Name: Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation (Video) | JoVE Journal
Uploaded: 2018-06-26T12:30:00.000+00:00
Duration: 4 min 42 s
Description: Learn spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients. This standardized technique optimizes device positioning for enhanced pain relief and improved patient outcomes.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

The authors would like to thank Gabrielle Leyden for revising the final draft of this paper.

1. Patient Selection
<ol>
	<li>Make a diagnosis of FBSS20.</li>
	<li>Be sure that the FBSS patient meets all the inclusion criteria before being accepted for an SCS trial:
	<ol>
		<li>Chronic low back pain and/or radicular leg pain that were refractory to optimal medical therapy for a minimum of 6 months.</li>
		<li>Persistent pain despite 3 types of pharmacological treatments (paracetamol, non-steroidal anti-inflammatory drugs, opioids, antidepressant medications, anticonvulsant medications, etc.).</li>
		<li>Lemniscal pathways must remain at least partially intact (for paresthesia coverage of the painful area).</li>
	</ol>
	</li>
	<li>Rule out exclusion criteria for SCS in FBSS patients such as active infection, drug addiction or ongoing withdrawal, psychological contraindications, documented mechanical causes of low BP (discogenic pain, spondylolisthesis, spinal instability, and posterior joint osteoarthritis), and coagulopathy (due to risk of bleeding and epidural hematoma). Make sure that no coagulopathy is present by asking relevant questions, examining the patient and, if necessary, checking relevant blood tests for coagulopathy.</li>
</ol>
2. Neuromodulation Specialist
<ol>
	<li>If the FBSS patient meets the criteria for SCS, refer him to the neuromodulation specialist (NMS). 
	NOTE: The neuromodulation specialist in our team is a nurse. He is fully dedicated to pain and neuromodulation and is the coordinator of the pluridisciplinary team, which includes a psychologist, a physiotherapist, and a specialist pain nurse.</li>
	<li>Describe the anatomy of the pain pathways to the patient and explain the difference between nociceptive and neuropathic pain. Explain the sites of action of the different analgesic and co-analgesic medications. 
	NOTE: It is important that the patient understands the nature of neuropathic pain and can differentiate it from nociceptive pain. Once the patient has understood the physiology of their neuropathic pain, they are ready to learn about SCS.</li>
	<li>Explain to the patient the theoretical concept of SCS. The technique is believed to inhibit chronic pain by stimulating the large-diameter afferent nerve fibers in the spinal cord, in accordance with the gate control theory of pain.</li>
	<li>Measure the Visual Analog Scales (VAS) score21 for leg and back pain.</li>
	<li>Explain the objectives of the therapy:
	<ol>
		<li>Paresthesia coverage of the painful area of 50 to 70%.</li>
		<li>Reduction of pain (VAS score).</li>
		<li>Reduction in analgesic and co-analgesic medications.</li>
		<li>Improvement in the quality of sleep.</li>
		<li>Improvement in the quality of life.</li>
		<li>Improvement in the distance walked.</li>
	</ol>
	</li>
	<li>Explain the different components of an SCS device (epidural lead, internal pulse generator, and the extension cable connecting the lead to the IPG) and let the patient manipulate them to understand the system better.</li>
</ol>
3. Creation of the Health Insurance File by the NMS
<ol>
	<li>Describe in this file the characteristics of the patient&#39;s pain, quality of life, and quality of sleep, but also the patient&#39;s activities, walked distance, and analgesic and co-analgesic consumption. 
	NOTE: Under Belgian law, psychiatric evaluation is mandatory before any surgery to implant a foreign body. The psychiatrist has to rule out any psychiatric disorder and evaluate the patient&#39;s functional capacities in order to be able to accept and live with a foreign body.</li>
	<li>Attach the patient&#39;s medical record and the psychiatric evaluation to the Health Insurance File.</li>
</ol>
4. Implantation of the Multicolumn Lead
<ol>
	<li>Obtain the patient&#39;s informed consent after explaining the details of the surgical procedure, including the complications (infection 3&#8211;6%; serious neurological complications 0.54&#8211;1.71%; epidural hematoma 0.19&#8211;0.63%; spinal cord injury 0.022&#8211;0.067%; and cerebrospinal fluid leakage 0.05&#8211;0.001%)22. 
	NOTE: The long testing period required in Belgium is presumed to be the main reason for the higher infection rate (11%) observed in our institution, and we are currently trying to address this issue. This must be explained to the patient.</li>
