Treatment of chronic pain by epidural spinal cord stimulation: a 10-year experience

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✓ Epidural spinal cord stimulation by means of chronically implanted electrodes was carried out on 121 patients with pain of varied benign organic etiology. In 116 patients, the pain was confined to the back and lower extremities and, of these, 56 exhibited the failed-back syndrome. Most patients were referred by a pain management service because of failure of conventional pain treatment modalities. Electrodes were implanted at varying sites, dictated by the location of pain. A total of 140 epidural implants were used: 76 unipolar, 46 Resume electrodes, 12 bipolar, and six quadripolar. Patients were followed for periods ranging from 6 months to 10 years, with a mean follow-up period of 40 months. Forty-eight patients (40%) were able to control their pain by neurostimulation alone. A further 14 patients (12%), in addition to following a regular stimulation program, needed occasional analgesic supplements to achieve 50% or more relief of the prestimulation pain. Pain secondary to arachnoiditis or perineural fibrosis following multiple intervertebral disc operations, when predominantly confined to one lower extremity, seemed to respond favorably to this treatment. Uniformly good results were also obtained in lower-extremity pain secondary to multiple sclerosis. Pain due to advanced peripheral vascular disease of the lower limbs was well controlled, and amputation below the knee was delayed for up to 2 years in some patients. Pain due to cauda equina injury, paraplegic pain, phantom-limb pain, pure midline back pain without radiculopathy, or pain due to primary bone or joint disease seemed to respond less well. Patients who responded to preliminary transcutaneous electrical nerve stimulation generally did well with electrode implants. Notable complications included wound infection, electrode displacement or fracturing, and fibrosis at the stimulating tip of the electrode. Three patients in this series died due to unrelated causes. Epidural spinal cord stimulation has proven to be an effective and safe means of controlling pain on a long-term basis in selected groups of patients.

The mechanism of action of stimulation-produced analgesia remains unclear; further studies to elucidate it might allow spinal cord stimulation to be exploited more effectively in disorders that are currently refractory to this treatment modality.

Abstract

✓ Epidural spinal cord stimulation by means of chronically implanted electrodes was carried out on 121 patients with pain of varied benign organic etiology. In 116 patients, the pain was confined to the back and lower extremities and, of these, 56 exhibited the failed-back syndrome. Most patients were referred by a pain management service because of failure of conventional pain treatment modalities. Electrodes were implanted at varying sites, dictated by the location of pain. A total of 140 epidural implants were used: 76 unipolar, 46 Resume electrodes, 12 bipolar, and six quadripolar. Patients were followed for periods ranging from 6 months to 10 years, with a mean follow-up period of 40 months. Forty-eight patients (40%) were able to control their pain by neurostimulation alone. A further 14 patients (12%), in addition to following a regular stimulation program, needed occasional analgesic supplements to achieve 50% or more relief of the prestimulation pain. Pain secondary to arachnoiditis or perineural fibrosis following multiple intervertebral disc operations, when predominantly confined to one lower extremity, seemed to respond favorably to this treatment. Uniformly good results were also obtained in lower-extremity pain secondary to multiple sclerosis. Pain due to advanced peripheral vascular disease of the lower limbs was well controlled, and amputation below the knee was delayed for up to 2 years in some patients. Pain due to cauda equina injury, paraplegic pain, phantom-limb pain, pure midline back pain without radiculopathy, or pain due to primary bone or joint disease seemed to respond less well. Patients who responded to preliminary transcutaneous electrical nerve stimulation generally did well with electrode implants. Notable complications included wound infection, electrode displacement or fracturing, and fibrosis at the stimulating tip of the electrode. Three patients in this series died due to unrelated causes. Epidural spinal cord stimulation has proven to be an effective and safe means of controlling pain on a long-term basis in selected groups of patients.

The mechanism of action of stimulation-produced analgesia remains unclear; further studies to elucidate it might allow spinal cord stimulation to be exploited more effectively in disorders that are currently refractory to this treatment modality.

Pain is a complex behavioral process, of which the anatomy and physiology are still poorly understood and are the subject of continuing exploration and research. The therapeutic use of electricity has been applied since ancient times28 to cardiac, musculoskeletal, urinary, visual, auditory, and nervous systems15 with varying degrees of success.

Neurological applications include stimulation of the peripheral nerve, spinal cord, and deep brain for control of pain, each having a unique history and theoretical basis of action. Shealy, et al.,34 were the first investigators to apply the concept to the spinal cord, Wall and Sweet40 and Long19 to peripheral nerves, and Adams, et al.,1 to subcortical brain.

