Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 28471-24581

Neuromodulation Johnathan Goree, MD Director of Interventional Pain Management Services Assistant Professor Department of Anesthesiology University of Arkansas for Medical Sciences

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Disclosures I have no financial interests to disclose related to this presentation I will present some non-FDA approved uses of medications which include steroids (dexamethasone) for lumbar epidural steroid injections and anti-convulsants/anti-depressants for the treatment of neuroinflammatory chronic pain. Both of these medications have been used for these indications for over 20 years.

Outline What is Neuromodulation Can neuromodulation help your patients?

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Case Discussion 59 y/o female with severe low back and buttock pain for 15 years but acutely worse for the past 2 years. PSH: multiple lumbar spine surgeries for degenerative scoliosis in the 1980s, last in 1985 Past medical treatments: gabapentinoids, TCAs, muscle relaxants, opioids Past treatments: Multiple rounds of PT, steroids, epidurals, caudal, Si joint injections, Radiofrequency Ablations.

Case Discussion

What are our Options? Rotation of anti-neuropathics? Rotation of muscle relaxants? Dose escalation of opioids? Continued physical therapy?

Spinal Cord Stimulation What is it? Delivery of electrical stimulation through leads placed in epidural space Goal of Pain Relief

Spinal Cord Stimulator Indications Post-Laminectomy Syndrome (Failed Back Surgery Syndrome) Lumbar Radiculopathy Complex Regional Pain Syndrome Peripheral Vascular Disease Refractory Angina

Surgical Implant

Recharging

New Indications Current large scale multi-centered trials for spinal cord stimulation Diabetic Peripheral Neuropathy Non Surgical Low Back Pain Abdominal Pain Pelvic Pain

Ideal Target for ablative or obstructive therapy. Purely sensory distal afferent nerve Possibly mixed sensory motor nerve Anatomically reliable landmarks Minimal risk of injury to overlying or adjacent visceral and neurovascular structures Targets to avoid Mixed sensory motor nerve with important motor function

Dorsal Root Ganglion Stimulation. Houses the cell bodies of the AFFERANT sensory neurons Afferant (AFFECTS you) Efferent ( causes an EFFECT – motor) Ideal target for therapy, only place on nerve root which is purely sensory.

Dorsal Root Ganglion Stimulation. Level 1 evidence for CRPS of lower extremity L1 – post inguinal hernia pain L2 – hip pain L3 – medial knee pain L4 – lateral knee pain L5 – ankle pain S1 – foot pain L1 and S2 – pelvic pain.

Case discussion Patient was trialed with Dorsal Column Stimulation at T8-T10. Patient had 90% pain relief of all painful areas at 1 week. Patient returned in 4 weeks for surgical implantation

Case Discussion

Take Home Points Spinal cord stimulation is NOT the answer to the opioid crisis BUT it provides a great evidence based option for patients with post laminectomy syndrome who had failed physical therapy, medical, interventional and surgical options. Dorsal Root Ganglion Stimulation has level 1 evidence for the treatment of complex regional pain syndrome. There are currently ongoing trials for multiple pain states including pelvic pain, abdominal pain, and diabetic peripheral neuropathy

Take Home Points There are multiple companies that make devices (seven and counting), all claim to be superior, be careful with all information that you receive from a device company Trial is ESSENTIAL. Patients should not expect more improvement from an IMPLANT than they get from a TRIAL. If planning to refer for SCS, suggest referring to a content expert that has familiarity with multiple devices and the literature. Some disease states may have benefit from a particular type of stimulation.

Thank You

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 28471-24581

Case Conference and Feedback Continuing Education Credit: TEXT: 501-406-0076 Event ID: 28471-24581