Spinal Cord Stimulator

What is a spinal cord stimulator?

A spinal cord stimulator is a medical device that a healthcare provider can implant in your body to treat severe pain. These devices come in several types, and can be an alternative to other forms of treatment, such as opioids, which may become addictive.

How does a spinal cord stimulator treat pain?

To understand how a spinal cord stimulator works, it helps to know a little about how pain and your nervous system work.

Understanding pain

Under ordinary circumstances, pain is a protective process. It tells you when you’re hurt or if something is happening to your body that’s about to hurt you. It’s also a key sign of many illnesses and diseases.

However, pain isn’t always protective. Many conditions cause overwhelmingly severe pain, or pain that doesn’t let up or go away. That can make it hard to sleep or work. Over time, living with chronic (long-term) pain can have serious — or even severe — consequences.

Chronic pain causes changes in your brain and nervous system. Those changes can make pain feel more severe (hyperalgesia) or cause your nervous system to send pain signals for things that shouldn’t hurt (allodynia). In some cases, your nervous system may send pain signals randomly or constantly.

Understanding the nervous system

Your nervous system forms an intricate network throughout your body, providing two-way communication between your brain and different body parts. Think of your nervous system like a phone line and pain signals like phone calls.

Spinal cord stimulation (another term for this is neuromodulation) uses a mild electrical current to stimulate certain nerve fibers in your spinal cord. In effect, that current acts like another call is using the phone line, which keeps pain signals from reaching your brain.

Who needs to have this treatment?

Spinal cord stimulation treats chronic, severe pain. It’s usually an option when other means of controlling pain are unsuccessful. The conditions and circumstances that result in needing a spinal cord stimulator are most common in adults. However, adolescents and teenagers may also have conditions that are treatable with spinal cord stimulation.

What conditions does spinal cord stimulation treat or manage?

Chronic pain can happen for many reasons, but some are more likely than others. Potential reasons include:

• Back pain.
• Complex regional pain syndrome (CRPS).
• Continued back pain after laminectomy surgery. Previously known as “failed back surgery syndrome,” experts now often refer to this as post-laminectomy syndrome or persistent spinal pain syndrome (PSPS).
• Diabetes-related neuropathy (nerve damage).
• Pain that happens because of malfunctions in your nerves (neuropathic pain).

Researchers are also investigating if spinal cord stimulation can help people with the following:

• Central pain syndrome, heterotopic ossification (bony tissue developing inside soft tissues).
• Ischemic pain (this happens because of low blood flow).
• Chest pain (angina) that isn’t controllable through other means.
• Spinal cord injuries and other types of nerve injuries.
• Postherpetic neuralgia (nerve pain caused by damage from shingles).

Researchers are considering other conditions that may benefit from spinal cord stimulation, as well. Some examples of these conditions include cerebral palsy and traumatic brain injuries. However, more research is necessary to determine whether spinal cord stimulation is effective for those conditions.

How common are these procedures?

More than 30,000 people annually undergo surgery to implant a spinal cord stimulator.

What happens before this procedure?

Spinal cord stimulation isn’t a first-line procedure. That means it’s an option when other treatments don’t work, such as physical therapy and medication injections. Before you can have this surgery, you’ll undergo lab, imaging and diagnostic tests to make sure that you’re healthy enough for surgery, and to rule out any other circumstances that might mean you shouldn’t have this procedure.

You’ll also need to see several healthcare providers and specialists before undergoing this surgery. The specialists typically include:

• A neurologist. These physicians specialize in conditions affecting your brain and nervous system. These providers often diagnose the pain-related condition that causes you to need spinal cord stimulation.
• A pain management specialist. These specialist physicians determine if less-invasive treatments haven’t treated the problem, or if there’s another reason why you can’t receive or undergo those treatments.
• A neurosurgeon. This provider can do the surgery to implant the spinal cord stimulator. In some cases, this is a physician you’ve already seen for other treatments to try to help your pain condition.
• A psychiatrist or psychologist. These mental health providers can evaluate your mental health and any related conditions you might have. Chronic pain can severely affect your mental health, causing conditions — such as anxiety and depression — that also need treatment. Some mental health conditions reduce the odds that spinal cord stimulation will work in the long run, so diagnosing and treating these conditions is also important.
• An anesthesiologist. This surgery involves general anesthesia, so an anesthesiologist will need to talk to you beforehand. They’ll also review your medical history for information or details that might change how general anesthesia affects you.

Once you’re cleared for surgery, you’ll receive information and guidance on exactly how to prepare for the surgery. This typically includes topics like the following:

• Medications you take. Be sure to tell your provider about every medication you’re taking, including vitamins and supplements. They may have you switch certain medications or stop others (such as blood thinners). You should only stop taking medications after discussing them with your provider.
• Bathing and grooming. Your healthcare provider will likely give you instructions on how to bathe and prepare for the procedure. This commonly includes a special type of soap or other hygiene products for your skin for the procedure.
• Because this surgery involves general anesthesia, your healthcare provider will have you fast. That means no solid food for at least eight hours before the procedure and no liquids for at least two hours before.

