Interview: A neurostimulator as a “jammer” of severe chronic pain

29. 5. 2017

rozhovor_1Chronic pain can literally paralyze a person. If the patient undergoes all of the treatment from rehabilitation through drug use to frequently repeated surgery, he/she does not feel any relief and the pain persists, one of the solutions could be neurostimulation. During this therapy, when the brain and the spinal cord are stimulated by electrical impulses, a neurostimulator guided into the patient’s spine is used. Neurostimulators have been used in treatment for a number of years. At the beginning of April, the University Hospital in Bratislava carried out the first implantation of a technological innovation – the smallest neurostimulator in the world that works as Wi-Fi – a wireless device without the need to surgically implant  the battery under the skin of the patient. One of the main operators is the algesiologist and pain management specialist MUDr. Róbert Rapčan, FIPP. We asked him some questions about neurostimulation and neurostimulators.

When does chronic pain become severe chronic pain and can it be determined which type of pain is best for a neurostimulator?
Generally, it concerns pain in a patient experiencing severe damage to the nerve structures. This is a chronic pain that loses its protective significance and persists even after whatever was causing the pain stops acting. To put it simply, if you somehow damage a joint or a disc, the healing phase takes place with pain that is informative – it says that the process is still ongoing and that the person is not cured yet. After the healing phase, the person should be healthy. If this does not happen and the pain continues, then we evaluate its intensity. If it is so strong that it affects the person’s quality of life in such a way that they are unable to perform normal functions in everyday life, be it social, work or, for instance, sexual, or they are unable to sleep or they do not want to perform these functions, then it concerns severe chronic pain. It is often associated with psychological problems and suicidal tendencies, that is, people have a tendency towards committing suicide or even commit it. Pain arising from damage to nerve structures is referred to as neuropathic, and is also the most common indication for the implantation of a neurostimulator.

Neurostimulation is the “culmination” of treatment, before that the patient goes through different healing “stages” – physiotherapy, drug use, surgery. When is this therapy used?
Previously, after the failure of any conservative treatment, an operation was approached as the final solution. The trend in today’s modern treatment is that if the condition does not improve or worsens after surgery, we refrain from further surgery and we prefer neurostimulation treatment. Especially because a neurostimulator is reversible. If, for some reason, it did not work, it can be removed. If, however, even after implantation, the patient does not feel any relief, there is no other solution. The operator is in permanent communication with a team of experts as to whether to choose surgery or the introduction of a neurostimulator. If it concerns a young patient, it is a realistic assumption that the neurostimulator will be the most appropriate option.

The neurostimulator, like a pacemaker, works in the patient’s body. How long will it last?
From the point of view of how long a neurostimulator lasts, it is necessary to take into account two aspects. On the one hand, the technical, which means that, with the correct maintenance, the pacemaker can last for decades. But this is not the most important. Far more important is how long the patient can respond to the neurostimulator’s positive effect. In the case of neuropathic pain, we talk about so-called neurotoxication of the nervous system. It may happen that the patient will feel great relief from pain for three or four years and then, for some reason, this effect will stop. It is similar to when the patient is taking a certain dose of opiates for some time. When it ceases to be sufficient, after a certain period, the amount increases. In a patient with a neurostimulator, this is similar, but it is only the effect of an electrical current on the nervous tissue. If, however, despite the neurostimulator being in good working order and placed in a good anatomical position, it does not increase the intensity of the effect, the therapy is no longer meaningful.

The neurostimulator is placed in the spinal cord. Can it move from there, migrate? How long does it take to implant it?
The epidural space is the space between the spinal coatings, filled with, for example, blood vessels and fatty tissues. The electrode is precisely implanted and solidly anchored in the subcutaneous tissue, so such movement is not possible. Moreover, it is made of material that is fully compatible with the human body. The patient does not have to worry because this device is designed and made specifically for this purpose. Usually the operation itself lasts up to 60 minutes, depending on the type of neurostimulator.

Is a patient with a neurostimulator particularly limited in their activities?
Above all, it is important to realize that neurostimulation is a palliative exercise, that is, an exercise designed to reduce the patient’s hardship. For a patient who has had two operations on the spine without postoperative indications it is clear that the spine is not healthy. It won’t mean they’ll return to their top performances, it is not possible to expect extreme miracles. To put it simply, neurostimulators act as a pain “jammer” and the aim of therapy is to return the patient to normal daily activities. It is about improving the patient’s quality of life, including the basic joy of being able to “function” normally.

Who is a good patient for introducing a neurostimulator and how can it be obtained?
In essence, it is a patient with a severe type of pain, which is suitable for this kind of therapy, and a patient who generally responds well to treatment. There are, however, other types of pain and indications where the neurostimulator can be used, for example in refractory angina pectoris, which is resistant to all treatment. Therefore, there is no clear indication of who is or is not a suitable candidate. It is important for the patient to be motivated for the treatment and, of course, to meet a number of clinical conditions. Patient recommendations for neurostimulator implantation are decided upon by a commission on the basis of psychological, psychiatric, algesiological and neurological examinations.

Thank you for the interview.