	<li>In addition to the above risks, which are similar to those associated with other spinal procedures, explain the other risks normally associated with the use of an implant, such as allergic or immune system responses to the implanted materials; lead, extension, or neurostimulator erosion through the skin or migration; and formation of reactive tissue around the lead in the epidural space that can result in delayed spinal cord compression and paralysis, requiring surgical intervention. Time to onset can range from weeks to many years after implant. 
	NOTE: The neurological complication rates for percutaneous dorsal column stimulation leads are slightly higher (infection 3&#8211;6%; serious neurological complications 0&#8211;2.35%; epidural hematoma 0.75%; spinal cord injury 0.03&#8211;2.35%; and cerebrospinal fluid leakage 0.3%)22.</li>
	<li>If the patient doesn&#39;t have any contraindication, conduct an MRI to rule out any anomaly of the conus medullaris projection such as spinal dysraphism or other congenital spinal cord anomalies23.</li>
	<li>Perform antibiotic prophylaxis 30 min before incision using a single intravenous (IV) dose of Cefazolin, 50 mg/kg, with a maximum of 2 gm, through a 16 G needle placed in a peripheral route.</li>
	<li>With the patient under general anesthesia (use 0.1 &#181;g/kg Sunfentanil, 2 mg/kg Propolipid 1%, 0.3 mg/kg Ketamine Hydrochloride (see Table of Materials), and 0.3 mg/kg Rocuronium) and in the prone position, define the incision site between the spinous processes of T10 and T11 under fluoroscopic assistance.</li>
	<li>Infiltrate the incision site with 5 mL of a 20 mL solution of 0.5% Bupivacaine and 1:200,000 adrenaline (see Table of Materials).</li>
	<li>Incise until the thoracic aponeuroses are revealed.</li>
	<li>Dissect the paravertebral musculature on both sides of T10&#39;s supraspinous process and place the retractor.</li>
	<li>Resect the supraspinous and interspinous ligaments and dissect the lamina of T10 (5 mm on each side and 5 mm in the craniocaudal direction).</li>
	<li>Before inserting the lead, perform a partial laminectomy of T10 to create enough space to allow the insertion of the lead (no need to remove the entire lamina).</li>
	<li>Insert the phantom lead into the epidural space, while keeping the insertion of the flavum ligament on the upper part of the T11 lamina intact. 
	NOTE: This T11 lamina is used as a guide for the insertion of the lead into the epidural space.</li>
	<li>Place the lead as medially as possible under fluoroscopic guidance. The final lead&#39;s position is reached when placed midline in the projection of the bodies of T8&#8211;T9 under fluoroscopic control.</li>
	<li>Fix the lead to the interspinous ligament of T11 by doing a single interrupted stitch.</li>
	<li>Tunnel the extensions from your operative field to the lateral side of the back (often the right one) by using the tunneling tool provided by the company, and then connect them to the lead.</li>
	<li>Check fluoroscopically to be sure the lead has not moved and is still in the epidural space, midline, in the projection of T8&#8211;T9.</li>
	<li>Remove the retractor and make sure there is no bleeding.</li>
	<li>Suture the musculo-aponeurotic layer by means of simple interrupted stitches of braided synthetic absorbable suture material (see Table of Materials).</li>
	<li>Connect the two intrinsic external extensions to the two extrinsic external extensions. Tunnel them in the subcutaneous fat in such a way that they exit through the skin 15 cm laterally to the incision site. 
	NOTE: The choice of the side is discussed preoperatively with the patient and depends on the implantation location of the internal pulse generator.</li>
	<li>Wrap the intrinsic and extrinsic extensions and suture the subcutaneous layer by means of simple interrupted stitches of braided synthetic absorbable suture material (see Table of Materials).</li>
	<li>Make a dermic subcuticular suture using finer absorbable 3/0 suture material (see Table of Materials) and apply antiseptic and bandages. During this step, administer a single IV dose of 1g Paracetamol and 100 mg Tradonal.</li>
</ol>
5. Postoperative Trial
<ol>
	<li>When the lead is placed, connect it to an external stimulator for a period of four weeks. 
	NOTE: This long test period is required by the Belgian law as a condition to reimburse the implantation of the pulse generator during a second operation.</li>
	<li>Begin the programming sessions a few hours after surgery. The objective of the therapy is to cover the painful area by pleasant paresthesia.</li>
	<li>Connect the external neurostimulator to the extrinsic external lead extensions.</li>
	<li>Place the clinician programmer on the external neurostimulator. Turn the clinician programmer on and then turn the neurostimulation on. Start by setting the pulse width (PW) to 260 &#181;s, at a rate of 60 Hz.</li>
	<li>If LP was bilateral, perform a first screening using a guarded cathode (+-+), starting with the top-left tripolar longitudinal stimulation configuration (Figure 1), in order to identify the laterality of the lead (right/left).</li>