What happens during spinal cord stimulation?

Spinal cord stimulator implantation is a process that usually involves two procedures. The first is a “trial” procedure. The second — if the trial succeeds — will involve the full surgery to implant the pulse generator or battery. (The preparations before both procedures, as noted in the above, “What happens before this procedure?” section, are the same.)

A spinal cord stimulator involves attaching one or more electrical leads (insulated wires or small, flat panels with conductive contacts near the tip). The conductive parts of leads go into the epidural space, which is between the dura mater (the outer membrane that surrounds the spinal cord itself) and the ligaments on the inside of your spine. The leads connect to a pulse generator, which generates the electrical current that will stimulate the spinal cord.

The location of the leads on your spinal cord can vary. For most people, the best place is in your back at about the same level as the lower edge of your breastbone (sternum). For those with pain in the arm, the neck may be a possible option for placement.

Trial procedure

The trial procedure generally involves a percutaneous (meaning “through the skin”) approach. During this procedure, you’re usually under sedation (light sleep). You might receive general anesthesia under certain circumstances, but this is less common. They’ll also use a special type of x-ray called fluoroscopy (the real-time video equivalent of an x-ray), which lets them see where to place the lead.

After you’re under sedation or anesthesia, your provider makes a small incision (cut) in your skin and inserts a special needle through the incision and into your back. Once the needle tip reaches epidural space, your provider will thread the temporary lead(s) into position and remove the needle, leaving part of the lead outside your skin.

Once the leads are in place, your provider will secure the external end of the lead to your skin and connect it to a pulse generator, also attached to your skin (attaching the lead and the external generator can use a suture or skin glue). They’ll then program and start testing to see whether or not the stimulator works without having to do a full surgery.

These trials typically last between a few days to a few weeks (this varies in different parts of the world). Your provider will remove these leads at the end of the trial. Experts consider a stimulator trial successful if you have at least a 50% decrease in pain level. If the trial is successful, most people undergo the next step, implantation surgery, about a week or two after the trial procedure.

If a percutaneous electrode isn’t possible, your provider may recommend placing a paddle electrode instead. This is a wider electrode that requires additional surgery to make room for it. If you have a paddle electrode implanted, you’ll need to stay overnight in the hospital.

Implantation surgery

During this procedure, which involves general anesthesia, your provider will perform surgery to place permanent leads in the same location as the trial. That starts with an incision (cut) over your spine. If your provider is placing a paddle electrode, they’ll need to make a space to pass through muscle tissue for the electrode to fit through. If they’re placing a percutaneous electrode, they won’t need to create that kind of space.

Once they place the leads, they’ll anchor the electrode end of the lead(s) into place and thread the near end of the lead under your skin to where they’ll implant the pulse generator. They’ll then create a small, pocket-like space where they can implant the pulse generator.

Where they implant the pulse generator depends on a few factors. They’ll usually place the generator just above or below belt level on the side that’s easiest for you to reach (either on the belly side or in one of your buttocks). They may also put it on the opposite side of whichever side is your preference for sleeping.

Being able to reach the skin over the top of the pulse generator is important, depending on which type of generator you have implanted. Some pulse generators are constantly active. Others need switching off and on, which you do with a remote you hold next to the generator. There are also rechargeable generators, which you charge by holding a special charging device above or against the skin just over the generator.

Once your provider finishes implanting the generator, they’ll use sutures and/or staples to close the incisions. The process of programming the generator can happen in the operating room, the recovery room after surgery or both. They can also make adjustments to the programming at follow-up appointments.

What happens after this procedure?

After the trial procedure, you’ll likely be able to go home that same day or the following day. After the generator implantation surgery, most people can go home within one or two days.

Your healthcare provider will give you guidance and instructions on caring for the procedure site after the trial lead placement and the generator implantation. In most cases, that involves taking care of the surgical wound, keeping it clean and changing its bandages for seven to 10 days. You’ll have a follow-up appointment about 10 to 14 days after the generator implantation surgery, where your provider will remove the staples and/or stitches.

What are the advantages of this procedure?

Spinal cord stimulation is a procedure that has many potential advantages:

• It can treat pain that resists other forms of treatment. Spinal cord stimulation is mainly used as an alternative when other methods don’t work.
• It can treat many different types of pain. The potential uses for spinal cord stimulation include heart-related chest pain, nerve pain, and spine or back pain.
• It can help a person rely less on stronger pain medications. Opioid-based painkillers are often necessary for chronic pain. Unfortunately, these medications have many potential side effects and risks. Spinal cord stimulation can reduce pain levels, which can help you reduce the dosage of your pain medications, how often you take them or both.
• You can try it temporarily before undergoing a major surgery. The most common approach to spinal cord stimulation involves a trial period. If the trial is unsuccessful, it’s typically reversible without surgery.