The dorsal column stimulator, the first spinal cord system,24,34,36 initially showed good results in 90% of cases; however, this fell to 35% at the 2-year follow-up evaluation due to poor patient selection, and thus the entire mode of treatment fell into disrepute.9,12,25,26,35 Long-term results have improved with the advent of epidural stimulation, improved patient selection,18,20 and the recognition of site-specific pain control with varying electrode placement.27,29,30 Further refinements have included percutaneous insertion and trial stimulation for several days before internalization of the system.

This study summarizes our experience with long-term neurostimulation of the spinal cord for relief of chronic organic pain of nonmalignant origin by means of epidural stimulating electrodes inserted either percutaneously or through a small laminotomy.

Clinical Material and Methods
Patient Selection

Patients were selected through a well-defined pathway involving evaluation and treatment by medical pain-control personnel in the setting of a pain clinic. In an attempt to quantify the intensity of pain, we use a visual analog scale6,10 with values of 0 to 100, and a modified McGill Pain Questionnaire.23 These were used to evaluate the pain and the patient's reaction to it, and to assign an objective “pain score.” The process was repeated at 6 months and at yearly intervals thereafter, and formed one of the yardsticks for evaluation of our results.

Patient selection is a key factor. Our patients fulfilled the following basic criteria: 1) Pain was due to a known benign organic cause. We did, however, accept two cases of spinal cord tumors as both were histologically of low-grade malignancy with anticipated long-term survival. 2) All conventional methods of pain control had failed. 3) Patients had no major abnormal personality traits. Depression, anxiety, and lack of sleep were considered normal responses to chronic pain and did not constitute a contraindication provided they had responded satisfactorily to psychological management. 4) Drug dependency had been gradually eliminated and inappropriate drug use terminated before the electrode was implanted. 5) Most patients had initial satisfactory pain relief with transcutaneous electrical nerve stimulation, but could not continue that type of treatment due to allergic skin reactions, bulkiness of the apparatus, or a reduction in its effectiveness. 6) A trial of percutaneous epidural stimulation had been effective in producing appreciable pain relief. 7) Surgical risks were understood by the patient and informed consent had been obtained.

Technique of Electrode Implantation

The electrodes were implanted either by a percutaneous technique or through a small laminotomy, depending upon the type of electrode to be implanted, as discussed in our earlier report.14 It is imperative that intraoperative stimulation-induced paresthesias should fully encompass the area of pain to achieve success. The locations of the stimulating tips were usually between the C-6 and T-1 vertebral bodies for upper-extremity pain and between T-9 and T-11 for lower-extremity pain.

Clinical Material

In this series, 119 patients with chronic organic pain of varied benign etiology and two patients with cancer pain (spinal cord tumors of low-grade malignancy) were treated by insertion of epidural spinal cord implants. The causes of pain are summarized in Table 1. These patients were followed for periods from 6 months to 10 years. Seventy-nine patients were male and 42 female, with a mean age of 49 years. One hundred sixteen (96%) presented with pain in the back and lower extremities. Each patient had undergone and average of two previous operations (range none to seven operations); 98 (81%) had had at least one previous operation. In all cases, pain had been refractory to conventional medical management, and activities including employment or daily housework were consequently markedly curtailed.

TABLE 1

Initial and long-term results of spinal cord stimulation*

Etiology of PainNo. of CasesInitial ResultsResults With Permanent Implantation
SuccessFailureSuccessFailure  
low-back & leg pain665793720
multiple sclerosis99072
peripheral vascular disease54140
intercostal neuralgia75241
spinal cord tumor21110
facet syndrome54131
causalgia32111
bone & joint disease31210
cauda equina syndrome64213
brachial plexus/peripheral nerve injury54122
perianal pain3121
phantom-limb pain202
peripheral neuropathy21101
post-herpetic neuralgia101
spinal cord trauma21101
total cases12194276232

Success = good or excellent pain relief; initial failure = system not internalized; subsequent failure = initial pain relief but late loss of pain relief.

Electrode Combinations

Including electrodes replaced after initial fracture, a total of 140 epidural implants were used. Of these, 76 (54%) were unipolar Sigma electrodes with a 3-mm stimulating tip; 46 (33%) were Resume electrodes with four large-contact stimulating surfaces, each measuring 12.5 sq mm and needing a laminotomy for placement; 12 (9%) were bipolar; and six (4%) quadripolar with four contact points for stimulation, each 3 mm long and spaced 6 mm apart.* When electrodes had to be replaced because of failure, the Resume electrode was commonly employed (Table 2). In no patient was an electrode replaced more than once.

