Researching the use of spinal cord stimulation after failed back surgery

Failed back surgery syndrome (FBSS) is a problematic source of chronic low back pain. This syndrome is estimated to effect between five and forty percent of all patients who have had surgery for low back pain. This chronic pain can often result in long term disability and contributes large costs to the health care system. Even with the rising frequency of spinal surgery, there is no agreed upon best management for FBSS. This article by Shivanand et al seeks to determine if the use of spinal cord stimulation (SCS) can help to control costs and provide pain relief for this syndrome.

Patients with FBSS are typically treated with conventional medical management (CMM) which mostly includes medicines for pain and depression, physical therapy, and psychosocial therapy. Other treatments may include epidural injections, nerve blocks, and home based portable electrical stimulation units (TENS). If these usual courses of treatment continue to fail, the last options are either to perform another back surgery or to implant a spinal cord simulator. Repeat back surgery has poor outcomes ranging from only twenty-two to forty percent success rate. Repeat surgery also increases the risk for complications and is very expensive. Several randomized controlled trials have shown SCS to have superior outcomes for pain relief over CMM and repeat surgery. This article examines the complications and long-term health care costs of SCS compared to repeat surgery in order to increase the body of knowledge to help decide on the most economic and effective treatment for FBSS.

Spinal cord stimulation is the use an electrode implanted into the spinal cord which provides stimulation to the nerves that come from the source of the pain. This electricity changes the impulses of both the excitatory and inhibitory neurotransmitters to effectively block the sensation of pain. Since its inception in the 1960s many innovations such as smaller and more effective electrodes, and better surgical techniques have made SCS an increasingly viable option for treating chronic back pain.

In this study Shivanand et al looked at the MarketScan commercial Claims and Encounters, Medicare Supplemental and Medicare database records from the year 2000 through 2009. These databases contain patient specific information about usage and costs from claims of employers, health plans, government and public organizations. They searched for all cases with a lumbar surgery or an implantation of SCS which was performed for FBSS or postlaminectomy pain syndrome. They found 16,455 patients who fit this criteria, and among this group there were 6,497 patients who had at least two years of continuous records following this procedure. Only a little over two percent of this group underwent the SCS surgery (395 patients) and the remaining patients, over ninety seven percent, had spinal reoperation (16,060 patients).

Some of the interesting data that they found was that the proportion of females undergoing SCS was higher than those that underwent lumbar surgery. Patients who had SCS also had more comorbidites. Patients with Commercial and Medicare insurance were more likely to have a reoperation, but Medicaid patients were more likely to have the SCS. Complications following the procedure were significantly higher for lumbar reoperations at almost twelve per cent versus only five per cent for SCS. Even at the ninety day follow up the reoperation group was two times more likely to be experiencing complications than the SCS group.

Total costs on the health care system were also investigated by this study. They found that lumbar reoperation patients had a longer initial hospital stay, four days versus two days on average for SCS patients, however this increased stay did not result in significant difference in cost of the initial hospital stay. They also found no significant difference in total costs within the two year follow up timeframe. There was no significant difference in the use of prescription medications in either group either.

In conclusion this study has shown that in a large national group of patients there were fewer complications, shorter initial hospital stay, but similar costs in the first two years for SCS compared to reoperation for FBSS. This study was unable to directly monitor outcomes, but it did see that there was no difference in opioid medication use in either group. Considering this positive information the authors suggest that, at a rate of only two and half per cent utilization, SCS is an underused option of treatment for the increasing number of patients with FBSS.