Spinal Cord Stimulation: Indications and Outcomes

Anthony W. Lee, M.D.1; Julie G. Pilitsis, M.D., Ph.D.2

Disclosures

Neurosurg Focus. 2006;21(6) 

In This Article

Summary and Introduction

Spinal cord stimulation (SCS) is the most commonly used implantable neurostimulation modality for management of pain syndromes. In this paper the authors describe the current indications for SCS and its efficacy in the treatment of those diseases. Specifically, the literature on patient selection and outcomes after SCS for failed-back surgery syndrome (FBSS), refractory angina pectoris, peripheral vascular disease, and complex regional pain syndrome (CRPS) Type I was reviewed. Effective pain relief was obtained in 60 to 80% of patients with FBSS and CRPS Type I. Furthermore, these patients had significant improvements in quality of life (QOL) and a significantly greater chance of returning to work than patients who did not undergo SCS. The use of SCS in patients with inoperable angina (that is, refractory angina pectoris) resulted in significant decreases in chest pain and hospital admissions as well as increased exercise duration, with less morbidity than with open procedures that were performed for pain control only. Patients with inoperable PVD also demonstrated significant improvements in pain relief, QOL, and limb mobility. Reported complications were mostly related to hardware and were relatively minor. Review of randomized controlled studies supports the use of SCS as an effective treatment modality for pain associated with FBSS, refractory angina pectoris, peripheral vascular disease, and CRPS Type I.

Spinal cord stimulation is a pain treatment modality predicated on reducing the intensity, duration, and frequency with which pain is felt. Although it was developed on the basis of the gate control theory of pain proposed by Melzack and Wall,[37] its mechanism of action involves more than inhibition of pain pathways in the dorsal horn nucleus.[39] Experimental studies involving neurotransmitters (for example, g-aminobutyric acid and adenosine[34,40]) have been used to explain other pathways by which SCS works. Further more, modulation of the autonomic nervous system may explain the efficacy of SCS for pain syndromes such as refractory angina pectoris and CRPS.[2,7,13,20] Although its exact mechanisms of action are not fully understood, SCS has been shown to be beneficial in the treatment of several pain syndromes, with fairly consistent results.[9,28,32,46] A number of randomized control led trials and numerous case series with long-term follow-up reports on SCS have been performed.[9,12,21,24,25,27,28,31,42,43,44,59,60] In this paper we discuss general patient selection criteria for SCS and summarize indications and outcomes that have been reported for SCS in the treatment of FBSS, refractory angina pectoris, peripheral vascular disease causing critical leg ischemia, and CRPS Type I.

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