b. Spinal cord stimulation-spinal cord pacemaker

1.  What is a spinal cord stimulator, its purpose, and how does it work?

• The spinal cord extends from the base of the skull to the tailbone, passing through a channel inside the spine, giving off nerves to both sides of the body. It can be thought of as the body’s electrical system, where stimuli from the body are transmitted through nerves to the spinal cord and then to the brain.

 • In this sense, the spinal cord is an intermediate station but not just a simple one. It filters incoming information and tries to stop pain signals. This is known as the "gate control" system which tries to keep the gate closed against pain. However, if the pain stimulus is too intense, the gate opens, and the pain information reaches the brain.

 • This theory is the foundation for spinal cord stimulators and implanted morphine pumps. • The goal of stimulators implanted in the spinal region is to constantly send signals to prevent the spinal cord and brain from perceiving pain.

 • The spinal cord maps out the body through what are called dermatomes. Initially, a temporary electrode is placed in the region corresponding to the pain. Whether the pain subsides or not is tested over a month by sending signals using a device similar to a transistor radio. If there is a reduction of pain by more than 50% during this first stage, a small surgical procedure is performed to connect a device similar to a heart pacemaker to this electrode, which is then placed under the skin.

 • Spinal cord stimulators generally have a lifespan of about five years. After five years, only the battery part needs to be replaced.

• Recently, rechargeable stimulators have been developed.

• Spinal cord stimulators are implanted only in patients who have not benefited from other treatment methods.

2. Which patient groups are typically treated?

• Patients who have undergone multiple back surgeries for herniated discs and have developed adhesions in that area

• Patients with spinal cord injuries who have developed paralysis but continue to experience pain • Pains originating from blood vessels

• Patients who have had limbs amputated and experience phantom limb pain • Pain associated with nerve damage and neuropathies

 

3. Preparations before spinal cord stimulator implantation,

• Request a detailed explanation of the procedure from your doctor before the implantation of the spinal cord stimulator. Your doctor will require written consent from you as per legal requirements.
• Inform your doctor about any other conditions you have, any medications you are taking, potential allergens, and any drug sensitivities. Herbal supplements like vitamin E, glucosamine, garlic, and ginseng can also cause bleeding.
• Consult your doctor regarding the discontinuation of all blood thinners, excluding aspirin, since these need to be stopped.
• Bring all prior test results, such as MRI, computed tomography scans, and laboratory findings, when going for the procedure.
• Wear comfortable clothing and leave accessories such as watches, rings, and other jewelry at home.
• Avoid eating or drinking at least 4 hours before the procedure. However, medications required for other systemic illnesses can be taken with a small amount of water.
• Since sedation, also known as twilight anesthesia, will be applied during the procedure, you will not be allowed to return home alone. Come with a companion. Also, the local anesthesia applied can cause temporary weakness and numbness in the legs, preventing you from driving.

4. How is the spinal cord stimulator implanted, and how long does it take?

• The process of implanting a spinal cord stimulator is lengthy. Before deciding on a spinal cord stimulator, the patient must undergo consultations with psychiatry, psychology, neurosurgery, neurology, physical therapy, and rehabilitation. This is because the patient will carry the device for life, and it must be determined if they can manage it.
• The first stage is the placement of a trial electrode. This involves implanting an electrode, slightly thicker than a fishing line, into the level of the spinal cord that corresponds to the painful area under operating room conditions.
• The patient is taken to the operating room. The trial electrode is placed in a sterile environment with imaging guidance. Only local anesthesia is used, and the patient must be fully awake. The electrode is stimulated by an external device, and the patient should feel this stimulation in the painful area; otherwise, the system will not be effective. After the electrode is placed, it is secured under the skin. The patient is observed in the hospital for a week, discharged, and then the effectiveness of the trial electrode is monitored for a month. If effective, the permanent system is implanted.
• A device the size of a pacemaker is connected to the previously placed electrode, a pocket is created in the front of the abdomen, and the device is implanted there. The patient is then discharged.
• The first part of the operation takes about an hour, and the second part also takes about an hour.

5. Is the spinal cord stimulator implantation painful?

• The spinal cord stimulator is implanted under local anesthesia without sedatives. Therefore, it is somewhat more painful compared to other interventional methods. However, sedation is not applied for the success of the procedure.

6. What should I expect from the spinal cord stimulator?

• If effective, the spinal cord stimulator significantly improves the patient's quality of life. However, some patients may psychologically struggle to cope with carrying the device after some time. Nonetheless, it is one of the most effective interventional methods.

7. What are the risks and side effects?

• There are advantages and disadvantages to this method. Firstly, the patient will continuously be under medical supervision.
• Sometimes, the electrode placed in the spinal canal may move and need to be repositioned. The effect may decrease over time in some patients, necessitating a replacement.
• It is the most expensive among pain control methods, with costs reaching up to $20,000 per patient. However, it should be used when other methods are not effective.
• The state covers the cost of spinal cord stimulators, but this is done following a detailed evaluation by various medical disciplines and a committee report's outcome.

8. Who cannot receive a spinal cord stimulator?

• As with all interventional methods, it should not be applied to those with a general infection in the body or a blood clotting disorder. Additionally, if the patient's psychological makeup is not suitable, it is not appropriate to proceed with the implantation.