TABLE 2

Electrode combinations used in 121 patients

Electrodes UsedNo. of Cases
unipolar only59
bipolar only8
Resume only30
quadripolar only5
unipolar replaced by Resume13
unipolar replaced by bipolar1
bipolar replaced by Resume1
bipolar replaced by unipolar2
Resume replaced by unipolar1
quadripolar replaced by Resume1

Clinical Evaluation

Each patient entering our program who eventually had an epidural stimulator implanted was followed in a prospective manner with periodic re-examinations and follow-up telephone interviews for those who could not return to our clinic. The patients in the present study were selected only on the basis of having been followed for at least 6 months from the time of internalization of the system, but also included those without implantation. Our follow-up period ranged from 6 months to 10 years with a mean follow-up period of 40 months.

In evaluating any pain-relieving procedure, it is important to recognize the lack of uniformity of opinion about what constitutes a “good” result. In our earlier report14 on this subject we used “return to work or previous level of physical activities” as the criterion for identifying a “good” result. However, as our experience increased, we came to realize that pain relief does not parallel ability to return to work. As pointed out by Long, et al.,20 a middle-aged laborer who has had multiple back operations and suffers from arachnoiditis and who has not worked for over 2 years is unlikely to return to any job for which he is qualified, even with good pain relief.

The criteria for success in this study included: a patient's report of pain relief, both subjective and as judged by the visual analog scale6,10 and modified McGill Pain Questionnaire;23 reduction in drug intake; increased activity; and actual use of the implant. All patients able to respond to our survey in April, 1989, were categorized into one of four grades: those with an electrode that was never internalized (initial failures); those initial successes that later failed (late failures); those who used their implants regularly but required occasional narcotic supplementation (good pain relief); and those who regularly used their electrodes and did not require narcotic medication of any type (excellent pain relief). We have found that more complicated grading systems depend excessively on the patient's subjective impressions of pain quantity, severity, frequency, and character, and therefore lack consistency and reliability; however, it was noted that the use of occasional narcotic analgesics correlated strongly with subjective and objective impressions of good pain relief to levels of about 50% or more of the original pain. All patients were interviewed by a physician not otherwise involved with them, who also reviewed the charts and radiological studies.

Results
Pain Relief

Of the 121 patients included in this study, 27 (22%) did not undergo internalization of the electrode system because of inadequate pain relief during a 1- to 2-week trial stimulation period (initial failures). Of the remaining 94 patients (78%) entered in the study, 75 (62%) reported excellent pain relief and 19 patients (16%) reported good pain relief during trial stimulation; all 94 had their systems internalized (Table 3).

TABLE 3

Results at time of operation compared with late results in 121 patients*

Results of SurgeryNo. of Cases
At SurgeryLate Outcome 
initial failure2727
late failure032
successful1914
excellent7548

Follow-up period: mean 40 months, range 6 to 116 months. Late results obtained in April, 1989.

Initial failure = system not internalized after trial stimulation; late failure = initially internalized after trial stimulation but late loss of pain relief; successful = good pain relief using stimulator regularly, supplemented with occasional narcotics; excellent = patient using stimulator regularly, no adjunctive narcotics.

After the follow-up period, we found that the pain control of 32 patients with internalized systems (26%) declined to the point where they were not using the equipment (late failures). At the time of writing, 14 patients (11%) had good relief and the number with excellent pain relief had decreased to 48 (40%) from the initial 75 (62%) (Table 3). Overall, 62 (51%) of our patients selected for implantation after initial screening were receiving satisfactory pain relief from the electrode that warranted its continued use. If those whose system was not internalized are excluded, our adjusted success rate becomes 66%. It seems, then, that patients fall into two initial categories: those who have an intrinsic receptiveness to this type of electrical pain control (those with internalized systems) and another group whose physiology, anatomy, or pathology does not respond to epidural stimulation (initial failures, those whose systems were not internalized). We believe that further success in this field might be derived by anticipating and preventing a postimplant decline in pain relief; this should be a valuable area for future research.

Patients with the failed-back syndrome secondary to multiple intervertebral disc operations did well in our study (Table 1), as did patients with lower-extremity pain due to multiple sclerosis. One patient with spinal cord ependymoma did surprisingly well, and continues to have excellent long-term pain relief more than 7 years postimplantation; as a general rule, we do not use epidural stimulators in patients with malignant disease, but the low-grade histology of this tumor and the long-term expected survival prompted our intervention. Pain due to peripheral vascular disease also responded well; it is interesting to note the recent emphasis in the literature describing beneficial effects of epidural stimulation on the peripheral vascular disease itself.2,4,7,8,21,22,31,37 Unilateral lower-limb pain responded best in all cases. Patients with disease of the peripheral nerves, facet syndrome, bone and joint disease, cauda equina syndrome, paraplegic pain, and phantom-limb pain did not seem to do as well (Table 1), although there were few patients in these groups.

