Carol Banks, MSc (Pain Management), RN, Dip.
Nurse Specialist, Pain Management-Basildon and Thurrock General Hospitals NHS Trust, Orsett Hospital, Orsett
Chronic pain is a complex and multidimensional experience both for the person in pain and for the health-care team treating that person. It is for this reason that a multidisciplinary, biopsychosocial approach is used in chronic pain management clinics.
SCS is a reversible non-destructive treatment for some types of chronic pain. SCS is an electrical device consisting of implanted electrodes, connected by a lead to a receiver or pulse generator. The lead is inserted into the epidural space percutaneously or as an open operation. The receiver or pulse generator is usually implanted in the abdominal wall; it can then be connected to the lead via an extension cable, which is inserted subcutaneously.
Most physicians who perform SCS implantation for chronic pain perform the operation in two stages. The first stage involves the placing of the lead containing the electrodes into the epidural space using X-ray control to guide the lead placement. This is usually performed under local anaesthetic to enable the patient to feed back to the doctor operating where the tingling is felt. The aim is to produce stimulation-induced paresthesia (tingling) in the area of pain.
SCS, along with other pain-management techniques such as TENS (Transcutaneous Electrical Nerve Stimulation), developed as a direct consequence of the gate control theory. This theory was proposed by Melzack and Wall in 1965 and suggests that pain is influenced by internal factors in the central and peripheral nervous systems and by external factors such as emotions and cognition (Bonica 1990).
It is important that an accurate diagnosis of the underlying pain aetiology and type are made before SCS is considered for a patient. There is general agreement that SCS is a treatment for severe neuropathic pain and ischaemic pain. These include radiculopathy, complex regional pain syndromes type 1 and 2, peripheral nerve lesions, and ischaemic pain conditions such as peripheral vascular disease and, most recently, refractory angina (confirmed by a European Federation of IASP Chapters’ (EFIC) consensus statement) (Gybels et al, 1998). The European consensus statement on neuromodulation and more information regarding SCS for refractory angina are available. See ‘Useful websites’.
Over the many years that SCS has been in clinical use criteria to aid the selection process have gradually evolved. These criteria include both physiological and psychological issues, and the performance of a trial screening period. The selection process for SCS is a multi-step process. Increased refinement of patient-selection criteria has been an important focus to improve SCS outcome, and throughout the history of SCS application there has been a search to refine patient-selection criteria (Nelson et al, 1996). The goal of the selection process has developed in order to select those patients for whom SCS will be most effective, while also assuring that resources are not expended unnecessarily.
In order to make an informed choice about the appropriateness of SCS as a treatment for their pain it is crucial that patients are armed with relevant information. Patient education should address all aspects of SCS treatment, including expectations of outcome, complications and the possibility of treatment failure. This issue is of particular importance as these patients have often already undergone many treatment failures - failure of other forms of pain relief, including medication, is usually the main reason why they are being considered for SCS.
Patients are routinely reviewed in the outpatient clinic for wound care, programming and assessment and have open access to the nurse specialist for advice and trouble-shooting (Box 1).
SCS is only one of the possible treatment options and should not be seen as a last resort but as an option for certain patients who fit the criteria and undergo a detailed physiological and psychological assessment. New indications for SCS are emerging all the time. Nurses need to be aware of these new developments in order to be able to care for patients with chronic pain.
- Manufacturer’s website: www.medtronic.com
Bonica, J.J. (1990) History of pain theories, in: The Management of Pain, Bonica, J.J. (Ed.). Philadelphia: Lea and Febiger.
Gybels, J., Erdine. S., Maeyaert, J. et al. (1998) Neuromodulation of pain: a consensus statement prepared in Brussels 16-18 January 1998 by the task force of the European Federation of IASP Chapters (EFIC). European Journal of Pain 2: 3, 203-209.
International Association for the Study of Pain. (1997) Provision of Pain Services. London: Association of Anaesthetists of Great Britain and Ireland and IASP.
Kupers, R., Vanden Oever, R. Van Houdenhove, B. et al. (1994) Spinal cord stimulation in Belgium: a nationwide survey on the incidence, indications and therapeutic efficacy by the health insurer. Pain 56: 211-216.
Linderoth, B., Foreman, R.D. (1999) Physiology of spinal cord stimulation: review and update. Neuromodulation 2: 3, 150-164.
Melzack, R., Wall, P. (1965) Pain mechanisms: a new theory. Science 150: 971-973.
Nelson, D.R., Kennington, M., Nory, D.M., Sqriten, P. (1996) Psychological selection criteria for implantable spinal cord stimulation. Pain Forum 5: 93-103.
Shealy, C.N., Mortimer, J.T., Reswick, J.B. (1967) Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anaesthesia and Analgesia 46: 489-491.
Simpson, B. (1994) Spinal cord stimulation. Pain Reviews 1: 199-230.
van Buyten, J.P., Zundert, J.V., Vueghs, P., Vanduffel, L. (2001) Efficacy of spinal cord stimulation: 10 years’ experience in a pain centre in Belgium. European Journal of Pain 5: 299-307.