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SCS and IDDS: Patient Selection

SCS and IDDS: Patient Selection. Marshall D. Bedder M.D., F.R.C.P. (C) Director Interventional Pain Pacific Medical Centers Seattle, WA. SCS/ IDDS. Pain Management: A More Flexible Approach. Different time frames Multiple therapies at one time Different starting points. Corrective

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SCS and IDDS: Patient Selection

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  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 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. 2001 Sep;17(3):206-14.

  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

  7. 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

  8. 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

  9. SCS

  10. Spinal Cord Stimulation(SCS) • Patient Selection

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

  12. 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

  13. 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

  14. 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

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

  16. Evidence for IDDS • Pro • 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

  17. 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.

  18. Effects of SCS on Sensory Systems Electrical Electrical Chemical Chemical Segmental Central Non-segmental ? 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)

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