The use of high-dose cervical spinal cord stimulation in the treatment of chronic upper extremity and neck pain
Background:Dorsal column spinal cord stimulation is used for the treatment of chronic neuropathic pain of the axial spine and extremities. Recently, high-dose (HD) thoracic dorsal column stimulation for paresthesias has been successful. This study evaluates the utility of HD stimulation in the cervical spine for managing upper neck and upper extremity pain and paresthesias.
Methods:Three patients suffering from cervical and upper extremity chronic pain were assessed. Each underwent a two-stage process that included a trial period, followed by permanent stimulator implantation. Therapy included the latest HD stimulation settings including a pulse width of 90 μs, a frequency setting of 1000 Hz, and an amplitude range of 1.5 amps–2.0 amps. Pain relief was measured utilizing relative percent pain improvement as self-reported by each patient before and after surgery.
Results:After permanent implantation, (range 15–21 months), all three patients continued to experience persistent pain and paresthesia relief (70%–90%).
Conclusions:In three patients, HD cervical spinal cord stimulation successfully controlled upper extremity chronic pain/paresthesias.
Within the past few decades, the use of dorsal column stimulation has increased as an alternative method for the long-term treatment of chronic neuropathic pain of the axial spine and extremities. Here, we explored the efficacy of high-dose (HD) cervical column stimulation in three patients. Our aim was to better define the appropriate programming needed to attain cervical paresthesia-/pain-free control.
The three patients involved in this study averaged 48 years of age and included two males and one female [Table 1]. All patients presented with upper extremity pain and underwent cervical magnetic resonance (MR) studies to document sufficient space within the cervical canal to place a stimulator.
MR imaging findings
The MR for one patient showed that they have sustained a gunshot wound to the nerve roots; however, the spinal cord was intact, and there was no stenosis or significant degenerative disease. The second patient had as cervical degenerative foraminal disease with moderate central stenosis from C2 through C7; these contributed to cervicalgia and bilateral radiculopathy. Patient 3 did show no cervical degenerative changes (diagnosis of chronic regional pain syndrome).
Initial external trial
Each patient underwent a Stage 1 cervical spinal cord stimulator trial placement with externalized extension leads. This required two 1 × 8 percutaneous epidural arrays advanced to the c2/3 level bilaterally or eccentric to the affected side. A 5-day programming trial of both low-dose (LD) paresthesia and HD paresthesia-free therapy was applied. All three patients experienced >50% pain relief without paresthesias using pulse width 90 μs, frequency setting 1000 Hz, and amplitude range of 1.5 amps–2.0 amps. Stage 2 extension lead removal with generator connection and implantation (permanent) was performed in all three cases.
During the trial period, all patients experienced >50% pain relief (range 70%–90%) without paresthesias utilizing the HD program. Pain returned to baseline levels with the device off. LD therapy was less successful [Table 2]. Trial period results led to permanent cervical spinal cord stimulator implantation without any complications. All three patients continue to experience persistent and current paresthesia-free pain control (range 15–21 months).
These three patients indicate the feasibility of using HD cervical spinal cord stimulation to elicit paresthesia free pain control. One study in literature also reports the effective use of HD stimulation in both the cervical and dorsal spinal column for the sole purpose of pain control. Notably, all three patients like some found in literature disliked the paresthesias that accompanied LD stimulation in the programming trial; this led some in the other studies to defer therapy. In the future, more extensive studies should be conducted to determine the long-term effects of HD cervical spinal cord stimulation.
Risks and complications
These stimulators were placed in the same location as dorsal column stimulators. To date, there are no known complications of HD stimulation programming. A meta-analysis of surgical complications for spinal cord stimulator placement reports mean complication rates as follows: lead migration (15.49%), lead fracture/malfunction (6.37%), pain at the site (6.15%), infection (4.89%), battery failure (1.7%), major neurologic deficit (0.25%), and hardware erosion (7%). Further studies are required to investigate the long-term safety of HD stimulation.
Three patients underwent HD cervical spinal cord stimulation and attained pain-/paresthesia-free treatment of upper extremity/neck chronic pain generators. However, the significant risks and complications of these procedures must be carefully taken into account when choosing to use this treatment modality for pain alone.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
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