Journal of Clinical Anesthesia (2016) 28, 7477

Original Contribution

Efficacy of spinal cord stimulators in treating

peripheral neuropathy: a case series
Alaa Abd-Elsayed MD, MPH (Assistant Professor) a,b,, Nick Schiavoni MS c ,
Harsh Sachdeva MD (Assistant Professor)a
a

Anesthesiology, University of Cincinnati, Cincinnati, OH, USA

Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison WI, USA
c
Medical School, University of Cincinnati, Cincinnati, OH, USA
b

Received 27 December 2014; revised 4 April 2015; accepted 10 August 2015

Keywords:
Spinal cord stimulator;
Peripheral neuropathy;
Diabetes mellitus;
Chemotherapy;
Human immunodeficiency
virus

Abstract
Introduction: Peripheral neuropathy is a common cause of pain, and it is increasing in prevalence.
Peripheral neuropathic pain is very hard to treat and can be resistant to multiple pain management
modalities. Our series aimed at testing the efficacy of spinal cord stimulators (SCSs) in treating resistant
painful peripheral neuropathy.
Case Presentations: Case 1: A 79-year-old man presented to our clinic with long-standing history of painful
peripheral diabetic neuropathy resistant to conservative management. After failure of all possible modalities,
we offered the patient an SCS trial that was very successful, and we proceeded with the permanent implant
that continued to help with his pain and allowed the patient to wean down his medications.
Case 2: A 60-year-old man presented with chronic peripheral neuropathy secondary to HIV, patient failed
all conservative and procedural management. Patient then had an SCS trial that relieved his pain significantly.
Unfortunately, we did not proceed with the implant due to deterioration of the patient general health.
Case 3: A 39-year-old woman presented with painful peripheral neuropathy secondary to chemotherapy
for breast cancer. After failure of medication management and procedures, patient had a SCS trial that
improved her pain and we then proceeded with performing the permanent implant that controlled her pain.
Conclusion: We presented 3 cases with chronic painful peripheral neuropathy secondary to HIV, diabetes
mellitus, and chemotherapy that was resistant to conservative pain management and procedures that was
successfully treated with neurostimulation.
2016 Elsevier Inc. All rights reserved.

1. Introduction
Peripheral neuropathy can be a debilitating condition that
results from peripheral nerve damage. Peripheral neuropathy
Corresponding author at: Department of Anesthesiology, University of
Wisconsin School of Medicine and Public Health, B6/319 CSC, 600 Highland
Ave, Madison, WI 53792-3272. Tel.: +1 608 263 8106; fax: +1 608 263 8111.
E-mail address: alaaawny@hotmail.com (A. Abd-Elsayed).
http://dx.doi.org/10.1016/j.jclinane.2015.08.011
0952-8180/ 2016 Elsevier Inc. All rights reserved.

has an extremely diverse presentation that depends on the type

(sensory, motor, and autonomic) and location of the affected
nerve. Long nerves, such as the sensory nerves that extend to the
toes, are most susceptible to neuropathic pain. The pain is often
described as burning, sharp, jabbing, tingling, and/or electrical
and can have a severe impact on a patient's quality of life [1].
Peripheral neuropathies are most prevalent in Western
cultures. It has been estimated that more than 15 million
people in the United States and Europe have some degree

