1. Advanced Interventional Options for Chronic Pain October 9, 2105 Daniel Kwon, MD

2. Disclosure  No Conflict of Interest

3. Spinal Cord Stimulators (SCS)  Implanted medical device that delivers electrical pulses to the nerves in the spinal cord that can interfere with transmission of chronic pain signals and replace them with a paresthesia-like sensation (some devices offer paresthesia free stimulation of the spinal cord)  Manufacturers include: Boston Scientific, Medtronic, Nevro, and St. JudeMedical  Mechanism of action not completely understood, but theories include:  Effect on the dorsal horn level, including suppression of the wide-dynamic-range neurons.  Activation of inhibitory GABA-ergic and cholinergic spinal interneurons, while decreasing glutamate at the dorsal horn  Stimulation-induced suppression of central excitability  Stimulation-induced inhibition of sympathetic nervous system influence

4.  Appropriate patient selection.  Different manufacturers have slightly different indications but generally the same: FDA approval includes: … “chronic intractable pain of the trunk and/or limbs, including unilateral or bilateral pain associated with the following: failed back surgery syndrome, intractable low back pain and leg pain.”  Other indications include complex regional pain syndrome, reflex sympathetic dystrophy or caualgia.  Initially spinal cord stimulator trial leads are placed temporarily for several days.  If the patient has a positive test (50% or greater relief), then the system may be surgically implanted. Spinal Cord Stimulator Trial

5. Spinal Cord Stimulators (SCS)  Procedural  Surgically implanted generator in the body, often the hip/gluteal region  Electrodes placed into the epidural space

6. Spinal Cord Stimulators (SCS)

8. Intrathecal Drug Delivery (IT Pain Pump)  This is a device that delivers medications directly to the spinal cord.  The pump is generally implanted under the skin at the abdomen or posterior hip/gluteal region with a catheter that is tunneled into the spinal canal.  FDA approved medications for IT drug delivery include baclofen, morphine, and ziconitide  Manufacturers include Medtronic and Flowonix

9. Intrathecal Drug Delivery (IT Pain Pump)  FDA indications include treatment of chronic intractable pain and severe spasticity.

10. Intrathecal Drug Delivery (IT Pain Pump)

11. Conclusions  Spinal Cord Stimulators and Intrathecal Pain Pumps have a role in management of chronic pain.  However there is a significant risk associated with these interventional options, and a careful assessment of the risks and benefits needs to be performed prior to going forwards with these treatments.