Outcome does not appear to be correlated with age, sex, type or number of previous operations, or duration of pain before the implant.

Complications

Complications in our series (Table 4) related mostly to hardware problems, especially displacement of the stimulating electrode with a consequent shift in the area of paresthesias and failure of pain control. Movement of the electrode occurred axially as well as laterally, and repositioning of the electrode was usually possible. Although Resume electrodes have a reputation for stability, we encountered several instances of postoperative movement that called for repositioning.

TABLE 4

Complications of spinal cord electrodes*

ComplicationsNo. of CasesComment
displaced electrode25in 17 patients revision was followed by satisfactory pain relief; in eight, Sigma electrodes were changed to a Resume system
infection8required removal in seven; one case cleared with antibiotics
fractured electrode4replacement with another electrode successful in all; usually fractured at site of entry into the epidural space
battery depletion2replacement successful
electrical leak2usually at connection between cord and receiver; replacement successful
cerebrospinal fluid leak2resolved with bed rest

Three patients in the series died, all from causes unrelated to spinal cord implantation surgery.

The diagnosis of electrode movement is made by the history of sudden loss of pain control in conjunction with shifted paresthesias, usually after a fall or other trauma. The absence of radiological evidence of electrode shift is not a contraindication to electrode repositioning. Patients with scoliosis or similar spinal deformities were found to have a threefold higher incidence of electrode displacement.

Additional hardware problems included fracture of the electrode wire, usually at the site of entry into the epidural space or at the junction of the electrode with the extension cord of the receiver-stimulator; battery depletion; and electrical leak, usually at the junction of the receiver and extension cord. These accounted for about 80% of all significant complications encountered.

Eight infections occurred in our series, seven of which required removal of the hardware. There were two transient cerebrospinal fluid leaks, each treated by bed rest and not requiring implant removal (Table 4). Three patients died during the follow-up period, all from causes unrelated to the implant.

Tolerance

Thirty-two of our treatment failures were due to long-term loss of pain relief for reasons unrelated to mechanical problems. These patients all had internalized systems and initially enjoyed good or excellent pain relief with stimulation, but for unknown reasons developed tolerance to stimulation-produced analgesia resulting in gradually declining pain control, sometimes even in the presence of satisfactory coverage of the painful area by paresthesia. This loss tends to occur within the first 4 years after implantation, with the greatest decline during the first 2 years, although sporadic cases may occur throughout the follow-up period. Overall, it seems that systems surviving 4 years have an excellent long-term prognosis for successful pain relief (Fig. 1).

Fig. 1.
Fig. 1.

Time course of tolerance development in spinal cord stimulation patients. The black block indicates patients considered primary failures whose systems were not internalized. Our data suggest that the incidence of tolerance development is maximum in the first 2 years after electrode implantation.

Discussion

A review of experience with epidural stimulators at several centers worldwide is presented in Table 5. It is evident from these results that, overall, long-term relief can be achieved in close to 50% of cases. It must also be noted, however, that some series have a shorter follow-up period and comprise only certain selected pathologies (primarily the failed-back syndrome) that tend to respond well to electrostimulation and give better results3,5,20,39 than those from mixed populations13,16,22,38 that include pathologies with lower yields.

TABLE 5

Review of experience of epidural spinal cord stimulation

Authors & YearTotal CasesSuccessful ResultsFollow-Up Period (mos)
No.%MaximumMean  
Krainick, et al., 197777141884
Urban & Nashold, 19782063024
Le Roy, 19814929596031
Long, et al., 198130227384
Meglio, et al., 1981109232110321
Blume, et al., 198220178536
Broseda, et al., 1982119822012
Ray, et al., 19827836496419
Martinez (unpublished data, 1983)76648452
Lazorthes & Verdie, 198593444712047
Waisbrod & Gerbershagen, 19851612753016
Kumar, et al., 1991121625111640
totals70033848

It is a well-recognized phenomenon that epidural neurostimulation in some cases fails without an obvious mechanical cause;16 this is usually seen as a gradual decrease in the effectiveness of pain relief over several months or years with or without the persistence of paresthesias. Tolerance to the analgesia led to two-thirds of our long-term failures, and has been the subject of much speculation in the literature. We believe that the causes of this late failure, after unrecognized mechanical failure or noncompliance have been eliminated, can be classified as: 1) gross fibrotic changes isolating the stimulating tip of the electrode from the dura and interfering with the spread of current, and 2) plasticity and consequent alteration of ascending afferent nociceptive pathways allowing pain perception after the initially successful interruption of primary pathways.