Spinal cord stimulators in treating neuropathy

of neuropathic pain and approximately 2 of every 100
individuals have peripheral neuropathy [2]. Approximately
8% of primary care patients aged 55 years or older have a
polyneuropathy [3].
The incidence and prevalence of peripheral neuropathy
are on the rise. Two major contributing factors are: the
obesity/diabetes mellitus (DM) epidemic of Western society
and the aging of our population as a whole. The most
common cause of peripheral neuropathy is DM [4].
Researchers project that the number of Americans with
DM will increase 165% over the next 50 years. These
estimations predict that the prevalence of DM will grow
from 11 million in 2000 (4.0%) to 29 million in 2050 (7.2%)
[5]. Furthermore, the overall incidence of peripheral
neuropathy increases with age. In 1950, the elderly population
(age N 65 years) represented 8.1% of the total US population.
By 2009, this group represented 12.8% of the population and is
projected to reach 20.2% in 2050 [6]. As our nation's
demographic shifts to a more elderly population with higher
rates of DM, more people will inevitably develop painful
peripheral neuropathy.
More than 100 different causes of peripheral neuropathy
have been identified [7]. These causative agents are highly
diverse and include metabolic, infectious, and pharmacologic
sources [8]. The most common cause of peripheral neuropathy
is DM, with approximately 50% of diabetic patients
developing a neuropathy within their lifetime [4]. Different
studies have determined that HIV-related painful distal sensory
polyneuropathy may affect 1/3 of HIV patients being treated
with highly active antiretroviral therapy and 1/3 of all AIDS
patients [9]. The most common medications that induce
peripheral neuropathy are the chemotherapeutic agents such as
the vinca alkaloids (vincristine), taxols (taxane, taxol, and
docetaxel), platinum compounds (cisplatin, carboplatin, and
oxaliplatin), and suramin [10].
Regardless of the cause, neuropathic pain is usually not
successfully managed with pharmaceutical treatment. Recommended first-line medications include antidepressants,
calcium-channel ligands (gabapentin and pregabalin), and
topical lidocaine [11]. Other commonly used medications
are opioid analgesics, tramadol, and antiepileptics. Randomized controlled trials have proven that these medications
are not overwhelmingly effective. A systematic review
of evidence-based recommendations for pharmaceutical
management of neuropathic pain determined medications
only provide 40% to 60% of patients with partial pain relief
[11]. For this reason, it is time to consider a more lasting and
efficacious treatment such as SCS.
Literature about SCS is focusing mostly on using it for
the treatment of failed back surgery syndrome (FBSS),
complex regional pain syndrome, and radicular pain. This
case series is unique in that it illustrates SCS ability to
successfully manage 3 extremely diverse etiologies of
neuropathic pain: DM, HIV, and chemotherapy. An informed
consent was obtained from all patients for publishing this
case series.

75

2. Case presentation
2.1. Case 1
A 79-year-old man presented with lumbar and bilateral
lower extremity pain for 11 years secondary to diabetic
peripheral neuropathy. In addition to DM type II, the patient
had a significant medical history for coronary artery disease,
hypertension, and multiple failed back surgeries. His pain was
not well controlled with medications (Neurontin, Robaxin,
Tramadol, and Naproxen), physical therapy, epidural steroid
injections, or transcutaneous electrical nerve stimulation.
Upon initial presentation, the patient was mostly concerned
with the pain in his feet, which he reported to be 9/10 on the
visual analog scale for pain (VAS). He described this pain as
nonradiating, constant, sharp, burning, and tingling in nature.
The patient opted for an SCS trial that was performed and was
associated with decreased pain scores down to 3/10 with
improvement in the ability to perform daily activities. The SCS
trial was performed using 2 octad leads to provide bilateral
coverage and was performed for 1 week. We decided to
proceed with the permanent implant. The SCS implantation
leads were threaded under fluoroscopic guidance to T7
vertebral body, resulting in stimulation coverage of all painful
areas. At 1-month postoperation, the patient was very happy
with the 60% overall reduction in pain and a VAS score of
2/10. His oral pain medications were successfully weaned
down, and he no longer needed breakthrough pain medications. Patient also reported increase in his ability to perform his
daily activities as walking and grocery shopping and marked
improvement in his sleep. Patient had the SCS 3 years ago and
continues to do well.

2.2. Case 2
A 60-year-old man had been seen in our pain center for
HIV-induced peripheral neuropathy for 15 years. He has a
significant medical history of coronary artery disease, aseptic
necrosis of the hip, cytomegalovirus colitis, pancreatitis,
seizures, HIV, and herpes zooster virus infection of the lower
extremities. He presented with a 15-year history of bilateral
lower extremity pain that had a strong temporal correlation
with his diagnosis of HIV in 1990. His HIV is currently
treated with darunavir, emtricitabine-tenofovir, and ritonavir.
He described his lower extremity pain as burning, stinging,
and stabbing with a VAS pain score of 9/10. The pain was
affecting his sleep at night (self-reported 4 hours per night)
and his ability to ambulate without a walker. He had tried
numerous pain medications with minimal success: methadone,
morphine, hydromorphone, fentanyl, dilaudid, baclofen, ziconitide, gabapentin, pregabalin, amytryptyline, and duloxetine.
An intrathecal drug delivery system implanted in 2005
provided variable relief with VAS scores ranging from 4/10
to 10/10. The patient failed many attempts to wean off his
narcotic pain medications, and just before the SCS trial in 2013,
he was heavily medicated with amitriptyline, buproprion,