	<li>Perform a rapid scan of the left side with the four remaining left-side tripolar longitudinal stimulation configurations (Figure 2). An idea of the painful metameric level is determined during this unilateral screening. Thereafter, scan the right side following the same scheme (Figure 3).</li>
	<li>Finally, activate the stimulation configuration(s) allowing better paresthesia coverage of the painful leg area(s). 
	NOTE: If there is bilateral LP, two different stimulation configurations must be programmed to obtain optimal paresthesia coverage of the two painful areas.</li>
	<li>For back pain, test a transverse tripolar configuration at the top of the lead first, using the guarded cathode configuration (Figure 4). If this configuration gives insufficient paresthesia coverage, test a &#34;half flower-like pattern&#34; configuration of four anodes around a cathode (Figure 4). If this configuration does not provide sufficient paresthesia coverage and/or pain suppression again, use a tripolar longitudinal configuration in order to verify possible bilateral stimulation by one channel (Figure 4).</li>
	<li>Fine-tune back pain area coverage by increasing PW to 450 &#181;s. This makes it possible to enlarge the area of stimulation. Adjust the pulse rate between 40 and 60 Hz to obtain the most satisfying paresthesia coverage of the painful area. 
	NOTE: These settings are based on experience with this multicolumn surgical lead and may of course vary with a different device or stimulation strategy (high-intensity stimulation, for example). For more detailed instructions, please consult the Programmer Quick Guide24.</li>
	<li>Ensure close follow-up (at least once a week) of the patient during the trial phase (1 month in Belgium) to check appropriate wound healing and optimize paresthesia coverage by repeating Steps 5.7, 5.8 and 5.9. Use sterile technique bandage changes22. Educate the patient about the signs and symptoms of an emerging surgical site infection.</li>
	<li>At the end of the trial period, use sharp scissors to cut the external extension flush with the skin in order to reduce the risk of infection until the next surgical procedure.</li>
</ol>
6. Implantation of the Internal Pulse Generator
<ol>
	<li>If pain relief is higher than 50% at the end of the one-month trial period (Belgian reimbursement criteria), obtain the patient&#39;s informed consent and set a date for the IPG placement. Pain relief is assessed by using the VAS scale22. 
	NOTE: The patient decides on the site of the IPG placement after the advantages and drawbacks of the different locations are discussed with the NMS.</li>
	<li>Perform antibiotic prophylaxis 30 minutes before incision using a single intravenous dose of Cefazolin 50 mg/kg, with a maximum of 2 g, with a 16 G needle.</li>
	<li>With the patient under general anesthesia (same protocol as mentioned in Step 4.3), make a 7 cm-long and 2 cm-deep incision and create a pocket for the IPG in the subcutaneous fat of the abdominal wall or the external quadrant of a buttock, according to patients&#39; wishes (as discussed before surgery - Step 6.1).</li>
	<li>Excise the dorsal scar made for the lead implantation (Step 4.3), dissect the lead extensions from the surrounding tissues, and disconnect the lead from its external extrinsic extensions.</li>
	<li>Tunnel the intrinsic extension of the lead towards the implantation site of the IPG.</li>
	<li>Connect the lead&#39;s intrinsic extensions to its IPG.</li>
	<li>Suture the subcutaneous layer by simple interrupted stitches of 2/0 and 1/0 braided synthetic absorbable suture material.</li>
	<li>Make a dermal subcuticular suture using finer absorbable 3/0 suture material and apply antiseptic and bandages. During this step, administer a single IV dose of Paracetamol 1 gm and Tradonal 100 mg.</li>
</ol>
7. Postoperative Care and Follow-up Visits
<ol>
	<li>With the clinician programmer, set the programming parameters according to the ones that worked the best during the trial period (Step 5.7).</li>
	<li>Teach the patient how to use the programmer25. Explain again the different components of the neurostimulation system. Educate the patient to avoid activities requiring excessive twisting or stretching.</li>
	<li>Instruct the patient always to inform any healthcare personnel that they have an implanted neurostimulation system before any procedure is begun. Provide instructions about the warnings (CT-scan, defibrillation and cardioversion, electrocautery, lithotripsy, MRI, microwave ablation, and security screening devices) and precautions (bone growth stimulators, dental drills and ultrasonic probes, electrolysis, electromagnetic field devices, laser procedures, psychotherapeutic procedures, radiation therapy, and household items) for a neurostimulation system.</li>
	<li>Ensure close follow-up of the patient after the surgery to check for surgical site infection and appropriate paresthesia coverage.</li>
</ol>

