Spinal Cord Stimulation – Single Stage

This leaflet aims to answer your questions about having spinal cord stimulation. It explains the benefits, risks and alternatives, as well as what you can expect when you come to hospital. If you have any further questions, please speak to a doctor or nurse caring for you.

What is spinal cord stimulation (SCS)?

SCS systems, (sometimes known as neuromodulation), deliver small electrical fields to the spinal cord. These electrical fields mask areas of pain by changing the pain messages your body sends to your brain. This can significantly reduce pain in conditions such as failed back surgery syndrome, neuropathic (nerve) pain, and complex regional pain syndrome. It is effective in five to seven out of ten cases. SCS is reserved for patients who have severe chronic pain that is limiting their daily life and who have already tried all reasonable, more conservative therapies, such as medications, TENS, physiotherapy and injections.

SCS requires a minor surgical procedure under x-ray control in which a lead is precisely sited within the spine in the epidural space. The lead is then connected under the skin to a battery device which is surgically sited in the buttock or abdominal wall. The battery powers the electrical stimulation of the lead in the spine. Once the system is set-up, it can be controlled by the patient using a handheld controller.

It is important to remember that SCS can relieve pain in some people with certain types of chronic pain but is only one part of a treatment strategy and not a complete treatment on its own.

What are the different types of stimulators?

Many factors, including site and type of pain, are considered in determining which type of system to use. There are two types of stimulators:

• Lower frequency spinal cord stimulation. This uses frequencies which provide a tingling sensation in the painful area.
• High frequency spinal cord stimulation. This is usually not felt.

How do I know if spinal cord stimulation might be right for me?

SCS may be appropriate for you if you meet the criteria listed below. Medical and psychological (mental and emotional) factors are all important and all potential patients undergo assessment by a doctor, a nurse specialist and a psychologist. The criteria below list reasons why SCS may not be appropriate for you.

What are the guidelines for spinal cord stimulation?

The National Institute for Health and Care Excellence (NICE) is the organisation responsible for recommending which medicines and treatments are used by the NHS. NICE recommends SCS for severe prolonged pain that has responded to a trial of stimulation in failed back surgery syndrome, complex regional pain syndrome and neuropathic pain.

As per the British Pain Society recommendations, all patients are treated within a multidisciplinary team experienced in SCS that includes doctors, nurses, a psychologist and a physiotherapist. This helps patients to make an informed decision about whether they want to go ahead with SCS, as well as understanding what is happening to them throughout the treatment.

Who can have spinal cord stimulation?

In order to be considered for spinal cord stimulation you must:

• be eighteen years of age or older
• have been diagnosed with one of the following conditions, as per NICE guidelines:
• failed back surgery syndrome
• complex regional pain syndrome
• neuropathic pain
• have moderate to severe chronic pain measuring greater than five out of ten on a pain rating scale
• have tried and not responded to conservative treatments
• be willing to stop or reduce excessive medication, and use pain management strategies
• be able to manage the technical demands of the equipment.

Who cannot have spinal cord stimulation?

You should not have spinal cord stimulation if you:

• have significant pain that will not benefit from spinal cord stimulation (for example, pain due to arthritis or spinal instability)
• have significant pain beyond the area that a spinal cord stimulation system can cover (widespread pain syndromes)
• have anatomical problems that mean it is not possible to implant a spinal cord stimulation system safely. For example major spinal deformity, extensive spinal metalwork, or extensive spinal scar tissue in the epidural space
• have an active infective illness
• have some chronic medical illnesses, for example multiple sclerosis or severe respiratory disease
• have some psychiatric illnesses
• have a very high or very low body mass index (you are either very over or underweight)
• use alcohol, prescription drugs, and/or recreational drugs excessively
• have an allergy to nickel or any other components of the implantable device

What will happen at my first SCS appointment?

Prior to your first SCS appointment the SCS multidisciplinary team will have met to determine whether your type of pain is suitable for SCS and you meet the criteria to proceed on the SCS pathway.

Your first SCS appointment will be with a nurse specialist who will further assess you for SCS and provide you with more detailed information about SCS, the procedures, pathway and long term considerations. The nurse specialist will answer any questions you have about your chronic pain and SCS. You will be provided with written information about SCS for you to read and to further help you decide whether SCS is something you wish to trial.

What will happen at the psychologist appointment?

The psychology assessment looks at the impact of chronic pain on your activities, mood, relationships and sleep. The psychologist will take time to explore how you are managing your pain right now, ask you about your understanding and expectations of SCS, and how you would feel if SCS did not work for you.

Will I have a follow up appointment?

