A Review of Spine Neuromodulation Therapies:

Indications, Efficacy, and What (if any) influence SCS Has Upon the Tapering of Opioids

Outcomes

Learners completing this activity report improved abilities in:

Proper patient selection & screening
Post-procedure education & monitoring
Discussing the benefits and risks of spinal cord stimulation with patients
Managing opioids in relation to spinal cord stimulation
Making informed referrals

Learning Objectives

As a result of participating in this activity, learners will be able/better able to:

identify patients for whom spinal cord stimulation may be beneficial for the treatment of their chronic pain
identify patients who would NOT benefit from spinal cord stimulation

Overview

A contemporary clinical review of spinal cord stimulation therapy.

Including:

Differentiating SCS options

Evidence, Indications, Contraindications, & Patient Selection
- Failed back surgery syndrome
- Complex Regional Pain Syndrome (CRPS) Types I and II
- Intractable low back pain and leg pain
- Refractory angina
- Peripheral vascular disease
- Peripheral neuropathic pain
- Post-herpetic neuralgia
- Persistent back pain after surgery
- Chronic abdominal pain
- Painful diabetic neuropathy

New (effective July 1, 2021) Medicare prior authorization requirements

What, if any, impact SCS has upon tapering opioids

Desirable Physician Attributes

Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
Patient Care [ACGME/ABMS & IOM] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
Employ Evidence-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care and participate in learning and research activities to the extent feasible

Accreditation & Designation

Release date: This activity was released 8/28/2021.

Termination date: The content of this activity was eligible for CME Credit until 8/27/2024.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Richard Rosenquist discloses the following financial relationships within the past 24 months: Consulting: Mainstay Medical