<ol><li>Schofferman, J., Reynolds, J., Herzog, R., Covington, E., Dreyfuss, P., O'Neill, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Failed+back+surgery%3A+Etiology+and+diagnostic+evaluation%5BTitle%5D)+AND+%22Spine+Journal%22%5BJournal%5D)">Failed back surgery: Etiology and diagnostic evaluation.</a> Spine Journal. 3 (5), 400-403 (2003).</li>
<li>Hazard, R. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Failed+back+surgery+syndrome%3A+surgical+and+nonsurgical+approaches%5BTitle%5D)+AND+%22Clinical+Orthopaedics+and+Related+Research%22%5BJournal%5D)">Failed back surgery syndrome: surgical and nonsurgical approaches.</a> Clinical Orthopaedics and Related Research. 443 (443), 228-232 (2006).</li>
<li>Rigoard, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+Algorithmic+Programming+Approach+for+Back+Pain+Symptoms+in+Failed+Back+Surgery+Syndrome+Using+Spinal+Cord+Stimulation+with+a+Multicolumn+Surgically+Implanted+Epidural+Lead%3A+A+Multicenter+International+Prospective+Study%5BTitle%5D)+AND+%22Pain+Practice%22%5BJournal%5D)">An Algorithmic Programming Approach for Back Pain Symptoms in Failed Back Surgery Syndrome Using Spinal Cord Stimulation with a Multicolumn Surgically Implanted Epidural Lead: A Multicenter International Prospective Study.</a> Pain Practice. 15 (3), 195-207 (2015).</li>
<li>Thomson, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Failed+back+surgery+syndrome+-+definition%2C+epidemiology+and+demographics%5BTitle%5D)+AND+%22British+Journal+of+Pain%22%5BJournal%5D)">Failed back surgery syndrome - definition, epidemiology and demographics.</a> British Journal of Pain. 7 (1), 56-59 (2013).</li>
<li>Balagué, F., Mannion, A. F., Pellisé, F., Cedraschi, C. <a target="_blank" href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30970-9/abstract">Non-specific low back pain.</a> Lancet. 379 (9814), 482-491 (2012).</li>
<li>Melzack, R., Wall, P. D. <a target="_blank" href="https://www.ncbi.nlm.nih.gov/pubmed/5320816">Pain Mechanisms: A New Theory.</a> Science. 150 (3699), 971-979 (1965).</li>
<li>González, J. C. A., Melzack, R., Wall, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+gate+theory%3A+Beyond+the+scientific+concept+two+worlds+scientists+dedicated+to+the+understanding+of+pain%5BTitle%5D)+AND+%22Revista+de+la+Sociedad+Espanola+del+Dolor%22%5BJournal%5D)">The gate theory: Beyond the scientific concept two worlds scientists dedicated to the understanding of pain.</a> Revista de la Sociedad Espanola del Dolor. 20 (4), 191-202 (2013).</li>
<li>Loeser, D., John, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Concepts+of+pain%5BTitle%5D)+AND+%22The+Lancet%22%5BJournal%5D)">Concepts of pain.</a> The Lancet. 353 (May 8), 1607-1609 (1992).</li>
<li>Cui, J. G., Linderoth, B., Meyerson, B. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effects+of+spinal+cord+stimulation+on+touch-evoked+allodynia+involve+GABAergic+mechanisms.+An+experimental+study+in+the+mononeuropathic+rat%5BTitle%5D)+AND+%22Pain%22%5BJournal%5D)">Effects of spinal cord stimulation on touch-evoked allodynia involve GABAergic mechanisms. An experimental study in the mononeuropathic rat.</a> Pain. 66 (2-3), 287-295 (1996).</li>
<li>Song, Z., Meyerson, B. A., Linderoth, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Muscarinic+receptor+activation+potentiates+the+effect+of+spinal+cord+stimulation+on+pain-related+behavior+in+rats+with+mononeuropathy%5BTitle%5D)+AND+%22Neuroscience+Letters%22%5BJournal%5D)">Muscarinic receptor activation potentiates the effect of spinal cord stimulation on pain-related behavior in rats with mononeuropathy.</a> Neuroscience Letters. 436 (1), 7-12 (2008).</li>
<li>Song, Z., Meyerson, B. A., Linderoth, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Spinal+5-HT+receptors+that+contribute+to+the+pain-relieving+effects+of+spinal+cord+stimulation+in+a+rat+model+of+neuropathy%5BTitle%5D)+AND+%22Pain%22%5BJournal%5D)">Spinal 5-HT receptors that contribute to the pain-relieving effects of spinal cord stimulation in a rat model of neuropathy.</a> Pain. 152 (7), 1666-1673 (2011).</li>
<li>Waszak, P. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Spinal+Cord+Stimulation+in+Failed+Back+Surgery+Syndrome%3A+Review+of+Clinical+Use%2C+Quality+of+Life+and+Cost-effectiveness%5BTitle%5D)+AND+%22Asian+Spine+Journal%22%5BJournal%5D)">Spinal Cord Stimulation in Failed Back Surgery Syndrome: Review of Clinical Use, Quality of Life and Cost-effectiveness.</a> Asian Spine Journal. 10 (6), 1195-1204 (2016).</li>
<li>Kishima, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Modulation+of+neuronal+activity+after+spinal+cord+stimulation+for+neuropathic+pain%3B+H%282%2915O+PET+study%5BTitle%5D)+AND+%22Neuroimage%22%5BJournal%5D)">Modulation of neuronal activity after spinal cord stimulation for neuropathic pain; H(2)15O PET study.</a> Neuroimage. 49 (2), 2564-2569 (2010).</li>
