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Electrical spinal cord stimulation (SCS)

Electrical spinal cord stimulation (SCS) is een techniek die in Nederland belangstelling heeft. Onderzoekers van de universiteit van Twente onderzochten deze invasieve methode bij een handvol patienten met niet te behandelen chronische neuropathische pijnen op basis van diabetes. Zo werden 11 patienten met niet te behandelende neuropathische pijn met deze bijzondere techniek behandeld. De implantatie van de electroden van Medtronic werd als volgt gedaan:

In conformity to the Dutch Neuromodulation Study Group protocol, a quadripolar electrode lead (Medtronic, Minneapolis, MN, USA) was implanted in the thoracic epidural space via a percutaneous lumbar puncture. The single lead, containing four electrode contacts, was positioned medially over thoracic segments of the spinal cord according to the patient’s description of the paraesthesia. Before a permanent stimulator was implanted, a test period of a week with a percutaneously implanted externalised lead, and a handheld external pulse generator was performed to find out whether the patient achieved sufficient pain relief from spinal cord stimulation. When a patient reacted positively to the test stimulation (>30 points pain reduction on a 100-point VAS), a permanent stimulator was implanted (Itrel 3 or Synergy, Medtronic).

De resultaten waren aldus:[1]

More than 50% relief of neuropathic pain was experienced at 1 month by five patients, and one patient experienced 30–50% pain relief. At 3 and 6 months, more than 50% pain relief was achieved in six patients and 30–50% pain relief in two patients. 

De NNT was dus 1½; er moesten 1½ patienten behandeld worden opdat er een tenminste 50% reductie van de pijn ervaarde. Dat is op zich niet slecht, als je je realiseert dat de NNT bij amitriptyline ongeveer 3-4 is.En ook werden in deze studie patienten toegelaten die volledig uitbehandeld waren en die dus niet(genoeg) reageerden op medicatie of TENS. De methode is wel een operatie, net als het plaatsen van een pacemaker, en de kans op complicaties is niet nul.

Want:

Due to an inadequate connection between the lead and the extension cable, a surgical revision was performed on two patients. After revision the pain relief reappeared in both patients. One patient has had a mild infection that has been treated easily with antibiotics, without any influence on the SCS treatment. No other adverse events have been recorded. The SCS treatment seems to be safe for patients with diabetic neuropathy. 

Hoe de pijnstilling met medicatie reageerde op de therapie het volgende:

As a result of spinal cord stimulation, eight of nine patients have been able to reduce their pain medication significantly, and for six of them, the stimulator had become the sole treatment for their neuropathic pain. The three patients who used oral opioids did not use any medication anymore at 6 months of SCS treatment. Of the five patients who used gabapentin, only two still used it at a low dose (400 mg/day). The patient who used clonazepam still needed to use the same amount of medication.

Prof.dr. Jan M. Keppel Hesselink, MD en DJ Kopsky, MD, versie juli 200

Referentie

[1] de Vos CC, Rajan V, Steenbergen W, van der Aa HE, Buschman HP. | Effect and safety of spinal cord stimulation for treatment of chronic pain caused by diabetic neuropathy. | J Diabetes Complications. | 2009 Jan-Feb;23(1):40-5. Epub 2008 Apr 16.

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