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Spinal Cord Stimulation: Placement of Surgical Leads via Laminotomy: Techniques and Benefits
Introduction
Spinal cord stimulation (SCS) provides a nondestructive and adjustable method of providing symptomatic relief of neuropathic pain across several indications. Based on Melzak and Wall’s Gate Control Theory of Pain ( ), electrical stimulation of dorsal column fibers within the spinal cord replaces painful dysesthesia with a more tolerable tingling paresthesia ( ). Recently, paresthesia-free SCS has been explored, and perhaps a new mechanism of pain control will be established ( ). Many methods and configurations of SCS currently exist on the market, each with their unique advantages and limitations that can be selected to optimize coverage of these dorsal column fibers ( ). Understanding the principles that influence the neuromodulatory effect of SCS during the preoperative selection of patient and device and the operative implantation of each device within a specific patient’s anatomy is critical to optimizing pain relief and functional improvement.
Common Indications
Failed Back Surgery Syndrome
Failed back surgery syndrome (FBSS), or postlaminectomy syndrome, is a spectrum of chronic axial and limb pain refractory to, or exacerbated by, previous surgical interventions ( ). Typically, these patients describe axial low lumbar back pain, buttock pain, and limb pain without clear anatomic or dermatomal distributions or mechanical causes. Although poorly defined as a singular entity, chronic inflammation in the setting of arachnoiditis, radiculitis, microinstability, and recurrent disk herniations have been implicated in the pathophysiology of FBSS. However, patients who develop FBSS represents a group of chronic back pain patients who may have a neuropathic component to their pain complex and may respond to SCS therapy ( ). In randomized controlled trials completed to date, SCS has demonstrated significant benefit for patients with FBSS compared with repeat spine surgery in pain relief and opiate consumption at 3-year postoperatively ( ) and health-related quality of life measures at 6 months ( ).
Complex Regional Pain Syndrome
Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy (RSD), is chronic and progressive dysregulation of the peripheral autonomic nervous system resulting in hyperalgesia and allodynia, swelling, and progressive tissue injury of the affected limb ( ). Neurogenic inflammation leads to an abnormal vasomotor response within the tissue. CRPS type I occurs after a noxious stimulus, often nontraumatic, which initiates an inappropriate response to painful stimulation. CRPS type II occurs after nerve injury, resulting in a similar pattern of maladaptive nociception and physiologic response. Multiple trials support the use of SCS therapy for durable analgesia, which has resulted in significant improvements in patient quality of life ( ).
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