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Lumbar Spinal Cord Stimulation

What does “Lumbar Spinal Cord Stimulation” mean?

Here is the meaning of each word:

  1. Lumbar: the area of the spine located in the low-back
  2. Spinal Cord Stimulation: using electrical impulses to disrupt pain signals in the spinal cord.

Altogether, “Lumbar Spinal Cord Stimulation” means to use electrical impulses in the low back to disrupt pain signals in the spinal cord.

How does the technology of Spinal Cord Stimulation work?

Small electrical wires (spinal cord stimulation leads) are placed into the epidural spine, located outside the dural sac in the spine. This sac contains the spinal cord, spinal nerve rootlets and spinal fluid.

The wires are hooked up to an electrical generator, which sends electrical impulses from the epidural space through the dura and spinal fluid, to the spinal cord itself.

It is not exactly known what happens when the electrical impulses are received by the spinal cord. Here are some hypotheses:

  1. The electrical impulses keep pain signals from being transmitted.
  2. The electrical impulses change the chemistry in the spinal cord which inhibits pain.
  3. The electrical impulses stimulate chemicals which stop pain pathways.

Why is a Lumbar Spinal Cord Stimulation procedure done?

Lumbar Spinal Cord Stimulation is done to relieve pain by using electrical impulses to disrupt the transmission of pain signals in the spinal cord. Often there are no other surgical options for these patients, and they may have exhausted other options such as medications, injections, Physical Therapy, etc.. These patients usually have a poor quality of life.

What is the difference between a Lumbar Spinal Cord Stimulation “Trial” and a Lumbar Spinal Cord Stimulation “Permanent Implant”.

  1. A “trial” means that this technology is first tried out for a period of time before it is implanted in the body. The doctor places small wires (electrical leads) through the skin and into the epidural space for a period of time to see if this technology works for the patient. The wires are then hooked up to a small hand-held electrical generator. This device can be used to turn the electrical stimulation on and off, up and down. Also, the specific type of stimulation received by the patient can be modified. The patient then “tries out” the technology for a period of time (days to weeks). After this “trial”, the electrical leads are removed.
  2. A “permanent implant” means that a Lumbar Spinal Cord Stimulation System is permanently implanted into the patient. The wires (electrical leads) are placed into the epidural space and a small electrical generator is implanted under the skin. The patient has a “remote control” device to turn the generator on and off, up and down, and can adjust numerous settings or how and where the stimulation is felt. The whole Spinal Cord Stimulation system can stay in the patient indefinitely.

How is a Lumbar Spinal Cord Stimulation procedure done?

Here are the steps of how a Lumbar Spinal Cord Stimulation procedure is performed:

  1. Lumbar Spinal Cord Stimulation Trial
    1. This procedure is often done in a Procedure Room or Operating Room.
    2. An intravenous catheter (IV) is placed. The patient is given relaxing medication (sedation).
    3. The patient is placed on the stomach (prone).
    4. The area of the low-back is cleaned with a surgical antispectic solution and sterile sheets (drapes) are placed around the surgical area.
    5. The skin is injected with local anesthetic.
    6. A specialized needle is placed between the vertebrae and advanced to the epidural space with the help of an X-Ray machine.
    7. A spinal cord stimulation lead (electrical wire) is placed through the specialized needle into the epidural space.
    8. The spinal cord stimulation lead is advanced upwards into the epidural space to the targeted spinal level.
    9. The spinal cord stimulation lead is attached to an external small generator.
    10. The doctor applies small currents of electrical activity to the spinal cord stimulation lead with the generator. The patient’s response is recorded. The patient is asked how and where they feel the stimulation of the spinal cord. Usually this is felt as a vibration or tingling sensation. The doctor may move the spinal cord stimulation lead until the patient feels the stimulation in the area where the pain is typically located.
    11. The needle is now removed, but the spinal cord stimulation lead is left in the epidural space. The place where this lead leaves the skin is secured. Sometimes stitches (sutures) are used to secure the lead to the skin. The remaining lead outside the patient is taped in place to prevent it from being pulled out.
    12. The patient is turned on the back (supine) and brought to the Recovery Area.
    13. In the Recovery Area, the spinal cord stimulation lead is attached to a small hand-held generator. The generator is turned on and is then adjusted to provide stimulation in the area of the body where pain was usually felt. The pain is typically replaced by a vibration or tingling sensation, which is not painful.
    14. The patient is then discharged home to try this technology for a period of time (usually at least several days).

 

2. Lumbar Spinal Cord Stimulation Non-Surgical Implant

  1. This procedure is done in an Operating Room or Procedure Room.
  2. An intravenous catheter (IV) is placed and antibiotics are given.
  3. The patient will receive relaxing medication in the IV.
  4. The patient is initially positioned on their stomach (prone).
  5. The low-back is cleaned with a sterile surgical antiseptic and sterile sheets (drapes) are place around the surgical area.
  6. Local anesthetic medication is injected under the skin.
  7. A specialized needle is inserted through the skin and advanced with the help of the X-Ray machine into the epidural space outside the spinal cord, spinal fluid and their lining (dura).
  8. A spinal cord stimulation lead (electrical wire) is placed through the specialized needle and advanced upward into the epidural space.
  9. The spinal cord stimulation lead is attached to a Spinal Cord Stimulation Generator.
  10. The patient is instructed to tell the doctor and nurses when they feel a sensation in the low back or leg as the generator is turned on and the settings are adjusted.
  11. The spinal cord stimulation lead placement is adjusted until the doctor believes the area of the patient’s pain is covered by the stimulation.
  12. A small cut (incision) around the specialized needle is now made with a surgical knife.
  13. The specialized needle is then withdrawn and the electrical lead kept in place.
  14. The lead is attached to small anchoring devices which are attached to the spine with stitches (sutures).
  15. The lead is attached to a longer extension.
  16. At this point, a final position for the implanted generator is chosen. Depending on this location which could be on the abdomen or buttock area, the patient is repositioned to allow easy access to this area. This area is then cleaned with surgical antiseptic and draped.
  17. Another small cut (incision) is made to accommodate the spinal cord stimulation generator. The generator is attached to the lead extension and placed into the incision.
  18. Both of the cuts (incisions) are then closed using stitches (sutures).
  19. Bandages are placed over each wound.
  20. The patient is then turned on their back (supine) and brought to the Recovery Area.
  21. The spinal cord stimulation generator is then turned on and adjusted to cover the correct area of pain.

