1. SCS and IDDS: Patient Selection
Marshall D. Bedder M.D., F.R.C.P. (C)
Director Interventional Pain
Pacific Medical Centers
Seattle, WA

2. SCS/ IDDS

3. Pain Management: A More Flexible Approach
Different time frames
Multiple therapies at one time
Different starting points
Corrective
surgery
Complementary medicine, behavioral programs, adjuvant meds
Long-term
oral
opioids
SCS
Physical
therapy,
TENS
Pain Management: A More Flexible Approach
The traditional ladder approach suggests an equal trial at every step of the treatment
continuum. However, every chronic pain patient is different, and his or her physician’s
clinical experience is different.
For those reasons, a physician may decide a shorter trial of one type of therapy is
sufficient or that multiple therapies can be explored at the same time.
Or a physician’s clinical experience and the patient’s condition may suggest a different
starting point on the continuum.
Implantable therapies should be considered after failure of more conservative measures.
Graphic developed by Medtronic Pain Therapies (Medtronic U.S. Pain Business), 2000.
Published in Prager J and Jacobs M. Evaluation of patients for implantable pain modalities: medical and behavioral assessment. Clin J Pain Sep;17(3):
NSAIDs,
over-the-counter
drugs
Chronic
Pain
Patient
IDD
Neuroablation
* Prager J and Jacobs M. Evaluation of patients for implantable pain modalities: medical and behavioral assessment. Clin J Pain Sep;17(3):

4. IDDS

5. IDDS: Patient Selection
Severe spasticity
Chronic intractable cancer pain
Chronic intractable non cancer pain

6. Synchromed II Drug Infusion U.S. FDA approved Indications
Preservative free Morphine in the treatment of chronic intractable pain
Ziconotide for severe intractable pain
Baclofen for severe spasticity

8. Criteria Antispasmodic drugs for severe spasticity
Chronic intractable spasticity
Unresponsive to to less invasive medical therapy
Usually a 6 week trial of oral antispasmodic drugs
Responds favorably to a trial of intrathecal baclofen

9. Criteria Chronic Intractable Pain
Severe chronic intractable cancer or CNCP
Life expectancy of at least three months
Functional disability
Increasing pain and side effects despite rotating oral opioids
Surgery is ruled out
No active or untreated addiction
Lack of contraindications
Psychological assessment for appropriateness
Successful trial

10. SCS

11. Spinal Cord Stimulation (SCS)
Patient Selection

12. SCS FDA Indications
Difficult to treat chronic pain of the body and limbs
Pain associated with failed back surgery syndrome
Low back pain and leg pain.

13. SCS Indication
Intractable pain of the trunk and/or limbs-including unilateral or bilateral pain associated with the following conditions:
Failed Back Syndrome (FBS) or low back syndrome or failed back
Radicular pain syndrome or radiculopathies resulting in pain secondary to FBSS or herniated disk
Multiple back operations, Unsuccessful disk surgery
Degenerative Disk Disease (DDD)/herniated disk pain refractory to conservative and surgical therapies
Peripheral causalgia
Complex Regional Pain Syndrome (CRPS), Reflex Sympathetic Dystrophy (RSD), or causalgia

14. Neuropathic Pain
Caused by damage to the peripheral or central nervous system or by pathologic changes in neuro-functional relationships within these systems
Pain most often described in terms:
Tingling
Burning
Shooting, lightening like

15. Neuropathic Pain (cont)
Often opioid resistance with a rightward shift of dose response curve
Examples include:
Sciatica
Phantom limb pain
Postherpetic neuralgia
Complex regional pain syndrome (CRPS)
Diabetic neuropathy

16. Neuropathic Pain Central sensitization Wind-up
Role of NMDA and other receptors

17. Evidence for IDDS Pro Con Good evidence for spasticity
Good evidence for cancer pain
Con
Thimineur et al. Pain 2004 June. Three year prospective study.
Showed that when patients with extremely severe pain problems are selected as pump candidates, they will likely improve, but their overall severity of pain and symptoms still remains high

18. Evidence for IDDS
The systematic review by Patel et al (ASIPP) 2009 was unable to find any randomized trials evaluating the effectiveness of intrathecal infusion systems on a long-term basis. Consequently, a decision was made to develop consensus guidelines.

19. Effects of SCS on Sensory Systems
Segmental
Non-segmental
Central
Electrical
Chemical
Electrical
Chemical ?
Attenuation of SSEP’s
Thalamic activation
(VPL, CM)
Norepinephrine
Dopamine
Lamina I, II
Lamina V
GABA
Glycine
5-HT
substance P
Depolarization of large diameter fibers
Antidromically conducted AP’s
Frequency-related conduction block
Hyperpolarization effect (anodal)