<li>Stancák, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Functional+magnetic+resonance+imaging+of+cerebral+activation+during+spinal+cord+stimulation+in+failed+back+surgery+syndrome+patients%5BTitle%5D)+AND+%22European+Journal+of+Pain+%28London%2C+England%29%22%5BJournal%5D)">Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients.</a> European Journal of Pain (London, England). 12 (2), 137-148 (2008).</li>
<li>Yang, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Bipolar+spinal+cord+stimulation+attenuates+mechanical+hypersensitivity+at+an+intensity+that+activates+a+small+portion+of+A-fiber+afferents+in+spinal+nerve-injured+rats%5BTitle%5D)+AND+%22Neuroscience%22%5BJournal%5D)">Bipolar spinal cord stimulation attenuates mechanical hypersensitivity at an intensity that activates a small portion of A-fiber afferents in spinal nerve-injured rats.</a> Neuroscience. 199, 470-480 (2011).</li>
<li>North, R. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Spinal+cord+stimulation+versus+re-operation+in+patients+with+failed+back+surgery+syndrome%3A+an+international+multicenter+randomized+controlled+trial+%28EVIDENCE+study%29%5BTitle%5D)+AND+%22Neuromodulation%3A+Journal+of+the+International+Neuromodulation+Society%22%5BJournal%5D)">Spinal cord stimulation versus re-operation in patients with failed back surgery syndrome: an international multicenter randomized controlled trial (EVIDENCE study).</a> Neuromodulation: Journal of the International Neuromodulation Society. 14, 330-335 (2011).</li>
<li>Kapural, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+10-kHz+High-Frequency+and+Traditional+Low-Frequency+Spinal+Cord+Stimulation+for+the+Treatment+of+Chronic+Back+and+Leg+Pain%3A+24-Month+Results+From+a+Multicenter%2C+Randomized%2C+Controlled+Pivotal+Trial%5BTitle%5D)+AND+%22Neurosurgery%22%5BJournal%5D)">Comparison of 10-kHz High-Frequency and Traditional Low-Frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: 24-Month Results From a Multicenter, Randomized, Controlled Pivotal Trial.</a> Neurosurgery. 79 (5), 667-677 (2016).</li>
<li>Remacle, T. Y., Bonhomme, V. L., Renwart, H. J. P., Remacle, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+Multicolumn+Lead+Spinal+Cord+Stimulation+on+Low+Back+Pain+in+Failed+Back+Surgery+Patients%3A+A+Three-Year+Follow-Up%5BTitle%5D)+AND+%22Neuromodulation%3A+Technology+at+the+Neural+Interface%22%5BJournal%5D)">Effect of Multicolumn Lead Spinal Cord Stimulation on Low Back Pain in Failed Back Surgery Patients: A Three-Year Follow-Up.</a> Neuromodulation: Technology at the Neural Interface. 20 (7), 668-674 (2017).</li>
<li>Veizi, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Spinal+Cord+Stimulation+%28SCS%29+with+Anatomically+Guided+%283D%29+Neural+Targeting+Shows+Superior+Chronic+Axial+Low+Back+Pain+Relief+Compared+to+Traditional+SCS-LUMINA+Study%5BTitle%5D)+AND+%22Pain+Medicine+%28Malden%2C+Mass%29%22%5BJournal%5D)">Spinal Cord Stimulation (SCS) with Anatomically Guided (3D) Neural Targeting Shows Superior Chronic Axial Low Back Pain Relief Compared to Traditional SCS-LUMINA Study.</a> Pain Medicine (Malden, Mass). 18 (8), 1534-1548 (2017).</li>
<li>Chan, C., Peng, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Failed+back+surgery+syndrome%5BTitle%5D)+AND+%22Pain+Medicine%22%5BJournal%5D)">Failed back surgery syndrome.</a> Pain Medicine. 12 (4), 577-606 (2011).</li>
<li>Hawker, G., Mian, S., Kendzerska, T., French, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Measures+of+adult+pain%5BTitle%5D)+AND+%22Arthritis+Care+and+Research%22%5BJournal%5D)">Measures of adult pain.</a> Arthritis Care and Research. 63 (11), 240-252 (2011).</li>
<li>Deer, T. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Neurostimulation+Appropriateness+Consensus+Committee+%28NACC%29+Safety+Guidelines+for+the+Reduction+of+Severe+Neurological+Injury%5BTitle%5D)+AND+%22Neuromodulation%22%5BJournal%5D)">The Neurostimulation Appropriateness Consensus Committee (NACC) Safety Guidelines for the Reduction of Severe Neurological Injury.</a> Neuromodulation. 20 (1), 15-30 (2017).</li>
<li>Gupta, P., Kumar, A., Kumar, A., Goel, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Congenital+Spinal+Cord+Anomalies%3A+A+Pictorial+Review%5BTitle%5D)+AND+%22Current+Problems+in+Diagnostic+Radiology%22%5BJournal%5D)">Congenital Spinal Cord Anomalies: A Pictorial Review.</a> Current Problems in Diagnostic Radiology. 42 (2), 57-66 (2013).</li>
<li><a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Medtronic+N%27VISION%C2%AE+Programmer+Quick+Guide%22">Medtronic N'VISION® Programmer Quick Guide</a>. , (2009).</li>
<li><a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=%22Medtronic+MyStim%C2%AE+Programmer+Quick+Guide%22">Medtronic MyStim® Programmer Quick Guide</a>. , (2014).</li>
<li>Frey, M. E., Manchikanti, L., Benyamin, R. M., Schultz, D. M., Smith, H. S., Cohen, S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Spinal+cord+stimulation+for+patients+with+failed+back+surgery+syndrome%3A+a+systematic+review%5BTitle%5D)+AND+%22Pain+Physician%22%5BJournal%5D)">Spinal cord stimulation for patients with failed back surgery syndrome: a systematic review.</a> Pain Physician. 12 (2), 379-397 (2009).</li>
</ol>