Reports of fibrosis surrounding electrodes placed over the dura or spinal cord after several months of stimulation have described fibrotic changes,13,25,32 in some cases dense enough to cause symptoms of cord compression.32 It is not known whether the metal of the electrode causes a reaction in susceptible patients or whether the electrical current itself produces excessive fibrosis. Animal and autopsy studies might increase the understanding of this problem; it is certainly not an inevitable consequence of electrode placement in the epidural space.33 Our own experience in surgical re-exploration of such patients has shown that most epidural electrodes that have been in place for a few months have a longitudinal sheath of reactive fibrosis around the tip and stem.

A solution to the problem of anatomical plasticity of pain pathways is conceptually more difficult to grasp. It is clinically apparent that tracts such as the spinoreticular, spinotectal, spinocervical, and secondary afferents of the dorsal columns might all contribute to the production of pain after sectioning or electrical blockade of primary systems.11 Finally, patients unresponsive to a trial of epidural stimulation and whose systems therefore were not internalized might be examples of a population whose primary pain pathways are anatomically unsuitable for this treatment, or whose epidural anatomy in some way obviates correct electrode positioning. More sensitive screening methods might be required, perhaps along the lines of somatosensory evoked potential monitoring.

Epidural stimulation has proven to be an effective means of controlling chronic pain in a selected group of patients. It is a safe alternative to narcotics, behavior modification, or destructive operations. Patient selection criteria remain the most important determinants of success.

References

  • 1.

    Adams JEHosobuchi YFields HL: Stimulation of internal capsule for relief of chronic pain. J Neurosurg 41:7407441974J Neurosurg 41:

  • 2.

    Augustinsson LECarlsson CAHolm Jet al: Epidural electrical stimulation in severe limb ischemia: evidences of pain relief, increased blood flow and a possible limb saving effect. Ann Surg 202:1041111985Ann Surg 202:

  • 3.

    Blume HRichardson RRojas C: Epidural nerve stimulation of the lower spinal cord and cauda equina for the relief of intractable pain in failed back surgery. Appl Neurophysiol 45:4564601982Appl Neurophysiol 45:

  • 4.

    Broseta JBarberá JDe Vera JAet al: Spinal cord stimulation in peripheral arterial disease. A cooperative study. J Neurosurg 64:71801986J Neurosurg 64:

  • 5.

    Broseta JRoldan PGonzalez-Darder Jet al: Chronic epidural dorsal column stimulation in the treatment of causalgic pain. Appl Neurophysiol 45:1901941982Appl Neurophysiol 45:

  • 6.

    Carlsson AM: Assessment of chronic pain: aspects of reliability and validity of visual analogue scale. Pain 16:871011983Carlsson AM: Assessment of chronic pain: aspects of reliability and validity of visual analogue scale. Pain 16:

  • 7.

    Cook AWOygar ABaggenstos Pet al: Vascular disease of extremities. Electrical stimulation of spinal cord and posterior roots. NY State J Med 76:3663681976NY State J Med 76:

  • 8.

    Dooley DMKasprak M: Modification of blood flow to extremities by electrical stimulation of the nervous system. South Med J 69:130913111976South Med J 69:

  • 9.

    Fox JL: Dorsal column stimulation for relief of intractable pain: problems encountered with neuropacemakers. Surg Neurol 2:59641974Fox JL: Dorsal column stimulation for relief of intractable pain: problems encountered with neuropacemakers. Surg Neurol 2:

  • 10.

    Huskisson S: Visual analogue scaleMelzack R (ed): Pain Measurement and Assessment. New York: Raven Press19833340Pain Measurement and Assessment

  • 11.

    King RB: Principles of pain management. A short review. J Neurosurg 50:5545591979King RB: Principles of pain management. A short review. J Neurosurg 50:

  • 12.

    Krainick JUThoden U: Long-term results of spinal cord stimulation in amputeesCarrea RLe Vay D (eds): Sixth International Congress of Neurological Surgery. International Congress Series 433. Amsterdam: Excerpta Medica1977288293Sixth International Congress of Neurological Surgery. International Congress Series 433

  • 13.

    Krainick JUThoden URiechert T: Pain reduction in amputees by long-term spinal cord stimulation. Long-term follow-up study over 5 years. J Neurosurg 52:3463501980J Neurosurg 52:

  • 14.

    Kumar KWyant GMEkong CEU: Epidural spinal cord stimulation for relief of chronic pain. Pain Clin 2:91991986Pain Clin 2:

  • 15.

    Lazorthes YSiegfried JUpton ARM: A brief historical review of biostimulationLazorthes YUpton ARM (eds): Neurostimulation: An Overview. Mt Kisco, NY: Futura1985510Neurostimulation: An Overview

  • 16.