76
duloxetine, gabapentin, lorazepam, oral morphine, oral oxycodone, and dilaudid via intrathecal drug delivery system. His
SCS trial was performed using 2 octad leads to provide bilateral
coverage, and it lasted for 1 week. The SCS trial proved to be
highly effective with 95% pain relief. He could sleep better
during the trial period, which he had not been able to do in a
while because of severe pain in the legs; the patient said I was
unable to sleep like this for years. Unfortunately, shortly after
the trial, the patient's health has declined. He has elected to
postpone permanent SCS implantation until his other health
matters are resolved.

2.3. Case 3
A 39-year-old woman presented to our clinic with a
long-standing bilateral lower extremity peripheral neuropathy
for 3 years secondary to chemotherapy. The patient had a
medical history of breast cancer that was treated with a
lumpectomy in 2010 followed by 6 months of chemotherapy.
She described her pain as nonradiating, constant, sharp,
burning, and stabbing in nature with a VAS rating of 8/10.
The pain was primarily below her knees, resulting in a
significant negative impact on her ability to ambulate as well as
other activities of daily living. Over the next 6 months, her pain
was successfully managed with medications (Nortryptyline,
Lyrica, and Percocet) and bilateral lumbar sympathetic block.
After a while, the lumbar sympathetic block stopped working,
and her pain increased to an unacceptable level. At this point,
the patient agreed to an SCS trial for 1 week, which resulted in
95% pain relief. We used 2 octad leads for the trial to provide
bilateral coverage for all the painful areas. We then proceeded
with implantation of an SCS with lead placement at the
T10-T11 area resulting in stimulation coverage of all painful
areas. Three months later, the patient continued to have
excellent pain relief; marked improvement in her ability to
perform her daily activities, which made her less dependent on
others to help; improvement in her sleep pattern, and she was
successfully weaned off some of her pain medications. Patient
had the SCS implant 2 years ago and continues to report
improvement to date.

3. Discussion
There are few pharmacological agents that have been
proven to be consistently effective in relieving peripheral
neuropathic pain. For example, there are only 2 Food and Drug
Administrationapproved medications for DM-induced peripheral neuropathy: pregabalin and duloxetine [12]. Typical
first- and second-line medications for neuropathic pain include
antidepressants, anticonvulsants, and opiate analgesics, all of
which result in significant side effects, unconvincing efficacies, and a substantial financial burden [13].
The sale of opioid analgesics has quadripled between the
years 1999 and 2010 with the United States consuming 80%

