Retrospective review of 707 cases of spinal cord stimulation: indications and complications.

Appropriate patient selection and minimizing complications are critical for successful spinal cord stimulation (SCS) therapy in managing intractable pain. We thus reviewed electronic medical records of 707 consecutive cases of patients who received SCS therapy in the Cleveland Clinic from 2000 to 2005 with an emphasis on indications and complications. SCS was used to treat complex regional pain syndrome (CRPS) (345 cases), failed back surgery syndrome (235 cases), peripheral vascular disease (20 cases), visceral pain in the chest, abdomen, and pelvis (37 cases), and peripheral neuropathy (70 cases). CRPS and failed back surgery syndrome accounted for 82% of the cases. The implant-to-trial ratio was 75% on average, with the highest for CRPS type 2 (83%) and the lowest for peripheral vascular diseases (65%). The only documented complication associated with SCS trials was lead migration in 5 of 707 patients (0.7%). There were no permanent neurological deficits or deaths as a result of SCS implant or its complications. Hardware-related complications were common (38%) and included lead migration (22.6%), lead connection failure (9.5%), and lead breakage (6%). Revisions or replacements were required in these cases. Biologically related complications included pain at the generator site (12%) and clinical infection (4.5%; 2.5% with positive culture). The rates of infection varied among the different diagnoses with the highest in failed back surgery syndrome (6.3%). Patients with diabetes had an infection rate of 9%, over the 4% in non-diabetics. Infections were managed successfully with explantation and antibiotic therapy without permanent sequela.

Clinical applications of neurostimulation: forty years later.

With the recent technological advances, neurostimulation has provided new hope for millions of patients with debilitating chronic pain conditions that respond poorly to other therapies. Outcome research demonstrated that patients with failed back surgery syndrome and complex regional pain syndromes benefit significantly from neurostimulation in pain reduction, functional capacity, and quality of life. Increasing clinical evidence supports the use of neurostimulation in post-herpetic neuralgia, peripheral neuropathy, occipital neuralgia, and other neuropathic pain conditions. Strong clinical evidences indicate that neurostimulation offers less invasive and more effective therapies for many patients with ischemic pain caused by cardiovascular and peripheral vascular diseases. A growing body of literature supports neurostimulation for visceral pain in general and interstitial cystitis in particular. As a basic principle, patient selection for the appropriate neurostimulation modalities is essential for safe, efficacious, and cost-effective applications of this therapy. Research with more vigorous designs is needed to establish evidence-based applications of neuromodulation therapy in emerging indications of pain management.

Radiofrequency treatment in chronic pain.

Chronic pain management physicians and patients are always looking for long-term solutions rather than short-lived interventions. There are three main nonsurgical modalities to ablate nervous system elements. These involve the use of extreme cold (cryoablation), high temperature radiofrequency and chemical neurolysis, such as alcohol or phenol. Radiofrequency ablation offers the advantage of being precise, reproducible and effective to a great extent. It also has the ability to stimulate before the ablation to avoid ablating the wrong nerve elements, which provides a considerable safety margin. In this article we will review the basis of radiofrequency ablation and some of the most common applications in the management of chronic pain.