    Lazorthes YVerdie JC: Technical evolution and long-term results of chronic spinal cord stimulationLazorthes YUpton ARM (eds): Neurostimulation: An Overview. Mt Kisco, NY: Futura19856786Neurostimulation: An Overview

  • 17.

    Le Roy PL: Stimulation of the spinal neuraxis by biocompatible electrical current in the human. Appl Neurophysiol 44:1871931981Le Roy PL: Stimulation of the spinal neuraxis by biocompatible electrical current in the human. Appl Neurophysiol 44:

  • 18.

    Long DM: Current status of neuroaugmentation procedures for chronic painBeers RFBassett EG (eds): Mechanisms of Pain and Analgesic Compounds. New York: Raven Press19795169Mechanisms of Pain and Analgesic Compounds

  • 19.

    Long DM: Electrical stimulation for relief of pain from chronic nerve injury. J Neurosurg 39:7187221973Long DM: Electrical stimulation for relief of pain from chronic nerve injury. J Neurosurg 39:

  • 20.

    Long DMErickson DECampbell Jet al: Electrical stimulation of the spinal cord and peripheral nerves for pain control. A ten-year experience. Appl Neurophysiol 44:2072171981Appl Neurophysiol 44:

  • 21.

    Meglio MCioni BDal Lago Aet al: Pain control and improvement of peripheral blood flow following epidural spinal cord stimulation. Case report. J Neurosurg 54:8218231981J Neurosurg 54:

  • 22.

    Meglio MCioni BRossi GF: Spinal cord stimulation in management of chronic pain. A 9-year experience. J Neurosurg 70:5195241989J Neurosurg 70:

  • 23.

    Melzack R: The McGill Pain QuestionnaireMelzack R (ed): Pain Measurement and Assessment. New York: Raven Press19834148Pain Measurement and Assessment

  • 24.

    Nashold BS JrFriedman H: Dorsal column stimulation for control of pain. Preliminary report on 30 patients. J Neurosurg 36:5905971972J Neurosurg 36:

  • 25.

    Pineda A: Complications of dorsal column stimulation. J Neurosurg 48:64681978Pineda A: Complications of dorsal column stimulation. J Neurosurg 48:

  • 26.

    Pineda A: Dorsal column stimulation and its prospects. Surg Neurol 4:1571631975Pineda A: Dorsal column stimulation and its prospects. Surg Neurol 4:

  • 27.

    Ray CD: Electrical and chemical stimulation of the CNS by direct means for pain control: present and future. Clin Neurosurg 28:5645881981Ray CD: Electrical and chemical stimulation of the CNS by direct means for pain control: present and future. Clin Neurosurg 28:

  • 28.

    Ray CD: New electrical stimulation methods for therapy and rehabilitation. Orthop Rev 6:29391977Ray CD: New electrical stimulation methods for therapy and rehabilitation. Orthop Rev 6:

  • 29.

    Ray CD: Percutaneous spinal cord stimulation: techniqueHosobuchi YCorbin T (eds): Amsterdam: Excerpta Medica19811733

  • 30.

    Ray CD: Spinal epidural electrical stimulation for pain control: practical details and results. Appl Neurophysiol 44:1942061981Ray CD: Spinal epidural electrical stimulation for pain control: practical details and results. Appl Neurophysiol 44:

  • 31.

    Ray CDBurton CVLifson A: Neurostimulation as used in a large clinical practice. Appl Neurophysiol 45:1601661982Appl Neurophysiol 45:

  • 32.

    Reynolds AFShetter AG: Scarring around cervical epidural stimulating electrode. Neurosurgery 13:63651983Neurosurgery 13:

  • 33.

    Sharkey PC: Technological problems of spinal cord stimulation systems: a clinical perspective. Appl Neurophysiol 44:50541981Sharkey PC: Technological problems of spinal cord stimulation systems: a clinical perspective. Appl Neurophysiol 44:

  • 34.

    Shealy CNMortimer JTHagfors NR: Dorsal column electroanalgesia. J Neurosurg 32:5605641970J Neurosurg 32:

  • 35.

    Sweet WHWepsic JG: Electrical stimulation for suppression of pain in manFields WS (ed): Neural Organization and Its Relevance to Prosthetics. New York: Intercontinental1973219240Neural Organization and Its Relevance to Prosthetics

  • 36.

    Sweet WHWepsic JG: Treatment of chronic pain by stimulation of fibers of primary afferent neurons. Trans Am Neurol Assoc 93:1031071968Trans Am Neurol Assoc 93:

  • 37.

