the SCS. Every operation is going to be another new source of
CRPS pain.
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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#13
SCS can also cause disturbance of plasticity and causes rapid acceleration and deterioration of CRPS to later
stages of the disease. Another complication of SCS treatment is the fact that it stimulates the sensory neuropathic pain
fibers in the spinal canal facilitating the spread of the disease to other extremities.
In the rare and severe cases of spinal cord sensitization, the patient may develop myoclonic jerks, and urgency,
frequency, and even incontinence of urine, secondary to SCS irritating the urinary bladder and interstitial cystitis.
DISCUSSION
In regards to the more common somesthetic pain such as FBS or FNS, we have found that SCS to be quite
helpful and effective.
In contrast, in neuropathic pain, the beneficial effect of SCS may be short lived as little as a few hours or as long
as several months. On the average, due to the late stage CRPS, 14% cannot tolerate the foreign body of SCS and the only
way the SCS is kept in their body is by increasing the dosage of narcotics or using an additional narcotic to help the
patient tolerate the foreign body. The common example is adding MS Contin and MSIR together or Methadone and
MSIR together. Even then, the patient continues to have pain and discomfort and complains about the SCS, but that is
blamed as a pre-existing neuropathic pain.
Two percent (2%) of the SCS patients have had early (less than 24 hours) complications of the SCS causing
vasoconstriction in the distribution of the spinal artery branches resulting in temporary paraparesis. In one case the
stimulator was not removed or repositioned, and as a result the patient became permanently paralyzed.
Another complication is aggravation of spinal cord sensitization due to the electrical stimulation. This
complication was noted in 19% of the patients. The spinal cord sensitization is a relatively common late complication
of CRPS with or without SCS treatment. It is manifested by attacks of myelogenic myoclonic jerks, as well as myelogenic
akinetic attacks. These akinetic attacks usually go undiagnosed because of the fact that the patient already has poor
balance and a tendency for falling in late stage CRPS, and as a result the akinetic seizures are over looked or mistaken
for the chronic complication of poor balance in these patients. Akinetic seizures are quite stereotypical, and are easily
diagnoses by epileptologists due to its distinct clinical picture. This is manifested by the patient suddenly and briefly (one
second or more) losing the truncal muscle tonus and suddenly falling without any warning. The attacks may be quite brief
lasting for a few seconds to the point that the patient can catch their balance, or may be longer and the patient may fall.
The myoclonic and akinetic seizures are a common complication of spinal cord and brain stem dysfunction secondary
to chronic epilepsy, or even viral infections. It is not easily diagnosed by people who don’t have experience in
epiletology.
The 19% of cases that have had akinetic seizures were in contrast to 3% incidence in the chronic CRPS patients
who had not been treated with SCS.
ITI findings in patients that were treated with SCS showed no consistent vasodilation and hypothermic effect
by SCS treatment. Clinically, SCS may relieve the pain within the first few weeks or months of implantation. With the
passage of time, the pain and associated vasomotor response recur. This is simply another example of dysfunctional
sympathetic system in CRPS (4,10). In our study of 44 SCS implantations for CRPS pain, versus 42 SCS implantation
for FBS, the pain relief for CRPS patients was from five days to four months. In contrast, in FBS there was a tendency
for mild and partial pain relief lasting up to 18 months. Other researchers have tried ITI on SCS treated patients with
similar results (11,12).
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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#14
SUMMARY AND CONCLUSION
The use of spinal cord stimulators (SCS) is effective in treatment of somatic chronic pain (e.g., FBS and FNS)
but they are not helpful in the management of treating CRPS patients.
Finally, in the patients who cannot tolerate the hardware of SCS, the scar of surgery for the SCS becomes a new
and disabling source of neuropathic pain. The surgical area of insertion of the SCS becomes extremely hyperpathic,
allodynic, and the pain overshadows the original pathology for which the SCS was necessitated. This has nothing to do
with the quality of surgical procedure. I have had full training in neurosurgery and neurology, and I have found this
hypersensitivity of the scar not being related to the surgical technique, but seems to be due to the hyperpathia and
allodynia exacerbated by the electrical stimulation of the SCS.
The latter complication is so severe that when the patients are referred to us for treatment of late stage CRPS,
first we request that the SCS be removed before we can make any progress with pain management.
No single physician is smart and potent enough to treat CRPS. Successful treatment requires teamwork of
physical medicine, anesthesiology, and neuropharmacology physicians. The keys to successful treatment in CRPS are
early diagnosis, early mobilization and extensive physical therapy, and early detoxification of the patient from addicting
narcotics, alcohol, addicting tranquilizers and avoiding unnecessary surgical procedures such as SCS and amputation.
My ulterior motive in writing this paper is to help educate the patients and doctors in regard to these
procedures. It is for the welfare of the patients and as importantly it is a preventive medicine measure to avoid
wasted expense and further damage to the body.
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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#15
REFERENCES
1.McKenna KE and McCleane G: Dermatitis induced by spinal cord stimulator implant. Contact Dermatitis.1999; 41:
229.
2. Hooshmand H, and Hashmi H: Complex regional pain syndrome (CRPS, RSDS) diagnosis and therapy. A review of
824 patients. Pain Digest 1999; 9: 1-24.
3.Ochani TD, Almirante J, Siddiqui A, et al: Allergic reaction to spinal cord stimulator. Clin J Pain. 2000; 16; 178-180.
4. Hooshmand H: Chronic Pain: Reflex Sympathetic Dystrophy: Prevention and Management. CRC Press,
Boca Raton FL. 1993.
5. Poplawski ZJ, Wiley AM, Murray JF: Post traumatic dystrophy of the extremities. J Bone Joint Surg [Am]. 1983;
65:642-655.
6. Hooshmand H: Is thermal imaging of any use in pain management? Pain Digest 1998; 8:166-170.
7. Hooshmand H, Hashmi M, Phillips EM: Infrared thermal imaging as a tool in pain management - An 11 year study,
Part I of II. Thermology International 2001; 11: 53-65.
8. Hooshmand, H., Hashmi, M., Phillips, E.M.: Infrared Thermal Imaging As A Tool In Pain Management - An 11 Year
study, Part II: Clinical Applications, Thermology International 2001; 11: 1-13.
9. Rosenblum, JA: Spinal abdominal myoclonus. The Neurologist. 1996; 2: 784-787.
10. Birklein F, Riedl B, Claus D, et al: “Pattern of autonomic dysfunction in time course of complex regional pain
syndrome.” Clinical Autonomic Research 1998; 8: 79-85.
11. Devulder J, Dumoulin K, De Laat M, et al: Infra-red thermographic evaluation of spinal cord
electrostimulation in patients with chronic pain after failed back surgery. Br J Neurosurg 1996; 10: 379-383.
12. Pawl RP: Thermography in the diagnosis of low back pain. Neurosurg Clin N Am 1991; 2: 839-850.
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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#16
I hope this answers your questions why I am concerned.
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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#17
Sunshine go swimming and try the pain relief....if we worry about everything we get old and ugly.....pray and trust....
........I love cats, I just cant eat a whole one by myself......