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

Kretzschmar, M., Reining, M., & Schwarz, M. A. (2021). Three‐year outcomes after dorsal root ganglion stimulation in the treatment of neuropathic pain after peripheral nerve injury of upper and lower extremities. Neuromodulation: Technology at the Neural Interface, 24(4), 700-707.
Caylor, J., Reddy, R., Yin, S., Cui, C., Huang, M., Huang, C., ... & Lerman, I. (2019). Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectronic medicine, 5(1), 1-41.
Deer, T. R., Grider, J. S., Lamer, T. J., Pope, J. E., Falowski, S., Hunter, C. W., ... & Mekhail, N. (2020). A systematic literature review of spine neurostimulation therapies for the treatment of pain. Pain Medicine, 21(7), 1421-1432.
Vallejo, R., Kramer, J., & Benyamin, R. (2007). Neuromodulation of the cervical spinal cord in the treatment of chronic intractable neck and upper extremity pain: a case series and review of the literature. Pain Physician, 10(2), 305.
Sdrulla, A. D., Guan, Y., & Raja, S. N. (2018). Spinal cord stimulation: clinical efficacy and potential mechanisms. Pain Practice, 18(8), 1048-1067.
Al‐Kaisy, A., Van Buyten, J. P., Amirdelfan, K., Gliner, B., Caraway, D., Subbaroyan, J., ... & Kapural, L. (2020). Opioid‐sparing effects of 10 kHz spinal cord stimulation: a review of clinical evidence. Annals of the New York Academy of Sciences, 1462(1), 53.
Amirdelfan, K., Vallejo, R., Benyamin, R., Yu, C., Yang, T., Bundschu, R., ... & Caraway, D. (2020). High-frequency spinal cord stimulation at 10 kHz for the treatment of combined neck and arm pain: results from a prospective multicenter study. Neurosurgery, 87(2), 176-185.
Russo, M., Cousins, M. J., Brooker, C., Taylor, N., Boesel, T., Sullivan, R., ... & Parker, J. (2018). Effective relief of pain and associated symptoms with closed‐loop spinal cord stimulation system: preliminary results of the Avalon study. Neuromodulation: Technology at the Neural Interface, 21(1), 38-47.
Sharan, A. D., Riley, J., Falowski, S., Pope, J. E., Connolly, A. T., Karst, E., ... & Provenzano, D. A. (2018). Association of opioid usage with spinal cord stimulation outcomes. Pain Medicine, 19(4), 699-707.
De Ridder, D., Lenders, M. W., De Vos, C. C., Dijkstra-Scholten, C., Wolters, R., Vancamp, T., ... & Vanneste, S. (2015). A 2-center comparative study on tonic versus burst spinal cord stimulation: amount of responders and amount of pain suppression. The Clinical Journal of Pain, 31(5), 433-437.
Kumar, K., Taylor, R. S., Jacques, L., Eldabe, S., Meglio, M., Molet, J., ... & North, R. B. (2007). Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain, 132(1-2), 179-188.
Urits, I., Patel, A., Leider, J., Anya, A., Franscioni, H., Jung, J. W., ... & Viswanath, O. (2020). An evidence-based review of neuromodulation for the treatment and management of refractory angina. Best Practice & Research Clinical Anaesthesiology.
Mekhail, N., Levy, R. M., Deer, T. R., Kapural, L., Li, S., Amirdelfan, K., ... & Soliday, N. (2020). Long-term safety and efficacy of closed-loop spinal cord stimulation to treat chronic back and leg pain (Evoke): a double-blind, randomised, controlled trial. The Lancet Neurology, 19(2), 123-134.
Kapural, L., Yu, C., Doust, M. W., Gliner, B. E., Vallejo, R., Sitzman, B. T., ... & Burgher, A. H. (2015). 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, 123(4), 851-860.
Fishman, M. A., Calodney, A., Kim, P., Slezak, J., Benyamin, R., Rehman, A., ... & Vallejo, R. (2020). Prospective, multicenter feasibility study to evaluate differential target multiplexed spinal cord stimulation programming in subjects with chronic intractable back pain with or without leg Pain. Pain Practice, 20(7), 761-768.
Dougherty, M. C., Woodroffe, R. W., Wilson, S., Gillies, G. T., Howard III, M. A., & Carnahan, R. M. (2020). Predictors of reduced opioid use with spinal cord stimulation in patients with chronic opioid use. Neuromodulation: Technology at the Neural Interface, 23(1), 126-132.
Simopoulos, T., Sharma, S., Wootton, R. J., Orhurhu, V., Aner, M., & Gill, J. S. (2019). Discontinuation of chronic opiate therapy after successful spinal cord stimulation is highly dependent upon the daily opioid dose. Pain Practice, 19(8), 794-799.
Campwala, Z., Datta, P., DiMarzio, M., Sukul, V., Feustel, P. J., & Pilitsis, J. G. (2020). Spinal Cord Stimulation to Treat Low Back Pain in Patients With and Without Previous Spine Surgery. Neuromodulation: Technology at the Neural Interface.
Dones, I., & Levi, V. (2018). Spinal cord stimulation for neuropathic pain: current trends and future applications. Brain Sciences, 8(8), 138.
Caylor, J., Reddy, R., Yin, S., Cui, C., Huang, M., Huang, C., ... & Lerman, I. (2019). Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectronic Medicine, 5(1), 1-41.
Kapural, L., Brown, B. K., Harandi, S., Rejeski, J., & Koch, K. (2021). Effects of Spinal Cord Stimulation in Patients with Chronic Nausea, Vomiting, and Refractory Abdominal Pain. Digestive Diseases and Sciences, 1-8.
Sivanesan, E., Maher, D. P., Raja, S. N., Linderoth, B., & Guan, Y. (2019). Supraspinal mechanisms of spinal cord stimulation for modulation of pain: five decades of research and prospects for the future. Anesthesiology, 130(4), 651-665.
Schatman, M. E., Petersen, E. A., & Sayed, D. (2021). No Zero Sum in Opioids for Chronic Pain: Neurostimulation and the Goal of Opioid Sparing, Not Opioid Eradication. Journal of Pain Research, 14, 1809.
Petersen, E. A., Stauss, T. G., Scowcroft, J. A., Brooks, E. S., White, J. L., Sills, S. M., ... & Mekhail, N. A. (2021). Effect of high-frequency (10-kHz) spinal cord stimulation in patients with painful diabetic neuropathy: a randomized clinical trial. JAMA Neurology.
Liu, J. T., Su, C. H., Chen, S. Y., Liew, S. J., & Chang, C. S. (2018). Spinal cord stimulation improves the microvascular perfusion insufficiency caused by critical limb ischemia. Neuromodulation: Technology at the Neural Interface, 21(5), 489-494.