3. Lumbar Spinal Cord Stimulation Surgical Implant

  1. This procedure is done in an Operating Room.
  2. An intravenous catheter (IV) is placed and antibiotics are given.
  3. The patient will be placed under a general anesthetic while on their back (supine) and then carefully placed on the stomach (prone)
  4. The mid-back is cleaned with a sterile surgical antiseptic and sterile sheets (drapes) are place around the surgical area.
  5. A small cut (incision) is made over the spine.
  6. The tissue under the skin is opened with a cautery.
  7. The muscles of the low back area are carefully separated from the spinous process and pushed to the side using a retractor (device to push tissue aside).
  8. A small piece of the lamina bone is removed to see the epidural space below it.
  9. A surgical spinal cord stimulation lead (larger than the non-surgical lead) is then directly inserted into the epidural space until it is in the ideal location.
  10. The lead is then attached to small anchoring devices which are secured to the spine with stitches (sutures).
  11. The lead is attached to a longer extension.
  12. At this point, a final position for the implanted generator is chosen. Depending on this location which could be on the buttock or abdominal area, the patient is repositioned to allow easy access to this area. This area is then cleaned with surgical antiseptic and draped.
  13. Another small cut (incision) is made to accommodate the spinal cord stimulation generator. The generator is attached to the lead extension and placed into the incision.
  14. The retractors are removed and the muscles of the neck reattached to each other (sutured).
  15. Both of the cuts (incisions) are then closed using stitches (sutures).
  16. Bandages are placed over each incision.
  17. The patient is then turned on their back (supine) and awoken from anesthesia.
  18. The patient is then brought to the Recovery Room for observation.
  19. Once the patient is awake and alert, the spinal cord stimulation generator is then turned on and adjusted to cover the correct area of pain.

How long does it take to perform a Lumbar Spinal Cord Simulation procedure?

The time it takes to complete the procedure depends on a variety of factors. A Lumbar Spinal Cord Stimulation trial procedure may take 1-2 hours to complete.

A permanent Lumbar Spinal Cord Stimulation implant procedure, either Surgical or Non-Surgical may take 2-3 hours to complete.

What is the recovery like from a Lumbar Spinal Cord Stimulation procedure?

  1. Recovery from a Lumbar Spinal Cord Stimulation Trial:

The recovery from a Lumbar Spinal Cord Stimulation Trial is minimal. Since no cuts (incisions) were made, there is no real incision. The area where the spinal cord stimulation lead enters the skin must be kept clean and dry.

  1. The patient is instructed not to bath until the system is removed.
  2. The patient may be instructed to take oral antibiotics during the trial phase.
  3. The patient will be given a pain diary to take frequent notes about their pain and how they are tolerating the stimulation of the spinal cord.
  4. The patient will be seen by the doctor when the trial period is over (usually less than a week).
  5. The spinal cord stimulation lead is then removed.
  6. The patient and doctor will discuss the outcome of the trial. The patient will decide whether this technology is something they want to pursue for a permanent implant.

 

      2. Recovery from a Lumbar Spinal Cord Stimulation Implant:

  1. Non-Surgical System
    1. The patient is often discharged home after a period of recovery (outpatient).
    2. The patient is given detailed instructions on appropriate activities, which are initially limited.
    3. The patient is given detailed instructions on how to use the Spinal Cord Stimulator Generator with the “remote control” unit. This “remote control” is placed over the skin where the generator is implanted and can then communicate with it.
    4. The patient is usually reevaluated within a few weeks for a wound check and an analysis of the Spinal Cord Stimulation System. The system is adjusted at this point if needed.
    5. After the incisions are healed (2-4 weeks), some activity restrictions may remain in effect. Mainly, the movement of the low back has to be somewhat restricted out of fear that the spinal cord stimulation lead may move as well. This could change the pattern of the stimulation perhaps not covering the painful area as well.

      2. Surgical System

  1. The patient is admitted to the hospital after surgery. Often the admission is overnight or for 2 days.
  2. At the time of discharge, the patient is given activity restrictions, such as limited bending, lifting, twisting, etc..
  3. Detailed instructions on the use of the Spinal Cord Stimulation System are given.
  4. The patient is reevaluated by the surgeon within several weeks after surgery.
  5. The Spinal Cord Stimulation System is analyzed and may be adjusted if necessary.
  6. After the incisions are healed (2-4 weeks), usually no real limitations on activity remain.

What kind of benefit can patients gain from a Lumbar Spinal Cord Stimulation procedure?

A Spinal Cord Stimulation System can be very effective in controlling pain. One of the benefits of this system is its flexibility. These devices have become highly programmable like mini-computers. There are many options on how and where the stimulation is felt.

Over time the benefit from the stimulation of the spinal cord may lessen.