    Tallis RCIllis LSSedwick EMet al: Spinal cord stimulation in peripheral vascular disease. J Neurol Neurosurg Psychiatry 46:4784841983J Neurol Neurosurg Psychiatry 46:

  • 38.

    Urban BJNashold BS Jr: Percutaneous epidural stimulation of the spinal cord for relief of pain. Long-term results. J Neurosurg 48:3233281978J Neurosurg 48:

  • 39.

    Waisbrod HGerbershagen HN: Spinal cord stimulation in patients with a battered root syndrome. Arch Orthop Trauma Surg 104:62641985Arch Orthop Trauma Surg 104:

  • 40.

    Wall PDSweet WH: Temporary abolition of pain in man. Science 155:1081091967Science 155:

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Article Information

Address reprint requests to: Krishna Kumar, M.B., M.S., F.R.C.S.(C), 650 Medical and Dental Building, Regina, Saskatchewan S4P 1Z8, Canada.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Time course of tolerance development in spinal cord stimulation patients. The black block indicates patients considered primary failures whose systems were not internalized. Our data suggest that the incidence of tolerance development is maximum in the first 2 years after electrode implantation.

References

1.

Adams JEHosobuchi YFields HL: Stimulation of internal capsule for relief of chronic pain. J Neurosurg 41:7407441974J Neurosurg 41:

2.

Augustinsson LECarlsson CAHolm Jet al: Epidural electrical stimulation in severe limb ischemia: evidences of pain relief, increased blood flow and a possible limb saving effect. Ann Surg 202:1041111985Ann Surg 202:

3.

Blume HRichardson RRojas C: Epidural nerve stimulation of the lower spinal cord and cauda equina for the relief of intractable pain in failed back surgery. Appl Neurophysiol 45:4564601982Appl Neurophysiol 45:

4.

Broseta JBarberá JDe Vera JAet al: Spinal cord stimulation in peripheral arterial disease. A cooperative study. J Neurosurg 64:71801986J Neurosurg 64:

5.

Broseta JRoldan PGonzalez-Darder Jet al: Chronic epidural dorsal column stimulation in the treatment of causalgic pain. Appl Neurophysiol 45:1901941982Appl Neurophysiol 45:

6.

Carlsson AM: Assessment of chronic pain: aspects of reliability and validity of visual analogue scale. Pain 16:871011983Carlsson AM: Assessment of chronic pain: aspects of reliability and validity of visual analogue scale. Pain 16:

7.

Cook AWOygar ABaggenstos Pet al: Vascular disease of extremities. Electrical stimulation of spinal cord and posterior roots. NY State J Med 76:3663681976NY State J Med 76:

8.

Dooley DMKasprak M: Modification of blood flow to extremities by electrical stimulation of the nervous system. South Med J 69:130913111976South Med J 69:

9.

Fox JL: Dorsal column stimulation for relief of intractable pain: problems encountered with neuropacemakers. Surg Neurol 2:59641974Fox JL: Dorsal column stimulation for relief of intractable pain: problems encountered with neuropacemakers. Surg Neurol 2:

10.

Huskisson S: Visual analogue scaleMelzack R (ed): Pain Measurement and Assessment. New York: Raven Press19833340Pain Measurement and Assessment

11.

King RB: Principles of pain management. A short review. J Neurosurg 50:5545591979King RB: Principles of pain management. A short review. J Neurosurg 50:

12.

Krainick JUThoden U: Long-term results of spinal cord stimulation in amputeesCarrea RLe Vay D (eds): Sixth International Congress of Neurological Surgery. International Congress Series 433. Amsterdam: Excerpta Medica1977288293Sixth International Congress of Neurological Surgery. International Congress Series 433

13.

Krainick JUThoden URiechert T: Pain reduction in amputees by long-term spinal cord stimulation. Long-term follow-up study over 5 years. J Neurosurg 52:3463501980J Neurosurg 52:

14.

Kumar KWyant GMEkong CEU: Epidural spinal cord stimulation for relief of chronic pain. Pain Clin 2:91991986Pain Clin 2:

15.

Lazorthes YSiegfried JUpton ARM: A brief historical review of biostimulationLazorthes YUpton ARM (eds): Neurostimulation: An Overview. Mt Kisco, NY: Futura1985510Neurostimulation: An Overview

16.

Lazorthes YVerdie JC: Technical evolution and long-term results of chronic spinal cord stimulationLazorthes YUpton ARM (eds): Neurostimulation: An Overview. Mt Kisco, NY: Futura19856786Neurostimulation: An Overview

17.