A. Abd-Elsayed et al.
of the world's oxycodone and 99% of the hydrocodone [14].
It is not surprising that as the US prescription and consumption
of opioid analgesics have increased so has its abuse. The data
published in 2005 by The National Survey on Drug Use and
Health reported that 2.4% (6.4 million people) of the US
population 12 years and older have used prescription-type
psychotherapeutic drugs nonmedically in the past month [15].
Our nation continues to grow more dependent on pharmaceutical agents that are often ineffective and potentially harmful.
Utilization of SCS has the potential to hinder and perhaps
reverse this trend of pharmaceutical dependence.
SCS trial and implantation are typically performed in an
outpatient setting. The procedure is minimally invasive.
Real-time radiographs are used to confirm correct placement
of the stimulator leads corresponding to the dorsal horn of the
spinal cord at the appropriate vertebral level. The SCS trial is
done in an outpatient setting for a period of 1 week. SCS trial
is deemed successful if the patient has 50% or more pain
reduction during the trial period along with improvement in
activity. Permanent implantation involves placing the SCS
leads through a surgically created incision in the back
followed by attachment of the leads to a generator battery in
the pocket created in the buttock area.
The exact mechanism of SCS is still under debate. The
first and most accepted theory suggests that stimulation of
the dorsal horn via SCS suppresses the transmission of
noxious stimuli from the peripheral nerves [16].
Currently, there are only a few indications for SCS with
adequate support. One such indication is chronic spinal pain
and/or FBSS. A recently published comprehensive review
consisting of 10 different studies each with at least 50
subjects found that 48% to 77% of the participants in each
study achieved greater than 12 months of pain relief from
SCS. These data warranted level II-1 or II-2 evidence (US
Preventative Services Task Force criteria) for SCS treatment
of neuropathic pain of failed back surgery syndrome [17].
Recommendations assembled by a Cochrane Review and
The American Society of Interventional Pain Physicians
support the use of SCS for select patients with FBSS and
complex regional pain syndrome due to its effectiveness in
providing both short- and long-term pain relief [18].
There have been some published case reports in which
SCS has successfully managed and/or eliminated various
painful peripheral neuropathies such as meralgia paresthetica
[19], Lyme disease [20], postherpetic neuralgia [21],
postthoracotomy pain syndrome [22], pelvic visceral pain
and chronic abdominal pain [23], angina pectoris [24],
chemotherapy-induced neuropathy [25], diabetic neuropathy, ischemic heart disease, and peripheral vascular disease
[26]. However, for these indications, as well as the cases
presented in this series, further clinical trials are needed to
prove the efficacy of SCS therapy.
A recent study completed in the Netherlands analyzed the
effects of SCS on 15 patients with painful diabetic peripheral
neuropathy. Pain relief, quality of life, and amount of sleep
were measured at , 3, 6, and 12 months. After 12 months of

Spinal cord stimulators in treating neuropathy

SCS treatment, two-thirds of the patients continued to
experience clinically significant pain relief, increased sleep,
and improved quality of life [27]. This study not only
displays the efficacy of SCS but also recognizes the
importance of sleep and quality of life.
Another recently published retrospective study analyzed
the long-term effects of cervical spinal cord stimulation for
treatment of various upper extremity peripheral neuropathies. Eighteen patients were interviewed 5.8 years (mean)
after SCS implantation, and pain scores were 50% lower
than the scores reported before the procedure. This
demonstrates SCS's ability to serve as a long-term treatment
for a variety of peripheral neuropathy subtypes, regardless
of its origin [28].
In conclusion, the demand for a safe and efficacious
long-term therapy for peripheral neuropathy grows stronger.
This case series illustrates SCS's ability to effectively
manage diverse forms of painful peripheral neuropathy.
SCS has the potential to revolutionize peripheral neuropathy
treatment, but the current clinical evidence is too sparse for
mainstream application. Therefore, more extensive clinical
trials are needed to verify its success.

References
[1] National Institute of Neurologic Disorders and Stroke. http://www.ninds.
nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.
htm. [Accessed at 4/4/2014].
[2] Azhary H, Farooq MU, Bhanushali M, Majid A, Kassab MY.
Peripheral neuropathy: differential diagnosis and management. Am
Fam Physician 2010;81(7):887-92.
[3] Beghi E, Monticelli MI, Amoruso L, et al. Chronic symmetrical
polyneuropathy in the elderlya field screening investigation in 2
Italian regions. Prevalence and general characteristics of the sample.
Neurology 1995;45(10):1832-6.
[4] Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, et al.
The prevalence by staged severity of various types of diabetic
neuropathy, retinopathy, and nephropathy in a population-based
cohort: the Rochester Diabetic Neuropathy Study. Neurology 1993;
43:817-24.
[5] Boyle JP, Honeycutt AA, Narayan KMV, Hoerger TJ, Geiss LS, Chen
H, et al. Projection of Diabetes Burden Through 2050, impact of
changing demography and disease prevalence in the U.S. Diabetes
Care 2001;24(11):1936-40.
[6] Shrestha LB, Heisler EJ. The changing demographic profile of the
United States. Congressional Research Service; 2009 [http://www.
aging.senate.gov/crs/aging4.pdf. accessed at 3/12/2014].
[7] The Neuropathy Association. http://www.neuropathy.org/site/PageServer?pagename=About_Facts. [Accessed at 4/2/2014].