The authors have nothing to disclose.

Recent studies have demonstrated that SCS can reliably improve the different pain components of FBSS patients, improve their quality of life (e.g., quality of sleep and physical activity), and these benefits are sustained during a long-term follow-up3,17,18,19.
Depending on the localization of the pain, we use a different approach. When the patient has only ...

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Before FBSS can be established, other conditions, such as persistent nerve root compression, permanent nerve root injury as a consequence of the original compression or surgery, arachnoiditis, incorrect initial diagnoses, and documented mechanical causes for low back pain (such as spinal instability, posterior joint osteoarthritis, spondylolysthesis, and discogenic pain), should be excluded1,2,3. FBSS patients may have severe or disabling neuropathic pain, and the syndrome is worrisome since it is chronic and resistant to conventional treatment. Its incidence and prevalence are similar to those of rheumatoid arthritis4. It is thus a great burden for industrialized societies5.
Spinal cord stimulation (SCS) with dorsal epidural leads can be used to treat back pain (BP) and leg pain (LP) in FBSS patients, although the SCS pain relief mechanism has not been fully investigated. According to the gate control theory, which was first proposed by Ronald Melzack and Patrick Wall in 1965, the brain monitors the activity of a tiny neural network distributed along the dorsal horn of the spinal cord that is regulated by nociceptive but also non-nociceptive afferents6. These complex circuits in the superficial dorsal horn of the spinal cord are responsible for relieving pain in a specific location in the body when an intense tactile stimulus is applied to the same place7,8. However, several studies have shown that SCS is not only dependent on this theory. Several neurotransmitters (acetylcholine, gamma-aminobutyric acid, and serotonin) have been reported to have a role in the SCS mechanism9,10,11,12, as well as numerous brain areas13,14 and different spinal fibers15.
An SCS device includes an epidural lead, internal pulse generator (IPG), and an extension cable to connect the lead to the IPG. The stimulation settings are adjusted by an external remote control. Two types of electrode can be used, namely, percutaneous and surgical leads.
The efficacy of SCS in improving the radicular LP component of FBSS has already been demonstrated in previously published studies, including the EVIDENCE study16, and two new technologies have recently been shown to be effective for treating the BP component, which is known to be recalcitrant to SCS. The first one is high-frequency stimulation17. The second one is the use of surgical multicolumn lead3,18. The main disadvantages of the former technique are that their batteries need more frequent charging and that the programming optimization is challenged by longer &#34;wash-in&#34; times19. The latter technique is more invasive than the percutaneous high-frequency stimulation technique because it requires a small laminectomy, making peroperative paresthesia mapping under local anesthesia challenging, although possible3. Indeed, this procedure can be performed under local anesthesia supplemented by conscious sedation or spinal anesthesia3. In our institution, when targeting back pain in FBSS patients, we place such surgical leads through a small laminectomy at the 10th thoracic level with the patient under general anesthesia. The lasting efficacy of this method with such multicolumn leads for treating LP and BP in FBSS patients has been demonstrated by 3 year follow-up18. A detailed protocol of our method is given below.

