1. 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)
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2. 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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4. 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.

5. Outline What is Neuromodulation
Can neuromodulation help your patients?

10. 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.

11. Case Discussion

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

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

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

15. Surgical Implant

16. Recharging

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

18. 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

19. 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.

20. 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.

21. 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

22. Case Discussion

23. 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

24. 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.

25. Thank You

26. Questions about the Topic
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27. Case Conference and Feedback
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