Patient Selection Criteria
When to Use Neurostimulation or Intrathecal Drug Delivery

Cancer Pain

Nonmalignant Pain
Failed Back Syndrome
Osteoporosis
Arachnoiditis
Visceral Pain
Complex Regional Pain Syndrome

Failed Back Syndrome (FBS) is an umbrella term that describes residual pain that persists despite multiple spine surgeries or other interventions--such as spinal manipulation or nerve blocks--to reduce back and leg pain or repair neurological deficits.

Examples of interventions that may have failed to relieve pain or repair deficits in FBS patients include:

• Discectomy--surgery to move a herniated or protruding disc.
• Spinal Fusion--surgical joining together of two or more vertebrae.
• Surgical decompression of spinal stenosis--a surgical procedure done to relieve pressure on neural structures caused by the narrowing of the spinal canal.
• Rehabilitation--therapeutic program involving patient and family education, physical, occupational, and psychological counseling to improve function in an impaired person.
• Spinal manipulation--manipulation of the bones and joints by a chiropractor, osteopath, or other professional to reduce pain and restore function.
• Back school--formal program of education and therapy to promote function and independence.
• Drug therapy--such as analgesics, NSAIDs (non-steroidal anti-inflammatory drugs), or muscle relaxants.
• Nerve blocks--injection of a substance, such as a local anesthetic or steroid, into an appropriate site to block the transmission of pain impulses to specific body areas innervated by spinal nerves.

Osteoporosis refers to a group of conditions characterized by loss of bone mass due to either reduced bone formation or bone resorption (Type I) or increased removal of calcium from bone (Type II). The loss of bone mass increases bone fragility, which increases the risk of fractures from only minimal trauma. Osteoporosis is primarily a disease of postmenopausal women, affecting 85% to 90% of women in their seventies. Osteoporosis can also occur secondary to endocrine disorders (i.e., Cushing's syndrome) or rheumatoid arthritis.

Chronic pain from osteoporosis can be caused by compression (fracture of a vertebra due to pressure along the vertebral column), hip, and wrist fractures. Such fractures cause chronic pain and disability in approximately 25% of patients and intractable pain in 10% to 15%. Compression fractures cause loss of height and low back pain that may radiate around the trunk. Symptoms of vertebral compression fracture include sudden onset of severe pain and paraspinal muscle spasms, which severely restrict spinal movement. Intestinal obstruction or ileus can also occur due to greatly increased sympathetic activity.

The risk of vertebral fracture is high in patients with Type I osteoporosis, which involves rapid bone loss. Postmenopausal females with fair skin and a small stature are at high risk for Type I. Type II osteoporosis is less destructive because bone loss occurs more slowly. Hip rather than vertebral fractures are common in Type II.

Pain treatment focuses on reducing pain and preventing future fractures. It includes external supports to limit motion, internal fixation, and analgesics. Weight-bearing exercise is key to preventing future fractures. Potentially bone-building drugs include calcium, estrogen replacement therapy, calcitonin, biphosphonates, and fluoride.

According to the Department of Neurology at Massachusetts General Hospital, Arachnoiditis is a condition which begins with inflammation of the arachnoid membrane covering the spinal cord and brain. This can cause a gradual build up of fibrotic scar tissue which tethers the nerves to the arachnoid membrane. This scarring disrupts the flow of cerebrospinal fluid (CSF) around the nerves and deprives them of nutrition.

The early symptoms of this condition can be all or some of the following: severe low back and leg pain, numbness and chronic pain in leg(s) and/or feet, burning sensations especially in the legs and feet, bladder and bowel dysfunction, and severe headaches. Many patients with this condition complain of a feeling of walking on broken glass. Often there are no outward signs of the condition and sufferers look deceptively "normal." As the condition progresses the symptoms may increase and become more permanent. Some patients use wheelchairs, and most patients with arachnoiditis have to give up work entirely.

Known causes of the condition are the following: tuberculosis, meningitis, spinal tumors, abcesses, spinal surgery or trauma. By far, the largest single cause is medical intervention such as myelograms, radiculargrams, epidurals (steroids) and lumbar punctures. (This definition was posted on Gateway to Neurology at Massachusetts General Hospital.)

Visceral pain originates in the abdominal organs. Chronic pancreatitis, for example, is one of the most challenging pain syndromes to treat. Pancreatitis is a serious inflammatory disorder of the pancreas. The chronic form, clinically distinct from acute pancreatitis, often results from alcoholism. It involves permanent, progressive destruction of pancreatic tissue. Experts believe that pain is caused by blockage or inflammation in pancreatic ducts. Chronic abdominal pain is usually severe, stabbing, and burning, and it is constant in about 50% of patients. A surgical procedure that corrects pancreatic duct abnormalities controls pain in 70% to 80% of patients. Pain relief can also occur when the pancreas completely loses its secretory capacity.

Complex Regional Pain Syndrome (CRPS) is a newer term adopted by the International Association for the Study of Pain (IASP) for what used to be called Reflex Sympathetic Dystrophy (RSD) or causalgia.

CRPS Treatment Guidelines: Stanton-Hicks, 1998.
Permission for reproduction granted by Lippincott Williams & Wilkins

According to a consensus report by Stanton-Hicks, 1998, a typical treatment path for CRPS begins with diagnosis, including an examination of pain characteristics, vasomotor abnormalities, trophic and motor changes. Once diagnosed, CRPS is best treated early with progressive physical therapy.

Pain interventions are an integral part of treatment and facilitate the patient’s physical therapy progress. Pharmacologic management should be used in conjunction with regional anesthetic techniques to achieve functional restoration. This includes oral, IV, epidural and intrathecal drug delivery. If the desired results are not achieved, a screening test for neurostimulation should be considered.¹

¹Stanton Hicks M. Consensus report- Complex regional pain syndromes: Guidelines for therapy, The Clinical Journal of Pain,14(2); 1998: 155-166.

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Patient Selection Criteria
When to Use Neurostimulation or Intrathecal Drug Delivery
Cancer Pain
Nonmalignant Pain
Failed Back Syndrome
Osteoporosis
Arachnoiditis
Visceral Pain
Complex Regional Pain Syndrome