What are the risks or complications of spinal cord stimulation?

Spinal cord surgery isn’t a first-line treatment because of potential complications and risks. These include:

• Risk of infection. One of the most common — and most serious — risks with spinal cord stimulation devices is the risk of infection. That risk exists because spinal cord stimulation involves placing a device inside your body. If you get an infection around the implanted hardware, you may need surgery to treat the infection. Sometimes, treatment isn’t enough, and you need surgery to remove the generator and leads entirely.
• Leads moving out of position. This is less common than in years past due to advances in medical technology and procedures. There are now special devices and components that can anchor spinal cord stimulation leads, reducing the risk of them moving out of place.
• Leads breaking or malfunctioning. Your spine is a column of interlocking bones known as vertebrae (the term for one is “vertebra”). The vertebrae and their related connective tissues (ligaments and muscles) can flex and bend. In some cases, the hardware of the leads can’t match that flexibility, causing the leads to break or malfunction. That usually requires surgery to correct.
• Injuries from broken or displaced leads. When the hardware involved in spinal cord stimulation breaks or moves out of place, it can sometimes damage your spinal cord or the surrounding tissues. In severe cases, that can permanently damage your spinal cord or nearby nerves. Fortunately, permanent injuries are rare.
• Pulse generator malfunction or failure. Spinal cord stimulation relies on a pulse generator that has a lifespan. Pulse generator batteries typically need replacement after several years. The generators themselves can also fail, and repairing or replacing them involves surgery.
• Gradual loss of pain relief.
• Possible side effects, depending on the type of stimulator and location. An example of this is how some stimulators deliberately cause a feeling of tingling or numbness. While that isn’t pain, it may also feel uncomfortable or unpleasant to some people.

What is the recovery time?

You can usually return home the same day or the day after you undergo implantation of trial stimulator leads. Your healthcare provider will likely recommend that you take it easy and avoid bending, stretching, lifting and other forms of physical activity while you get used to the stimulator leads and their effects.

The generator implantation surgery is a more involved procedure, which also means you’ll need more time to recover. You can usually go home the following day after the surgery, but your healthcare provider will have you limit your physical activity for several weeks (usually four to six weeks). That will allow the pocket around the implanted generator to heal and your body to get used to the stimulation leads.

Your healthcare provider is the best person to give you information and guidance about the recovery time and how you can best care for yourself after this procedure. They are the ones best able to give you relevant and important information for your specific situation.

When should I see my healthcare provider?

Your healthcare provider will schedule follow-up visits after you undergo the generator implantation surgery. You should see them as recommended for these visits, which can help with adjustments to the electrical stimulation your device delivers. You should also call or see your healthcare provider if you notice any increases in your pain levels or any gradual increase in side effects.

Some of the possible complications include:

• Headache that’s constant when you stand or sit up but goes away when you lie down. This can be a symptom of a cerebrospinal fluid (CSF) leak, which can happen if a lead damages the dura mater and allows CSF to leak out.
• Signs of infection around surgical sites. These include redness, swelling, pain and an oozing (and sometimes foul-smelling) discharge.

You should seek emergency medical attention right away if you notice any of the following:

• Sudden appearance of numbness, tingling or muscle weakness. This can affect one or both sides of your body anywhere below the location of the lead(s). This is a possible sign of a shift in the lead(s) position, which can damage the spinal cord or nearby nerves. Some tingling is normal with certain types of stimulators, so it’s a good idea to ask your provider for guidance on which sensations are normal or expected, and which are potential warning signs.
• Any of the symptoms of sepsis. This is when a widespread infection in your body triggers a massive, life-threatening immune reaction. Sepsis is a medical emergency and can cause permanent damage or death without immediate treatment.

What is the success rate of a spinal cord stimulator?

The success rate for spinal cord stimulators depends partly on the condition they’re treating and the device type. On average, about half of people see more than a 50% improvement in their pain. The effectiveness of spinal cord stimulators can also decrease over time for unknown reasons. Because of these factors (and others), your healthcare provider is the best person to tell you the odds of success. The information they give you will be the most relevant to your circumstances.

Can you live a normal life with a spinal cord stimulator?

If you have a spinal cord stimulator, you may have to make some changes to your life. Depending on where the leads are in your spine, you may be unable to bend or twist in certain ways due to the risk of damaging or breaking a lead.

However, many people with spinal cord stimulators can adapt. That means they can have and enjoy a routine and activities without worrying about the stimulator, its lead(s) and the device’s effects. Your healthcare provider is the best source of information on the changes (if any) you might need to make to your life.

A note from Cleveland Clinic

Spinal cord stimulators are a treatment option that may offer relief for people living with pain that isn’t responding to more common forms of treatment. The likelihood of success from this treatment is also greater than in years past, thanks to advances in technology, surgery techniques and science’s understanding of the nervous system. While there are still some drawbacks and risks of complications, the benefits of spinal cord stimulators mean more people can live with lower pain levels without relying on stronger, habit-forming medications.