Name: treating low back pain in failed back surgery patients with multicolumn-lead spinal cord stimulation
Uploaded: 2018-06-26T12:30:00
Description: Watch this Scientific Journal Video about Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation at JoVE.com

The authors would like to thank Gabrielle Leyden for revising the final draft of this paper.

1. Patient Selection
<ol>
	<li>Make a diagnosis of FBSS20.</li>
	<li>Be sure that the FBSS patient meets all the inclusion criteria before being accepted for an SCS trial:
	<ol>
		<li>Chronic low back pain and/or radicular leg pain that were refractory to optimal medical therapy for a minimum of 6 months.</li>
		<li>Persistent pain despite 3 types of pharmacological treatments (paracetamol, non-steroidal anti-inflammatory drugs, opioids, antidepressant medications, anticonvulsan...

<ol>
	<li>Schofferman, J., Reynolds, J., Herzog, R., Covington, E., Dreyfuss, P., O'Neill, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Failed+back+surgery:+Etiology+and+diagnostic+evaluation.">Failed back surgery: Etiology and diagnostic evaluation.</a> Spine Journal. 3 (5), 400-403 (2003).</li><li>Hazard, R. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Failed+back+surgery+syndrome:+surgical+and+nonsurgical+approaches.">Failed back surgery syndrome: surgical and nonsurgical approaches.</a> Clinical Orthopaedics and Related Research. 443 (443), 228-232 (2006).</li><li>Rigoard, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+Algorithmic+Programming+Approach+for+Back+Pain+Symptoms+in+Failed+Back+Surgery+Syndrome+Using+Spinal+Cord+Stimulation+with+a+Multicolumn+Surgically+Implanted+Epidural+Lead:+A+Multicenter+International+Prospective+Study.">An Algorithmic Programming Approach for Back Pain Symptoms in Failed Back Surgery Syndrome Using Spinal Cord Stimulation with a Multicolumn Surgically Implanted Epidural Lead: A Multicenter International Prospective Study.</a> Pain Practice. 15 (3), 195-207 (2015).</li><li>Thomson, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Failed+back+surgery+syndrome+-+definition,+epidemiology+and+demographics.">Failed back surgery syndrome - definition, epidemiology and demographics.</a> British Journal of Pain. 7 (1), 56-59 (2013).</li><li>Balagu&#233;, F., Mannion, A. F., Pellis&#233;, F., Cedraschi, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Non-specific+low+back+pain.">Non-specific low back pain.</a> Lancet. 379 (9814), 482-491 (2012).</li><li>Melzack, R., Wall, P. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pain+Mechanisms:+A+New+Theory.">Pain Mechanisms: A New Theory.</a> Science. 150 (3699), 971-979 (1965).</li><li>Gonz&#225;lez, J. C. 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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+spinal+cord+stimulation+on+touch-evoked+allodynia+involve+GABAergic+mechanisms.+An+experimental+study+in+the+mononeuropathic+rat.">Effects of spinal cord stimulation on touch-evoked allodynia involve GABAergic mechanisms. An experimental study in the mononeuropathic rat.</a> Pain. 66 (2-3), 287-295 (1996).</li><li>Song, Z., Meyerson, B. A., Linderoth, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Muscarinic+receptor+activation+potentiates+the+effect+of+spinal+cord+stimulation+on+pain-related+behavior+in+rats+with+mononeuropathy.">Muscarinic receptor activation potentiates the effect of spinal cord stimulation on pain-related behavior in rats with mononeuropathy.</a> Neuroscience Letters. 436 (1), 7-12 (2008).</li><li>Song, Z., Meyerson, B. A., Linderoth, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spinal+5-HT+receptors+that+contribute+to+the+pain-relieving+effects+of+spinal+cord+stimulation+in+a+rat+model+of+neuropathy.">Spinal 5-HT receptors that contribute to the pain-relieving effects of spinal cord stimulation in a rat model of neuropathy.</a> Pain. 152 (7), 1666-1673 (2011).</li><li>Waszak, P. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spinal+Cord+Stimulation+in+Failed+Back+Surgery+Syndrome:+Review+of+Clinical+Use,+Quality+of+Life+and+Cost-effectiveness.">Spinal Cord Stimulation in Failed Back Surgery Syndrome: Review of Clinical Use, Quality of Life and Cost-effectiveness.</a> Asian Spine Journal. 10 (6), 1195-1204 (2016).</li><li>Kishima, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modulation+of+neuronal+activity+after+spinal+cord+stimulation+for+neuropathic+pain;+H(2)15O+PET+study.">Modulation of neuronal activity after spinal cord stimulation for neuropathic pain; H(2)15O PET study.</a> Neuroimage. 49 (2), 2564-2569 (2010).</li><li>Stanc&#225;k, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+magnetic+resonance+imaging+of+cerebral+activation+during+spinal+cord+stimulation+in+failed+back+surgery+syndrome+patients.">Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients.</a> European Journal of Pain (London, England). 12 (2), 137-148 (2008).</li><li>Yang, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bipolar+spinal+cord+stimulation+attenuates+mechanical+hypersensitivity+at+an+intensity+that+activates+a+small+portion+of+A-fiber+afferents+in+spinal+nerve-injured+rats.">Bipolar spinal cord stimulation attenuates mechanical hypersensitivity at an intensity that activates a small portion of A-fiber afferents in spinal nerve-injured rats.</a> Neuroscience. 199, 470-480 (2011).</li><li>North, R. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spinal+cord+stimulation+versus+re-operation+in+patients+with+failed+back+surgery+syndrome:+an+international+multicenter+randomized+controlled+trial+(EVIDENCE+study).">Spinal cord stimulation versus re-operation in patients with failed back surgery syndrome: an international multicenter randomized controlled trial (EVIDENCE study).</a> Neuromodulation: Journal of the International Neuromodulation Society. 14, 330-335 (2011).</li><li>Kapural, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+10-kHz+High-Frequency+and+Traditional+Low-Frequency+Spinal+Cord+Stimulation+for+the+Treatment+of+Chronic+Back+and+Leg+Pain:+24-Month+Results+From+a+Multicenter,+Randomized,+Controlled+Pivotal+Trial.">Comparison of 10-kHz High-Frequency and Traditional Low-Frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: 24-Month Results From a Multicenter, Randomized, Controlled Pivotal Trial.</a> Neurosurgery. 79 (5), 667-677 (2016).</li><li>Remacle, T. Y., Bonhomme, V. L., Renwart, H. J. P., Remacle, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+Multicolumn+Lead+Spinal+Cord+Stimulation+on+Low+Back+Pain+in+Failed+Back+Surgery+Patients:+A+Three-Year+Follow-Up.">Effect of Multicolumn Lead Spinal Cord Stimulation on Low Back Pain in Failed Back Surgery Patients: A Three-Year Follow-Up.</a> Neuromodulation: Technology at the Neural Interface. 20 (7), 668-674 (2017).</li><li>Veizi, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Spinal+Cord+Stimulation+(SCS)+with+Anatomically+Guided+(3D)+Neural+Targeting+Shows+Superior+Chronic+Axial+Low+Back+Pain+Relief+Compared+to+Traditional+SCS-LUMINA+Study.">Spinal Cord Stimulation (SCS) with Anatomically Guided (3D) Neural Targeting Shows Superior Chronic Axial Low Back Pain Relief Compared to Traditional SCS-LUMINA Study.</a> Pain Medicine (Malden, Mass). 18 (8), 1534-1548 (2017).</li><li>Chan, C., Peng, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Failed+back+surgery+syndrome.">Failed back surgery syndrome.</a> Pain Medicine. 12 (4), 577-606 (2011).</li><li>Hawker, G., Mian, S., Kendzerska, T., French, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Measures+of+adult+pain.">Measures of adult pain.</a> Arthritis Care and Research. 63 (11), 240-252 (2011).</li><li>Deer, T. 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Recent studies have demonstrated that SCS can reliably improve the different pain components of FBSS patients, improve their quality of life (e.g., quality of sleep and physical activity), and these benefits are sustained during a long-term follow-up3,17,18,19.
Depending on the localization of the pain, we use a different approach. When the patient has only ...