77
[8] England JD, Asbury AK. Peripheral neuropathy. Lancet 2004;
363(9427):2151-61.
[9] Smith HS. Treatment considerations in painful HIV-related neuropathy.
Pain Physician 2011;14:E505-24.
[10] Quasthoff S, Hartung HP. Chemotherapy-induced peripheral neuropathy.
J Neurol 2002;249:9-17.
[11] Dworkin RH, OConnor AB, Backonja M, Farrar JT, Finnerup NB,
Jensen TS, et al. Pharmacologic management of neuropathic pain:
evidence-based recommendations. Pain 2007;132:237-51.
[12] Sheth NU, Tata AL. Diabetes-induced peripheral neuropathy: a
treatment review. Formulary 2012;47(4):142-6 [150-153].
[13] Trivedi JR, Silvestri NJ, Wolfe GI. Peripheral neuropathies treatment
of painful peripheral neuropathy. Neurol Clin 2013;31(2):377-403.
[14] Manchikanti L, Helm S II, Fellows B, Janata JW, Pampati V, Grider
JS, et al. Opioid epidemic in the United States. Pain Physician 2012;
15:ES9-S38.
[15] Substance Abuse and Mental Health Services Administration. Results
from the 2005 National Survey on Drug Use and Health: National
Findings. Office of Applied Studies, NSDUH Series H-30, DHHS
Publication No. SMA 06-4194; 2006[Rockville, MD. www.oas.
samhsa.gov/nsduh/2k5nsduh/2k5Results.pdf. Accessed at 3/23/2014].
[16] Melzack R, Wall P. Pain mechanism: a. new theory. Science 1965;150:
951-79.
[17] Manchikanti L, Boswell MV, Datta S, Fellows B, Abdi S, Singh V,
et al. Comprehensive review of therapeutic interventions in managing
chronic spinal pain. Pain Physician 2009;12:E123-98.
[18] Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S,
et al. Interventional techniques: evidence-based practice guidelines in the
management of chronic spinal pain. Pain Physician 2007;10(1):7-111.
[19] Barna SA, Hu MM, Buxo C, Trella J, Cosgrove GR. Spinal cord
stimulation for treatment of meralgia paresthetica. Pain Physician
2005;8:315-8.
[20] Shui Y, Tao W, Huang D, Li Y, Fan B. Spinal cord stimulation for chronic
pain originating from Lyme disease. Pain Physician 2012;15:511-4.
[21] Cameron T. Safety and efficacy of spinal cord stimulation for the
treatment of chronic pain: a 20-year literature review. J Neurosurg
2004;100:254-67.
[22] Graybill J, Conermann T, Kabazie J, Chandy S. Spinal cord
stimulation for treatment of pain in a patient with post thoracotomy
pain syndrome. Pain Physician 2011;14:441-5.
[23] Kim CH, Issa MA. Spinal cord stimulation for the treatment of chronic
renal pain secondary to uretero-pelvic junction obstruction. Pain
Physician 2011;14:55-9.
[24] Deer TR, Raso LJ. Spinal cord stimulation for refractory angina pectoris
and peripheral vascular disease. Pain Physician 2006;9:347-52.
[25] Cata JP, Cordella JV, Burton AW, Hassenbusch SJ, Weng HR,
Dougherty PM. Spinal cord stimulation relieves chemotherapy-induced
pain: a clinical case report. J Pain Symptom Manag 2004;27(1):72-8.
[26] Stojanovic MP. Stimulation methods for neuropathic pain control.
Curr Pain Headache Rep 2001;5:130-7.
[27] Pluijms WA, Slangen R, Bakkers M, Faber CG, Merkies ISG, Kessels
AG, et al. Pain relief and quality-of-life improvement after spinal cord
stimulation in painful diabetic polyneuropathy: a pilot study. Br J
Anaesth 2012;109(4):623-9.
[28] Wolter T, Kieselbach K. Cervical spinal cord stimulation: an analysis of
23 patients with long-term follow-up. Pain Physician 2012;15:203-12.