<table><tbody><tr><td>16-20 GA needle</td><td>BD Insyte- W</td><td></td><td></td></tr><tr><td>NaCl 0.9% 1 L</td><td>Baxter</td><td>AKE1324</td><td></td></tr><tr><td>Iso-betadine Dermic (500mL)</td><td>MEDA</td><td>09461.16</td><td></td></tr><tr><td>Iso-betadine Soap (500mL)</td><td>MEDA</td><td>09462.10</td><td></td></tr><tr><td>Iso-betadine hydroalcoolic (125 mL)</td><td>MEDA</td><td>41534.1</td><td></td></tr><tr><td>Ziehm Vision R FD</td><td>Ziehm Imaging Inc.</td><td>CB05183</td><td></td></tr><tr><td>Marcain 0.5% + adrenaline 1/200.000 20 mL</td><td>Astrazenca</td><td>PA 970/46/2</td><td>0.5% Bupivacaine/1:200,000 adrenaline solution&amp;nbsp;</td></tr><tr><td>external Neurostimulator (eNs)&amp;nbsp;</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>37022</td><td></td></tr><tr><td>Trousse de colonne lombaire CHR Citadelle (Procedure pack)&amp;nbsp;</td><td>M&amp;ouml;lnlycke</td><td>97061425-01</td><td></td></tr><tr><td>OR Table</td><td>Maquet</td><td>1150.30D0</td><td></td></tr><tr><td>OR Lights</td><td>Trumpf</td><td>1929278</td><td></td></tr><tr><td>Specify SureScan MRI</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>977C165</td><td>Multicolumn lead</td></tr><tr><td>Primeadvanced surescan mri neurostimulator&amp;nbsp;</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>97702</td><td>Internal Pulse Generator</td></tr><tr><td>Monocryl 3/0</td><td>Ethicon</td><td>Y423</td><td></td></tr><tr><td>Polysorb 2/0</td><td>Covidien</td><td>GL123</td><td></td></tr><tr><td>Polysorb 1</td><td>Covidien</td><td>CL535</td><td></td></tr><tr><td>Polysorb 2</td><td>Covidien</td><td>CL055</td><td></td></tr><tr><td>Cutiplast Steril 20x10 cm</td><td>Smith&amp;amp;Nephew</td><td>66001475</td><td>Bandage</td></tr><tr><td>MyStim Programmer</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>97740</td><td></td></tr><tr><td>FixoCath</td><td>Pajunk</td><td>001151-37Z</td><td></td></tr><tr><td>N&#039;Vision Programmer&amp;nbsp;</td><td>&amp;nbsp;Medtronic Inc., MN, USA</td><td>8840</td><td></td></tr><tr><td>3M Tegaderm Film 10x12cm</td><td>3M Deutschland GmbH</td><td>1626W</td><td></td></tr><tr><td>Extension Kit</td><td>Medtronic Inc., MN, USA</td><td>37081-40</td><td></td></tr><tr><td>Paracetamol</td><td>Fresenius Kabi</td><td></td><td></td></tr><tr><td>Tradonal&amp;nbsp;</td><td>Meda Pharma</td><td></td><td></td></tr><tr><td>Sufentanil</td><td>Janssen- Cilag</td><td></td><td></td></tr><tr><td>Propolipid 1%</td><td>Fresenius Kabi</td><td></td><td></td></tr><tr><td>Ketalar (Ketamine Hydrochloride)</td><td>Pfizer</td><td></td><td></td></tr><tr><td>Rocuronium Bromide</td><td>Bbraun</td><td></td><td></td></tr><tr><td>Cefazolin</td><td>Milan</td><td></td><td></td></tr></tbody></table>

treating low back pain in failed back surgery patients with multicolumn-lead spinal cord stimulation

Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be used to treat back and leg pain in FBSS patients. This paper presents a detailed protocol for using spinal cord stimulation with surgical leads in FBSS patients. In our department, with the patient under general anesthesia, we place the lead in the epidural space by means of a small laminectomy at the 10th thoracic level. Placement of the lead is followed by a 1 month trial period with an externalized lead. If pain relief is greater than 50% at the end of this 1 month stimulation trial (required by Belgian reimbursement criteria), an internal pulse generator is then placed under the skin and connected to the lead in a second surgical procedure. We have demonstrated that using this technique in rigorously selected FBSS patients can significantly improve back pain, leg pain, patient activity, and quality of life for a sustained period of time.