 
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#18
There is no research that has documented improvement of CRPS after SCS implantation as you have begun to find out. There is an increasing body of evidence that actually implanting one ( since pain Dr.s have to eat too.....and pay for their country club membership, house in Fla, 4 cars and therapists for the dog ) leads to increase costs of care over not doing it and the outcomes as measured by improved function, including return to work, tended downwards.

On the other hand the data demonstrates improvement and often complete resolution with aggressive PT and elimination of narcotics etc.

Ask him to show you the data as the most common complication, infection into the spinal canal.........isn't a good one.

Sunshine7 Wrote:My new PMD is asking the insurance to approve Spinal cord stimulation for my pain, I'm worried about it please any info is appreciated thanks. also he wants me to go to Aquatic therapy, I have CRPS IN right great toe, foot, up to my lower back. also he put on there transpertation is needed and my husband told him that he wants to be there for me but the pmd still put it on the papers what should i do? When we went to the PMD today a nurse told my husband that men usurally don't stick or go to these DR. appt. with them, I can't imagine not having him there, and I do give him credit for putting up with me you could say, brave soul. I love him so very much.
 
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#19
The thing is going be used as a Trail first before the Implanted one takes place. That is the first thing. Next, you just can't shot down every treatment, as there are always risk with any treatment. What you need to do is ask plenty of question first when in front of the doctor. Such as why not just try PT AQUA and minor medication first, as a Stage one of your new program, instead of going all out at Stage 1.

Sunshine, trust me, for every article you find bad on this or anything, I am sure your going to find just as many that are good. I've been through this many times before. Yes, I did the research, and ask many questions, then if my treating doctor still said lets try, I would go for it. Like me any others, I too tried every conservative medical treatment first.
Reply's are intended solely for informational purposes. They are based on personal opinions, experience, or research and are "not to be taken as fact or legal advice", otherwise, always consult an attorney or a doctor.
 
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#20
Thanks for your replies and info.
Life is like the ocean, it can be calm one minute and the next a wave will knock you off your feet, it's up to you to get back up and take control.
 
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