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Before FBSS can be established, other conditions, such as persistent nerve root compression, permanent nerve root injury as a consequence of the original compression or surgery, arachnoiditis, incorrect initial diagnoses, and documented mechanical causes for low back pain (such as spinal instability, posterior joint osteoarthritis, spondylolysthesis, and discogenic pain), should be excluded1,2,3. FBSS patients may have severe or disabling neuropathic pain, and the syndrome is worrisome since it is chronic and resistant to conventional treatment. Its incidence and prevalence are similar to those of rheumatoid arthritis4. It is thus a great burden for industrialized societies5.
Spinal cord stimulation (SCS) with dorsal epidural leads can be used to treat back pain (BP) and leg pain (LP) in FBSS patients, although the SCS pain relief mechanism has not been fully investigated. According to the gate control theory, which was first proposed by Ronald Melzack and Patrick Wall in 1965, the brain monitors the activity of a tiny neural network distributed along the dorsal horn of the spinal cord that is regulated by nociceptive but also non-nociceptive afferents6. These complex circuits in the superficial dorsal horn of the spinal cord are responsible for relieving pain in a specific location in the body when an intense tactile stimulus is applied to the same place7,8. However, several studies have shown that SCS is not only dependent on this theory. Several neurotransmitters (acetylcholine, gamma-aminobutyric acid, and serotonin) have been reported to have a role in the SCS mechanism9,10,11,12, as well as numerous brain areas13,14 and different spinal fibers15.
An SCS device includes an epidural lead, internal pulse generator (IPG), and an extension cable to connect the lead to the IPG. The stimulation settings are adjusted by an external remote control. Two types of electrode can be used, namely, percutaneous and surgical leads.
The efficacy of SCS in improving the radicular LP component of FBSS has already been demonstrated in previously published studies, including the EVIDENCE study16, and two new technologies have recently been shown to be effective for treating the BP component, which is known to be recalcitrant to SCS. The first one is high-frequency stimulation17. The second one is the use of surgical multicolumn lead3,18. The main disadvantages of the former technique are that their batteries need more frequent charging and that the programming optimization is challenged by longer &#34;wash-in&#34; times19. The latter technique is more invasive than the percutaneous high-frequency stimulation technique because it requires a small laminectomy, making peroperative paresthesia mapping under local anesthesia challenging, although possible3. Indeed, this procedure can be performed under local anesthesia supplemented by conscious sedation or spinal anesthesia3. In our institution, when targeting back pain in FBSS patients, we place such surgical leads through a small laminectomy at the 10th thoracic level with the patient under general anesthesia. The lasting efficacy of this method with such multicolumn leads for treating LP and BP in FBSS patients has been demonstrated by 3 year follow-up18. A detailed protocol of our method is given below.