Le Roy PL: Stimulation of the spinal neuraxis by biocompatible electrical current in the human. Appl Neurophysiol 44:1871931981Le Roy PL: Stimulation of the spinal neuraxis by biocompatible electrical current in the human. Appl Neurophysiol 44:

18.

Long DM: Current status of neuroaugmentation procedures for chronic painBeers RFBassett EG (eds): Mechanisms of Pain and Analgesic Compounds. New York: Raven Press19795169Mechanisms of Pain and Analgesic Compounds

19.

Long DM: Electrical stimulation for relief of pain from chronic nerve injury. J Neurosurg 39:7187221973Long DM: Electrical stimulation for relief of pain from chronic nerve injury. J Neurosurg 39:

20.

Long DMErickson DECampbell Jet al: Electrical stimulation of the spinal cord and peripheral nerves for pain control. A ten-year experience. Appl Neurophysiol 44:2072171981Appl Neurophysiol 44:

21.

Meglio MCioni BDal Lago Aet al: Pain control and improvement of peripheral blood flow following epidural spinal cord stimulation. Case report. J Neurosurg 54:8218231981J Neurosurg 54:

22.

Meglio MCioni BRossi GF: Spinal cord stimulation in management of chronic pain. A 9-year experience. J Neurosurg 70:5195241989J Neurosurg 70:

23.

Melzack R: The McGill Pain QuestionnaireMelzack R (ed): Pain Measurement and Assessment. New York: Raven Press19834148Pain Measurement and Assessment

24.

Nashold BS JrFriedman H: Dorsal column stimulation for control of pain. Preliminary report on 30 patients. J Neurosurg 36:5905971972J Neurosurg 36:

25.

Pineda A: Complications of dorsal column stimulation. J Neurosurg 48:64681978Pineda A: Complications of dorsal column stimulation. J Neurosurg 48:

26.

Pineda A: Dorsal column stimulation and its prospects. Surg Neurol 4:1571631975Pineda A: Dorsal column stimulation and its prospects. Surg Neurol 4:

27.

Ray CD: Electrical and chemical stimulation of the CNS by direct means for pain control: present and future. Clin Neurosurg 28:5645881981Ray CD: Electrical and chemical stimulation of the CNS by direct means for pain control: present and future. Clin Neurosurg 28:

28.

Ray CD: New electrical stimulation methods for therapy and rehabilitation. Orthop Rev 6:29391977Ray CD: New electrical stimulation methods for therapy and rehabilitation. Orthop Rev 6:

29.

Ray CD: Percutaneous spinal cord stimulation: techniqueHosobuchi YCorbin T (eds): Amsterdam: Excerpta Medica19811733

30.

Ray CD: Spinal epidural electrical stimulation for pain control: practical details and results. Appl Neurophysiol 44:1942061981Ray CD: Spinal epidural electrical stimulation for pain control: practical details and results. Appl Neurophysiol 44:

31.

Ray CDBurton CVLifson A: Neurostimulation as used in a large clinical practice. Appl Neurophysiol 45:1601661982Appl Neurophysiol 45:

32.

Reynolds AFShetter AG: Scarring around cervical epidural stimulating electrode. Neurosurgery 13:63651983Neurosurgery 13:

33.

Sharkey PC: Technological problems of spinal cord stimulation systems: a clinical perspective. Appl Neurophysiol 44:50541981Sharkey PC: Technological problems of spinal cord stimulation systems: a clinical perspective. Appl Neurophysiol 44:

34.

Shealy CNMortimer JTHagfors NR: Dorsal column electroanalgesia. J Neurosurg 32:5605641970J Neurosurg 32:

35.

Sweet WHWepsic JG: Electrical stimulation for suppression of pain in manFields WS (ed): Neural Organization and Its Relevance to Prosthetics. New York: Intercontinental1973219240Neural Organization and Its Relevance to Prosthetics

36.

Sweet WHWepsic JG: Treatment of chronic pain by stimulation of fibers of primary afferent neurons. Trans Am Neurol Assoc 93:1031071968Trans Am Neurol Assoc 93:

37.

Tallis RCIllis LSSedwick EMet al: Spinal cord stimulation in peripheral vascular disease. J Neurol Neurosurg Psychiatry 46:4784841983J Neurol Neurosurg Psychiatry 46:

38.

Urban BJNashold BS Jr: Percutaneous epidural stimulation of the spinal cord for relief of pain. Long-term results. J Neurosurg 48:3233281978J Neurosurg 48:

39.

Waisbrod HGerbershagen HN: Spinal cord stimulation in patients with a battered root syndrome. Arch Orthop Trauma Surg 104:62641985Arch Orthop Trauma Surg 104:

40.

Wall PDSweet WH: Temporary abolition of pain in man. Science 155:1081091967Science 155:

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