The Leeds Teaching Hospitals NHS Trust

Spinal cord stimulation

Spinal cord stimulation - What is it?

Spinal cord stimulation (SCS) is a form of therapeutic neuromodulation, defined by the International Neuromodulation Society as “the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body.”

A spinal cord stimulator is a medical device which is used to treat severe nerve pain. It consists of a small battery pack which is surgically inserted beneath the skin and is connected to a lead placed near the spinal cord. The battery sends electric signals to the lead in the epidural space next to the spinal cord altering the long-standing pain signals often reducing the perception of pain and subsequently improving the patient’s quality of life.

Historically spinal cord stimulators used a system which caused tingling in the painful area often helping to mask some of the pain but this is no longer necessary. Many newer systems are free of this tingling sensation. As the science has evolved, so has technology and many systems have long-lasting batteries or ones that can be recharged. There are several reputable medical companies who produce spinal cord stimulators. The most appropriate will be selected for everyone treated by the PAIN Team at Leeds.

Spinal cord stimulation - Trial vs. full system

A spinal cord stimulator can be trialled for a few weeks to assess its effectiveness or fully inserted at the first sitting. The trial system allows patients to have a test run before committing to a full system but can involve additional delays and further surgical procedures. The decision on the most appropriate for each patient is made on an individual basis by a multidisciplinary team and will be discussed before committing to any procedure.

Spinal cord stimulation - How is it inserted?

A spinal cord stimulator is inserted as a surgical procedure in a clean operating theatre. It is usually performed as a day case procedure and patients are allowed home the same day. Patients lie face down on an operating table and using x-ray guidance, the lead is placed through the skin into the appropriate place in the epidural space. 

For a trial, the lead comes out of the back to an external battery.

For a fully implanted system, the lead is tunnelled under the skin to a battery placed under the skin normally in the chest or buttock.

To safely place this, the patient is required to be awake, and to ensure comfort during the procedure, local anaesthetic, strong pain killers and sedation are used under the supervision of an anaesthetist.

Spinal cord stimulation – Psychology assessment

As part of the process for spinal cord stimulator trial and/or implantation, patients might be referred to psychology for an assessment. Having SCS surgery is a big decision and is sometimes an emotional process. The Leeds PAIN Team is committed to ensure that the risk of psychological harm to patients is acceptably small and that patients are fully supported throughout this process.

The psychological assessment is an opportunity to explore the decision to have surgery and to discuss any associated social and psychological issues e.g. worries, impact on family and relationships, psychological well-being and support needs. It can help to identify if patients need any extra support before or after the surgery, to ensure that patients have a good outcome from the surgery.

Spinal cord stimulation - Potential issues and/or complications

Complications can occur at the time of insertion or after many years. These risks are generally rare but include serious complications such as paralysis, serious spinal or neurological infection and severe allergic reaction to drugs. These will be discussed on an individual basis by the PAIN Team, and patients will be given an opportunity to reflect and ask questions before committing to any intervention.

 

Spinal cord stimulation (SCS) - FAQs

Before the implant.
How long do I have to wait? The waiting times are variable. It may therefore be necessary to call our administration team in order to have a better understanding of the waiting times 0113 3925606.

What happens at the Multi Disciplinary Team (MDT) meeting? A discussion involving all the relevant team disciplines about the appropriateness of a spinal cord stimulator for you, any arising concerns from the team, the type of system to be considered and the decision to have a trial or full implant.

I have been referred to see a Psychologist before my SCS, do I have to have the assessment? When a referral for an SCS psychology assessment is made, this forms an integral part of the pathway for considering whether to proceed with an SCS trial/full implantation, so it is important that you attend your assessment. Patients often report that the discussions are useful. If you cannot attend the arranged appointment, please let the pain psychology service know, with as much notice as possible, so that your appointment can be rescheduled. Please be aware that if you choose not to have the assessment, this will usually stop the SCS pathway and further consideration for this will not continue until you feel able to engage in the assessment. Please be reassured that the psychology team will do their best to make you feel comfortable and supported during the assessment. If you have any concerns, please let us know and we will do our best to support you.

How will I find out about my operation date? You will receive a telephone call to confirm the date of your planned procedure. If this is not convenient then alternative dates can be explored. A letter of confirmation will be sent out to you in the post.

What happens at surgical pre-assessment? The appointment may include the following: routine bloods taken, height and weight measurement, COVID swabs taken and possibly a urine test and ECG. You will also be given MRSA prophylaxis treatment . This consists of a wash and a nasal ointment to use prior to the procedure. Please follow the instructions closely. The department will typically ask you to set aside approximately 60-90 minutes for this appointment if it’s necessary. It may be possible to conduct this appointment over the telephone but if this is the case you will be advised.

What is the final check appointment? This is to confirm that you wish to proceed and discuss any outstanding questions you may have with your Consultant. You will sign the consent form, having been fully informed and agreeing to the procedure.

Implant procedure
What should I do about my medication?
This will have been discussed already with your Consultant or the Pain Nurse you have spoken with. If you have stopped taking Warfarin, Clopidogrel or Aspirin prior to surgery, please follow advice from the Team as to when to restart this. Do not make any other changes to your pain medication without advice from either the Pain Nurses or your GP. Unless you have been told otherwise, you should continue to take your regular medication, especially if you have diabetes.

How long does the procedure take? Depending on the ease of insertion, the time for a trial is normally about 30-60 minutes and 60-120 minutes for a full implant, although sometimes it can be significantly longer. Everyone is different!