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			<td>Ziehm Vision R FD</td>
			<td>Ziehm Imaging Inc.</td>
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			<td>Marcain 0.5% + adrenaline 1/200.000 20 mL</td>
			<td>Astrazenca</td>
			<td>PA 970/46/2</td>
			<td>0.5% Bupivacaine/1:200,000 adrenaline solution&#160;</td>
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			<td>external Neurostimulator (eNs)&#160;</td>
			<td>&#160;Medtronic Inc., MN, USA</td>
			<td>37022</td>
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			<td>Trousse de colonne lombaire CHR Citadelle (Procedure pack)&#160;</td>
			<td>M&#246;lnlycke</td>
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			<td>Maquet</td>
			<td>1150.30D0</td>
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			<td>OR Lights</td>
			<td>Trumpf</td>
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			<td>Specify SureScan MRI</td>
			<td>&#160;Medtronic Inc., MN, USA</td>
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			<td>Multicolumn lead</td>
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			<td>Primeadvanced surescan mri neurostimulator&#160;</td>
			<td>&#160;Medtronic Inc., MN, USA</td>
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			<td>Covidien</td>
			<td>GL123</td>
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			<td>Polysorb 1</td>
			<td>Covidien</td>
			<td>CL535</td>
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			<td>Covidien</td>
			<td>CL055</td>
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			<td>Cutiplast Steril 20x10 cm</td>
			<td>Smith&#38;Nephew</td>
			<td>66001475</td>
			<td>Bandage</td>
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			<td>MyStim Programmer</td>
			<td>&#160;Medtronic Inc., MN, USA</td>
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			<td>Pajunk</td>
			<td>001151-37Z</td>
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			<td>N&#39;Vision Programmer&#160;</td>
			<td>&#160;Medtronic Inc., MN, USA</td>
			<td>8840</td>
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			<td>3M Tegaderm Film 10x12cm</td>
			<td>3M Deutschland GmbH</td>
			<td>1626W</td>
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			<td>Extension Kit</td>
			<td>Medtronic Inc., MN, USA</td>
			<td>37081-40</td>
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			<td>Paracetamol</td>
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			<td>Tradonal&#160;</td>
			<td>Meda Pharma</td>
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			<td>Fresenius Kabi</td>
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			<td>Ketalar (Ketamine Hydrochloride)</td>
			<td>Pfizer</td>
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treating low back pain in failed back surgery patients with multicolumn-lead spinal cord stimulation

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be used to treat back and leg pain in FBSS patients. This paper presents a detailed protocol for using spinal cord stimulation with surgical leads in FBSS patients. In our department, with the patient under general anesthesia, we place the lead in the epidural space by means of a small laminectomy at the 10th thoracic level. Placement of the lead is followed by a 1 month trial period with an externalized lead. If pain relief is greater than 50% at the end of this 1 month stimulation trial (required by Belgian reimbursement criteria), an internal pulse generator is then placed under the skin and connected to the lead in a second surgical procedure. We have demonstrated that using this technique in rigorously selected FBSS patients can significantly improve back pain, leg pain, patient activity, and quality of life for a sustained period of time.

A prospective, non-randomized, controlled study of 62 consecutive FBSS patients who were implanted with a multicolumn lead using this method in our center, CHR Citadelle, in Li&#232;ge, Belgium, was recently published in Neuromodulation18 . All patients had had previous spinal surgery, had been screened for possible secondary causes of their pain, and were refractory to optimal medical therapy. Multicolumn surgical leads were placed in all 62 patients in the projec...

Watch this Scientific Journal Video about Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation at JoVE.com

Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

This paper presents a method that uses spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients.

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be ...

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