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EMERGING TREATMENTS | PRAGER
cord, which provides a stronger effect. New lead configurations
have been and will be designed specifically for rechargeable
systems because the more-effective configurations will use more
energy. Thus, once again, rechargeability provides a platform to
allow for a more effective form of stimulation that conventional
primary cell internal pulse generator source would not support.
Cost-Effectiveness of SCS
TAYLOR ET AL (14) recently reviewed the cost effectiveness of
SCS for treating chronic pain. They conclude that in the
medium to long term, SCS is economically favorable compared
to other therapies for people with CRPS. Taylor indicates that
pay back ranged from 15 months to five years after the SCS
was implanted. The pay back period was sensitive to the efficiency
level of the battery/electrode life and the amount of
patient usage. However, this review was performed before
rechargeable batteries. Considering the advantages of rechargeability,
it is possible that pay back will be shortened and that
the costs of SCS plus physical therapy will be lower than the
cost of physical therapy alone. SCS initial costs are offset by a
reduction in healthcare expenditures after the implant.
The Future with Rechargeability
THE RELEASE OF RECHARGEABLE SYSTEMS has prompted the
development of many new lead configurations that will
enhance the effectiveness of SCS for the CRPS patient. New
leads and extensions are currently in development. In particular,
one product that will be available in the near future will allow
four limbs to be treated simultaneously from a single-pulse generator.
For patients with advanced four-limb CRPS, this eliminates
the need for multiple systems; four limbs can be treated
with a rechargeable single-pulse generator that, despite high
energy consumption, will not require frequent replacement.
Summary
SPINAL CORD STIMULATION has a demonstrated efficacy in
treating patients with CRPS when it is used in conjunction
with a comprehensive rehabilitation program. Rechargeability
enhances the ability to perform stimulation without requiring
as frequent internal pulse generator battery replacements.
SCS is cost effective in CRPS and future developments will
enhance its effectiveness.
REFERENCES
1. Stanton Hicks, M. et.al. An updated interdisciplinary clinical pathway for
CRPS: Report of an expert panel. Pain Practice 2002; 2(1):1-16.
2. Stanton-Hicks M., Spinal cord stimulation for the management of complex
regional pain syndromes. Neuromodulation 1999; 2(3):193-201.
3. Broseta J, et.al. Chronic epidural dorsal column stimulation in the treatment
of causalgia pain. Appl Neurophys 1982;45: 190-194.
4. Barolat G. Schwartzman R., et.al., Epidural spinal cord stimulation management
of reflex sympathetic dystrophy. Stereotact Funct Neurosurg
1999; 53:29-39.
5. Kumar K., et.al., Spinal cord stimulation is effective in the management
of reflex sympathetic dystrophy. Neurosurgery 1997; 40:503-508.
6. Robaina F. J., et.al., Transcutaneous electrical nerve stimulation and
spinal cord stimulation for pain relief in reflex sympathetic dystrophy.
Stereotact Funct Neurosurg 1989; 52(1): 53-62.
7. Bennett D. S., et.al., Spinal cord stimulation for complex regional pain
syndrome (RSD): A retrospective multicenter experience from 1995-1998
of 100 patients. Neuromodulation 1999;2:202-210.
8. Calvillo O, et.al., Neuroaugmentation in treatment of complex regional
pain syndrome of the upper extremity. Acta Orthop Belg 1998; 64: 57-
62.
9. Oakley, J. and Weiner, R. L., Spinal cord stimulation for complex regional
pain syndrome: A prospective study of 19 patients at two centers. Neuromodulation
1999; 2:47-50.
10. Kemler, M.A., et.al., Spinal cord stimulation in patients with chronic reflex
dystrophy. N Engl J Med 2000; 43:618-24.
11. Kemler, M.A., The effect of spinal cord stimulation in patients with
chronic reflex sympathetic dystrophy: Two years followup of the randomized
control trial. Ann Neurol 2004; 55:13-18.
12. Bennett, D.S., ibid.
13. Oakley, J., Prager, J., Mechanism of spinal cord stimulation. Spine. 27
(22):2574-2583.
14. Taylor, R. S., The cost effectiveness of spinal cord stimulation:
A systematic review of the literature. J Pain Symptom Manage 2004;
27 (4): 370-8.
JOSHUA P. PRAGER, MD,
MS, is Director, Center for
the Rehabilitation of Pain
Syndromes (CRPS), Departments
of Internal Medicine
and Anesthesiology, David
Geffen School of Medicine
at UCLA, Los Angeles,
California.
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