Will I be awake? Yes you will, although the Anaesthetist may provide some sedation which can make you feel sleepy. If we need to check the lead placement during the procedure, we need you to be awake and able to answer questions.

Does it hurt? The procedure is performed using local anaesthetic and sedation so it should not be too painful but the local anaesthetic does “sting” when it is first injected. During certain points of the procedure, you may feel pressure and tugging but this should not be painful and you can ask for more painkillers or sedation if needed. After the procedure, there will be pain and discomfort over the surgical wounds where the electrode and internal battery are sited immediately after the local anaesthetic starts to wear off. This pain can several weeks as with any surgery.

When will it be switched on? Generally, the device is switched on immediately. The company representative will guide you through the programs and the equipment immediately after the operation. Please ensure that you are happy that you know how to use the device before leaving, asking for help if necessary. This is particularly important if you are having a trial because the trial can only last a limited time for safety reasons.

 

SCS trial implant - FAQs

When can I shower? Showering and bathing is to be avoided throughout the whole trial period. A stripped wash is fine, but it is very important that your lead, external battery and dressings do not get wet.

When can I bathe? There should be no bathing throughout the entire period of the trial, due to the external lead and battery.

When will I start to get pain relief? This is variable. Most patients get some relief immediately, although with varying degrees.

When can I return to work? This is an individual decision and depends on many factors, including how the pain is, how quickly you recover from the procedure, the type of work you do, whether you work in a manual or physical job or where you need to sit for long periods e.g. at a computer. We can only guide patients, along with your GP. Your employer may need to make changes temporarily/permanently to try to help and support you in the work place. 

When can I start to exercise? Gentle mobilisation, such as walking can be performed during the trial period, but avoid exercise due to the risk of lead movement.

When can I go swimming? You can not go swimming during a trial.

When can I have sex? This again is down to the individual. During the trial this may be uncomfortable because of the external battery and the worry of the leads being pulled out.

Can my leads move and how will I know? Yes, the leads are only anchored to the skin and not to the spine like a fully implanted spinal cord stimulator, this make them vulnerable to movement. You may notice that the lead is hanging out more or has fully come out of the skin. If this happens contact the PAIN team.

Can I drive? No, you can not drive during a trial of SCS, but you can be a passenger in a car.

 

SCS full implant - FAQs

When should I get my wound checked? After implantation of a full system including a battery, we ask you to either make an appointment with your GP at 7-10 days post insertion to have a wound check and remove any sutures that may be in place, or have a video appointment with a PAIN team clinical nurse specialist. Any signs of infection or any problems noted should be reported to the PAIN Team as soon as possible and follow the advice of your GP.

When can I shower? With a full implant, unless you have been advised otherwise, you may remove your wound dressing and shower after three days. Please do not “scrub” or actively wash your wounds.

When can I bathe? Following a full implant, patients are advised there is no bathing or swimming for a period of 6-8 weeks. We also advise against stretching or bending post-operatively in order to allow the internal lead to settle into place 

When will I start to get pain relief? This is variable. Most patients get some relief immediately, although with varying degrees. There will be significant post-operative pain at the implanted battery site which often persists for a considerable amount of time.

When can I return to work? This is an individual decision and depends on many factors, including how the pain is, how quickly you recover from the procedure, the type of work you do, whether you work in a manual or physical job or whether you need to sit for long periods e.g. at a computer. We can only guide patients, along with your GP. Your employer may need to make changes temporarily/permanently to try to help and support you in the work place.

When can I start to exercise? Taking into account the lifestyle changes/restrictions we place upon you post-operatively, we would expect you to build up your exercise slowly when you feel able. You may find walking much easier or even feel much more motivated to do things around the house and garden because you may be sleeping better. As will have already been discussed in the nurse information session, contact sports or bungee jumping are not advisable! Following your 3 and 6 month checks at the hospital, you may be at a point where you can take up activities that you previously enjoyed such as cycling, running and golf. This would be a joint decision on when and how to proceed. Generally we would hope that by 6 months things would be well enough to move forward.

When can I go swimming? Once your sutures have been removed, the wounds have healed and the lifestyle restrictions have been lifted at 6-8 weeks, swimming should be fine. It may be a good thing to start off walking in the water initially to build up your core stability, obviously taking care not to over exert yourself!

When can I have sex? This again is down to the individual and may be uncomfortable at first due to pain from the wound sites.

Do I need to carry my remote everywhere? No, you do not need to. It is advisable to check regularly that the device is switched on by using the handset. Remember to take both the remote and the charger if applicable and any cables necessary with you if you travel away from home at any point, no matter how long you plan to be away, as you may decide to stay longer than planned!

Can my leads move and how will I know? There is always the chance that the internal leads can be displaced maybe following a slip, trip or fall (or even just bad luck!) or that you have perhaps not followed the initial guidelines on post-operative restrictions. Generally, if the lead has moved or broken, you would experience the return of your original pain, despite the device being turned on. If the movement has only been very slight, we can sometimes remedy this with reprogramming. If the movement has been significant, it could mean a whole new lead and/or a new battery depending on the extent of the damage. In this instance, the whole process needs to be repeated!

Can I drive? This is the key advice:

  • You can be a passenger in a car immediately following insertion of a spinal cord stimulator and during a trial.
  • Do not drive for at least 4 weeks following insertion of a fully implanted spinal cord stimulator.
  • After 4 week you may drive if you feel able to perform an emergency stop, make emergency maneuverers and safely operate all necessary controls of your car.
  • Please seek advice from your insurer prior to driving.
  • Do not drive with a paraesthesia (“tingling”) based spinal cord stimulator whilst it is turned on.