Sometimes additional input may be helpful to patients prior to a trial of SCS such as from nurse specialist, physiotherapy, occupational therapy or psychology sessions. If such input is felt to be helpful this will be discussed with you and appointments arranged.

If you are assessed as suitable for SCS and you wish to proceed you will be added to the waiting list to undergo an insertion of SCS with on table trial. About four weeks prior to the date of your SCS procedure you will have a pre-operative assessment with the nurse specialist. This includes recording your height, weight, MRSA (methicillin-resistant staphylococcus aureus) screening swabs, blood tests and often an ECG (electro-cardio graph). You will be given a SCS procedure specific information and consent form to take away with you. You must read this and bring it in with you on your SCS procedure date.

If you decide that SCS is not something you want to try an appointment will be made for you to have a review with your pain management consultant.

Why do I need a spinal cord stimulation trial?

A trial of spinal cord stimulation is carried out before considering a permanent implant because the effectiveness of spinal cord stimulation varies from patient to patient. This trial will be performed “on the table” during your procedure, where the SCS system will be tested to ensure it is working and covering the required areas before proceeding to a full implant. The SCS leads are placed in the epidural space within the spine at the desired level and SCS therapy is commenced. You may be asked if you can feel a pins and needles type of sensation – depending on the SCS system used this may not be in the painful area initially.

What happens if I receive the permanent implant?

If the on table trial is successful, you will then proceed to a full (permanent) implant. The permanent implant involves inserting the rechargeable battery, and this is performed under deep sedation or general anaesthetic. The battery placement is discussed with you before the procedure. A small incision in your skin is required to place the battery either in your buttock or abdomen. The therapy is then left switched off for 1 week to allow the wound over the battery insertion site to heal.

How long does the battery last?

This depends on the type of battery inserted and how much you use it., but on average somewhere between 7-10 years. Replacing the battery requires a simple day surgery procedure where the previous incision is opened under sedation and local anaesthetic and the battery replaced. The pain medicine specialist will decide on the most appropriate system and battery for you.

What are the risks or complications of a spinal cord stimulator?

• Painful battery/connection site. If this is severe, further surgery or removal of the system may be advised.
• Infection (less than five in 100 people). If this happens, the whole system may need to be removed.
• Bleeding, which may lead to bruising and in rare cases may require further surgery.
• Severe headache, which may require treatment with a spinal injection if it does not improve within days.
• The leads may move or not work. This may need another operation to correct.
• Unpleasant stimulation, which may not respond to stimulation adjustment and may require stimulation to be abandoned.
• Stimulation felt outside of the painful area is common, but only a problem if unpleasant (see above).
• Failure to capture the area of pain, or no pain relief, which may lead to consideration of revision surgery to re-site the leads or remove the system.
• Allergic reaction leading to removal of the system.
• Decrease in pain relief with time.
• Nerve damage leading to nerve pain, numbness and weakness. This may be temporary or permanent.
• Paralysis. This is extremely rare (two patients in one million).

Do I need to take any precautions with spinal cord stimulation?

Some physical activities may need to be avoided in the first 12 weeks to help prevent the leads moving. The nurse specialists and your doctor will discuss this with you.

• If you require surgery in the future, you must inform your surgeon and anaesthetist that you have SCS as they will need to make changes to equipment they use on you.
• Depending on the type of device chosen, it may not be possible for you to have an MRI (magnetic resonance imaging) scan, but CT (computerised tomography) scans and x-rays are allowed.
• Stimulators may activate airport detectors and anti-theft devices in shops. These, along with strong magnets, may turn your stimulator off and affect your battery.
• You should not drive with the device on if you have low frequency stimulation (sudden increases in sensed stimulation may interfere with driving).

Who will be responsible for my care?

Following your permanent implant, the SCS team in pain clinic at Addenbrookes' Hospital will be responsible for your SCS system. The nurse specialists will continue to provide ongoing support and advice. There will be booked clinic appointments organised following your SCS implant, these will be at one week, four weeks, 12 weeks, six months, nine months and 12 months post implant with yearly reviews thereafter for checks on the SCS system. Appointments can be arranged for review or programming in between this if needed.

Please discuss with your consultant or specialist nurse if you have further questions.

Further information

British Pain Society
Information about spinal cord stimulation for the management of pain, and recommendations for best clinical practice.
British Pain Society website (opens in a new tab)

National Institute for Health and Care Excellence (NICE)
Information about spinal cord stimulation for chronic pain of neuropathic or ischaemic origin.
National Institute for Health and Care Excellence (NICE) website (opens in a new tab)