Spinal cord stimulators

A spinal cord stimulator (SCS) is a small device that sends mild electrical pulses to the back of the spinal cord. Pain travels from your back, leg or arm up the spinal cord to the brain. The pulses change or block that signal, so less of the pain gets through. Doctors have used this treatment since the late 1960s, and today's devices are much smaller and smarter.

The stimulator does not fix the cause of the pain. It changes how your nervous system handles the pain signal. That is why results differ from person to person, and why everyone tries a temporary version first.

Older settings replace pain with a light tingling or buzzing feeling, called paresthesia. Many newer settings use high-frequency or burst pulses that most people cannot feel at all. Most devices can do both, so you can choose what feels best.

On the live X-ray (fluoroscopy) image, the leads show up as thin white lines running up and down the middle of the spine, with small bright dots marking each contact.

Stimulators are for long-lasting nerve-type pain, usually pain that has gone on for more than 3 to 6 months despite medicines, physical therapy, injections or surgery. A pain specialist, spine surgeon or physiatrist (a rehabilitation doctor) usually reviews your history first. Most insurers also require a short visit with a psychologist, because chronic pain affects sleep, mood and stress, and treating those helps the device work better.

Stimulators tend to work better earlier in the course of chronic pain, before long periods of inactivity, poor sleep and heavy medicine use take hold.

A stimulator is usually considered after simpler treatments have been tried. It can sit alongside other care rather than replace it. Here is how it compares with common choices.

Other options include epidural steroid injections, nerve blocks, peripheral nerve stimulation for pain in one area, and a pain pump for severe pain that needs medicine delivered to the spine.

The trial shows whether a stimulator helps your type and location of pain before you commit to an implant. It is an outpatient procedure that usually takes 30 to 60 minutes.

You lie on your stomach. The doctor numbs the skin of the lower or middle back and, using live X-ray, guides a needle into the epidural space. One or two trial leads are threaded up to the right level. The doctor may ask you what you feel while testing the leads, so you stay awake enough to answer. The leads come out through the skin and connect to a small stimulator worn on a belt. There is no incision for the trial.

At home, you use the device during your normal day and keep a simple log of your pain, activity, sleep and pain medicines. Keep the dressing dry: no showers or baths during the trial, sponge baths only, and avoid bending, twisting and heavy lifting so the leads do not move. After about 5 to 10 days, the leads are pulled out in the clinic in a few seconds. It feels like pulling off a bandage.

The trial counts as a success if your pain drops by about half or more and you can do more. If it does not help, nothing further is needed, and the trial leaves no damage to the spinal cord or nerves. If it does help, the skin is usually allowed to heal for about 2 weeks before the permanent implant.

More general advice is on before your procedure and sedation.

1. 1
   Preparing

   A nurse places an IV and you get antibiotics through it to lower the risk of infection. You lie on your stomach and receive sedation or light anesthesia. The skin of the back and buttock is cleaned and numbed.

2. 2
   Placing the leads

   Through a small opening in the middle of the back, the permanent leads are guided into the epidural space under live X-ray, in the same spot that worked during the trial. They are anchored so they stay in place.

3. 3
   Creating the pocket

   A small incision is made in the upper buttock or flank. The doctor creates a pocket under the skin for the pulse generator and tunnels the lead wires under the skin to it.

4. 4
   Connecting and testing

   The leads are connected to the generator and the system is checked. The generator is settled into its pocket.

5. 5
   Closing

   The incisions are closed with stitches under the skin and skin glue, and a dressing is applied. The whole procedure usually takes 1 to 2 hours.

Afterward, you recover for about 1 to 2 hours while nurses check your blood pressure, heart rate, oxygen and pain. A representative from the device company usually programs the stimulator before you leave. Most people go home the same day. Some stay overnight.

1. First 24 hours
   Rest at home. No driving, alcohol or important decisions after sedation. Soreness at the incisions is normal.
2. First 3 days
   Incision pain usually eases. Acetaminophen (Tylenol) and ice packs help. Showering is usually fine once the skin glue has sealed, but do not scrub the incisions.
3. First 2 weeks
   No baths, hot tubs or swimming. The skin glue falls off on its own in 1 to 2 weeks. A wound check visit is usually about 1 week after the implant.
4. First 6 weeks
   Avoid bending, lifting more than about 10 pounds, twisting and reaching over your head. Scar tissue forms around the leads during this time and holds them in place. Walking is encouraged.
5. After 6 to 8 weeks
   Most people return to normal activity. Your settings may be adjusted at follow-up visits to find the best relief.

Success means meaningful relief, not zero pain. The usual goal is at least 50% less pain, along with better sleep, more activity and fewer pain pills. Published studies show that roughly half to two-thirds of people with a successful trial keep good relief for years. Some people find that relief fades over time, and a settings change or new program often helps.

When I meet someone considering a stimulator, I want to understand exactly where the pain goes, what it feels like and what they hope to do again, like walking the dog or sleeping through the night. The trial is the most honest test we have, so I ask patients to keep a real log and judge it by what they can do, not just by a number. If the trial does not help, that is useful information, and we move on to other options.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

The treatment is reversible. If you decide you no longer want the stimulator, the leads and generator can be removed.