A prospective, non-randomized, controlled study of 62 consecutive FBSS patients who were implanted with a multicolumn lead using this method in our center, CHR Citadelle, in Liège, Belgium, was recently published in Neuromodulation18 . All patients had had previous spinal surgery, had been screened for possible secondary causes of their pain, and were refractory to optimal medical therapy. Multicolumn surgical leads were placed in all 62 patients in the projection ...

This paper presents a method that uses spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients.

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be ...

treating-low-back-pain-failed-back-surgery-patients-with-multicolumn

Research

JoVE Journal

Behavior

Using a mathematical model of spinal cord stimulation, we found that a multi-source system with independent power sources for each contact can target more central points of stimulation on the dorsal column (100 vs 3) and has 50-fold more field steering resolution (0.02mm vs 1mm) than a single-source system.

Dorsal Column Steerability with Dual Parallel Leads using Dedicated Power Sources:  A Computational Model

Source: Remacle, T., et al. Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation. J. Vis. Exp. (2018)This video demonstrates the method of using multicolumn paddle lead spinal cord stimulation to manage chronic lower back pain in Failed back surgery syndrome (FBSS) patients. The pre-implanted lead delivers targeted electrical pulses that activate non-painful sensory pathways, interrupting pain signals and reducing pain perception.

Modulation of Chronic Pain Using Multicolumn Paddle Lead Spinal Cord Stimulation

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Here, we present the third channel-assisted UBE technique, which allows for the vertical removal of herniated disc fragments. This technique can effectively address the limitations of traditional UBE techniques. This article will systematically elaborate on this procedure.

The Third Channel-Assisted Unilateral Biportal Endoscopic Technique for Lumbar Spinal Stenosis Combined with Contralateral Disc Herniation

This study shows the role of an innovative tool for assessing and treating biomechanical alterations in low back pain (LBP) patients. Three LBP patients demonstrated improved pain intensity and functional independence post-assessment. The technology aids in tailored rehabilitation strategies, offering insights into LBP biomechanics for personalized interventions.

Biomechanical Changes Related to Low Back Pain: An Innovative Tool for Movement Pattern Assessment and Treatment Evaluation in Rehabilitation

Lateral-PLIF is an advanced posterior lumbar interbody fusion technique allowing safer cage insertion with minimal neural manipulation. This article outlines the step-by-step procedure, highlighting the benefits of the bilateral approach, optimal cage orientation, high fusion rates, and low complication risks, offering a promising alternative to traditional PLIF.

Lateral-PLIF for Lumbar Spinal Arthrodesis: A Detailed Step-By-Step Surgical Technique

This article shows an optimized procedure for imaging of the neural substrates of auditory stimulation in the songbird brain using functional Magnetic Resonance Imaging (fMRI). It describes the preparation of the sound stimuli, the positioning of the subject and the acquisition and subsequent analysis of the fMRI data.

Functional Magnetic Resonance Imaging (fMRI) with Auditory Stimulation in Songbirds

We present a user-friendly, high-throughput operant system for the evaluation of pain behaviors in awake, conscious rodents. The Orofacial Pain Assessment Device (OPAD) can assess pain through a reward/conflict paradigm thus providing a more humane way of testing. This protocol will yield more clinically relevant and translational data from rodents.

Use of the Operant Orofacial Pain Assessment Device (OPAD) to Measure Changes in Nociceptive Behavior

Transcranial magnetic stimulation (TMS) has proven to be a useful tool in investigating the role of the articulatory motor cortex in speech perception.  This article describes how to record motor evoked potentials (MEPs) from the lip muscles and how to disrupt the motor lip representation using repetitive TMS.

Stimulating the Lip Motor Cortex with Transcranial Magnetic Stimulation

Here we present a protocol outlining the methodology for treatment of Major Depressive Disorder using the deep Transcranial Magnetic Stimulation (dTMS) system.

Treating Clinical Depression with Repetitive Deep Transcranial Magnetic Stimulation Using the Brainsway H1-coil

Learn spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients. This standardized technique optimizes device positioning for enhanced pain relief and improved patient outcomes.

Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

Explore More Videos