Neuromodulation for Chronic Pain

Leading the ‘Neuromodulation Revolution – 12/12/2016 – by Bob Kronemyer

Recent advances in neuromodulation and other innovative technologies have created viable alternatives to opioids for chronic pain, according to experts at a recent panel discussion.

Dr. Slavin said it is a myth that corrective spinal surgery can resolve long-term opioid use.

“In fact, there is plenty of literature that shows that people who use opioids have pain prior to spine surgery most likely will continue to use opioids have pain after surgery and that chronic opioid use pain significantly worsens surgical outcomes,” he said.

I had to correct the paragraph above because it confuses “using opioids” with “having pain”. This confusion is widespread and confounds all opioids studies these days.  

“This kind of makes sense because structural procedures are not expected to remedy the imbalance of transmitters or normalize receptors. Neuromodulation, on the other hand, can do that, and long term it is definitely safer than long-term opioids.”

Dr. Slavin is an advocate of neuromodulation, partly because the permanent device is reversible, adjustable and can be tested.

“However, it is always helpful to conduct a trial first of any therapeutic intervention before long-term treatment,” he said. “It is also nice to have therapy that can be adjusted, based on the individual patient’s condition and needs.” Third, being able to turn off treatment minimizes side effects, and if the need to treat diminishes with healing, the device may be permanently removed.

Today, there are many different approaches to neuromodulation

Advances in SCS

Dr. Slavin identified two new permanent implants from St. Jude Medical that he uses.

  1. Axium, FDA approved in February 2016, delivers stimulation through the dorsal root ganglion instead of stimulating the spinal cord.
    “The dorsal root ganglion is where the initial processing of pain takes place,” Dr. Slavin said. “By targeting this region, the device uses much less energy than conventional stimulation and provides more focused stimulation to the flow of painful information.”
  2. The other new system, BurstDR, approved in October 2016, transmits stimuli in patterns of burst at a specific frequency.
    “There is one signal, and the cell discharges several times as a single burst,” Dr. Slavin noted. “This provides significantly more potent activation downstream. By activating further downstream, you can achieve much more reliable and much more robust responses.”

Apart from better pain control, BurstDR also allows for the absence of paresthesia in most cases, Dr. Slavin added.

As technology advances, our treatments become more effective and safe. And instead of one size fits all, we now have much more individualized treatments that match the patient’s pain pattern, pain nature and pain location. So we are becoming much more sophisticated in choosing the right modality for the right indication.”

Over the past five years, “we have found that varying the frequency of electrical stimulation has a tremendous impact on the success of these devices,” said Dr. Poree in a postpanel interview.

For example, the Senza spinal cord stimulation (SCS) system from Nevro Corp., which was approved by the FDA in March 2015, benefits from its use of high frequency.

However, we are finding that much higher frequencies, like the Senza, which uses 10,000 Hz, provide significant pain control, but are not associated with the tingling/paresthesia sensation that most people get with most of the standard stimulators

The Evoke Spinal Cord Stimulation System (Saluda Medical Pty Ltd.) is scheduled to begin its first U.S. trial in January primarily for back and leg pain. “This brand-new type of device actually sends a signal to your spinal cord, and then the signal measures the response of the spinal cord,

the parameters of Evoke change, based on the electrical response of the spinal cord.”

Benefits of Intrathecal Therapy

Intrathecal therapy also has been shown to be effective in treating chronic pain.

The implantable pump into the abdominal wall delivers high concentrations of very low-dose medication to the cerebral spinal fluid for focal pain control.

“Patients taking 300 mg of oral morphine is approximately equivalent to 1 mg of intrathecal morphine,

About five years ago, he said, intrathecal treatment was enhanced by patients being able to control the delivery of medication rather than a continuous pump. “This has allowed for much better control, with a lot fewer side effects and problems,

Long-Term Relief With Radiofrequency

RF is a technique used to interrupt certain types of pain signals in the body.

Small RF lesions are created in pain nerves to treat some types of chronic neck pain, low back pain and knee pain.

Dr. Burton said RF is an established component of chronic pain medicine treatment. “Generally, a single RF procedure will provide somewhere between six to 12 months of pain relief,” he said.  

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