Michael Bottros, M.D., an assistant professor of anesthesiology at Washington University and the director of the Acute Pain service at Barnes Jewish Hospital in St. Louis, Missouri, talks about a device that can provide people with relief from years of back pain.
Interview conducted by Ivanhoe Broadcast News in January 2017.
Can you describe what is happening when you have spinal stenosis? What kind of pain is associated with that?
Dr. Bottros: Spinal stenosis is when there is stress on the spinal cord that could be due to increased tissue around it. That tissue could be from a disk bulge that’s coming from one side, or on the other side it could be an increased ligament–what we call ligamentous hypertrophy. These types of stenosis can create an hourglass effect on the spinal cord.
Meaning its being pinched, squeezed in that middle. How painful is it for patients and how much does it restrict their everyday activities?
Dr. Bottros: It depends on how much stenosis is occurring, but for mild stenosis, it can be an occasional discomfort with certain positioning. With moderate or severe stenosis, it can be quite debilitating. Pain can be radiating down to one or both legs. Severe back pain can greatly affect individuals, preventing them from walking or doing activities of daily living, such as cooking or cleaning the house.
What do patients do for pain relief? What are the avenues that doctors can take?
Dr. Bottros: There are a lot of different avenues at the Washington University Pain Management Center; we like to take a multidisciplinary approach. These include forms of physical therapy that are appropriate for the patient; they strengthen the core muscles that will help stabilize the spine under these types of circumstances. Pain psychology can also be very helpful. Medications such as over-the-counter anti-inflammatory medications, Tylenol, or muscle relaxants may also be beneficial. Anticonvulsants like Gabapentin or Lyrica can be very helpful for nerve pain. Certain types of antidepressants are very useful in these situations as well and considered first-line therapy for nerve pain, or sciatica that you may feel from an impingement. Then, there are injections that we can do for patients. There’s a wide variety that are available based on what’s going on anatomically and the way that the patients are describing their symptoms.
When all that fails when a patient is still not having any relief, or over time it just isn’t working anymore, then what can you do?
Dr. Bottros: There are more invasive procedures that are available. Things like spinal cord stimulation, or radiofrequency ablation for when arthritis can be the limiting factor associated with causing that impingement. These are more invasive things, and then ultimately, there’s surgery. There can be back surgery, different kinds of back surgery, back fusion, what we call laminectomy, shaving off the bone that could be causing a part of the stenosis. Unfortunately, there are patients who may continue to have pain even after surgery and that’s where things like spinal cord stimulation may be an option for patients who have already had that ultimate end point in terms of trying to get relief.
Let’s talk about spinal cord stimulation. How does it work?
Dr. Bottros: Spinal cord stimulators work by different mechanisms based on the different kinds of spinal cord stimulators that are out there. Essentially, what you’re trying to do is trying to lessen the pain by stimulating other kinds of nerves that interrupt the pain signals from reaching your brain. By doing so, patients end up not feeling as much pain.
Can you describe for us how the surgery to implant works?
Dr. Bottros: Spinal cord stimulators are placed by an epidural approach– similar to when women have epidurals in labor. We do this under fluoroscopy, an imaging technique, and once the leads are in place, the epidural needle is taken out. We tape it up as part of a trial and they go home. They try it for three to seven days, and if it’s helpful, we have them come back and discuss whether or not we should implant it. Implanting is very similar to the trial, except with an implant, we will go ahead and anchor those leads in the area that we want them to be in. Then, we make another small incision for a battery that we’ll connect the leads to. This battery will provide the energy source for the stimulator which can be recharged externally.
How is it a constant motion to stimulate, or is it once in a while?
Dr. Bottros: There are different programming options available. There can be constant stimulation; there can be stimulations that are based on certain frequency patterns, or it can change in intensity and strength based on how the patient is positioned, like when their sleeping versus when they’re getting up and walking. There can be high frequency modes, which are a newer concept in spinal cord stimulation, where they don’t even feel any stimulation (kind of like a dog whistle–they don’t even know it’s there but it’s definitely creating an effect).
Is there a new generation of stimulators, what is it called and what are you working with right now?
Dr. Bottros: Our Pain Management Center works with all spinal cord stimulation companies, but newer stimulators like high frequency stimulation have come out and have shown to be very successful. They have even been given a vote of superiority by the FDA. There are also newer stimulators that are called dorsal root ganglion stimulators which can be more specific in stimulating specific nerves that we know may be contributing to the pain syndrome that the patient is having.
Talk to me a little bit about Deanna’s case. Which stimulator is she using and what’s her situation?
Dr. Bottros: Deanna was referred to us because she was having significant back pain. She had back surgery in 2011, but unfortunately, it didn’t provide relief for her, so she continued to have significant pain. She had a series of injections, she tried different medications and she tried physical therapy. Ultimately her pain was so severe it was very hard for her to get around. It was also very hard for her to do activities of daily living, such as cooking and cleaning. When she came to see us, we discussed what options were left, and we discussed spinal cord stimulation. The type of pain she was having was predominantly low back pain, and with that kind of pain, high-frequency spinal stimulation was something that I thought may be of good use for her. We went through a trial, and it provided a lot of relief for her. When she came back, at the end of the trial period, we discussed whether or not she wanted to have it implanted, and it was decided to proceed with an implant.
Did she have to charge herself can you explain that?
Dr. Bottros: The charging device is something that’s basically plugged into the wall. It’s a disc that she will basically put up against the skin of her back where the battery is implanted underneath; and it’s an external charging device. It just transmits through the skin into the battery that’s implanted, and it will recharge it just like you recharge your mobile phone.
How long does it take, is it pretty quick procedure?
Dr. Bottros: It’s pretty quick. It depends on what kind of system that you have. For her, it is about twenty five minutes a night. If you use more, or if you deplete your battery more, it may be a little bit more time; if you don’t use it much, maybe a little less. Other different kinds of stimulator systems may take about one hour, but you only have to do it like once a week for example. It really depends on the system.
Is there anyone for whom this is not a good a good fit?
Dr. Bottros: People who have total body pain, fibromyalgia, multiple sclerosis, those types of pain syndromes are not conditions where we would talk about spinal cord stimulation. Also patients who fail psychological screening would not be appropriate candidates.
On the flipside, who are the best candidates?
Dr. Bottros: The best candidates are people who have sciatica, low back pain, and people who have had what we call failed back surgery syndrome, where they’ve had the surgery already, but unfortunately, it isn’t providing relief. Those types of patients may benefit greatly from this type of procedure.
Is there anything that I didn’t ask you that you want to make sure people know?
Dr. Bottros: I think one of the cornerstones of good proper pain management is a multidisciplinary approach. It’s not just enough that a procedure is done and then you walk away. I think it’s important to use the benefits of any intervention to allow that patient to do more physical therapy that strengthens muscles, to walk properly, to be able to do those things correctly. It’s not just like McDonald’s drive through; go in, get something done and you’re out the door. It is definitely a way of life for these patients. They need to know what to do properly, how to use helpful medications, and when to use pain psychology. How much of a difference in the quality of life is obtained?
Dr. Bottros: Well, in the case of Deanna Connelly, it’s significantly altered her life. She is now able to walk without a cane. You know, when she first came to see me, her daughter brought her up in a wheelchair because she couldn’t walk from the garage to our office here at the pain management center. After we implanted her, on her first postoperative visit, she came in walking without even a walker. She expressed to me her gratitude and how she was able to help prepare Thanksgiving dinner with her family and spend the holidays. She told me that previously one of the first things that she did when she walked in to a room was look for a chair, and now, she walks in and she doesn’t have to worry about that anymore.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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