Spinal Cord Stimulation To Treat Pain Our Philosophy Pain is a complex problem that requires treatment and management by a pain medicine specialist. Millions of people suffer from headaches and nerve pain at great personal cost. If you find that you cannot safely control your pain with over-the-counter medications, or have failed to find relief from other treatments or practitioners, you should consider consulting with our pain management physicians. For most patients, interventional pain management procedures can treat or reduce pain, allowing the patients to regain function, and thereby improving their quality of life. Introduction to Neuromodulation Neuromodulation is a term used to describe a rapidly developing technology utilized by physicians to manipulate the human nervous system to achieve a desired outcome. The human body communicates with itself in several ways, with the nervous system being responsible for the conveying and processing information to and from our external environment to our brain. The nervous system transmits signals along nerve fibers. A nerve fiber typically has specific receptors at one end which receive a stimulus and transmit the signal down a long stem called an axon. The axon relays the information to branches at the other end of the nerve, called the terminal, which releases. At transmitters to the next nerve. The manner in which these messages are sent along the nerve is similar to other electrical transactions. The cells in our body are maintained by an electrical gradient, maintained for the most part by Na+/K+ levels inside the cell compared to outside the cell. This electrical balance can be manipulated to with block or send signals along these nerve fibers. Local anesthetics such as lidocaine can block these channels and stop nerve transmission. We can also modulate the firing of these nerves, with the most common example using this technology being a cardiac pacemaker. When we suffer an injury, the human body has a remarkable ability to heal itself, to the best of its ability. When a condition gets to a point where further healing is unlikely, the injury can become chronic. Interventions such as medications, injections, and surgery are options specific for each case, however the underlying injury may not be amenable to these options. Spinal cord stimulation has been a treatment option for nerve pain syndromes for several decades, and recent advances have yielded better outcomes than previously recorded. There is a defined role for spinal cord stimulation in the treatment of chronic neuropathic pain syndromes. A recent form of neuromodulation applies an electrical stimulus to the dorsal root ganglion, the bundle of cell bodies of incoming sensory nerve tissue to modulate nerve function. Applying neural stimulation to the incoming nerve fibers has yielded very promising results that have demonstrated results that have not been seen with traditional spinal cord stimulation. What is Dorsal Root Ganglion Stimulation? DRG-S AT THE SPINE AND PAIN CENTER OF NEW YORK DORSAL ROOT GANGLION (DRG) STIMULATION WHAT IS THE DORAL ROOT GANGLION? SHORTCOMINGS OF SPINAL CORD STIMULATION DRG STIMULATION THERAPY MORE ON HOW DRG STIMULATION WORKS THE DRG-S TRIAL PROCEDURE LANDMARK STUDY REFERENCES The doctors at the Spine and Pain Institute of New York are considered thought leaders with dorsal root ganglion stimulation and have pioneered much of the research around the therapy. Our physicians have performed hundreds of DRG-S trial and implant procedures, among the most in the US and the world. This extensive experience has led to our physician’s role in the establishment of guidelines and treatment protocols with DRG-S. Along with our extensive experience, we have a dedicated research team conducting studies in DRG-S to perfect the procedure technique and continue to improve the safety and efficacy of this therapy as well as expand its use in chronic pain treatment. For a list of our study-related publications in peer-reviewed medical journals and conferences, and to learn more about ground-breaking research into DRG-S, please click here. Our expertise in DRG-S has resulted in hundreds of success stories for our patients, many of whom have experienced near-miraculous improvements in their pain. Some of our patient testimonials to the success DRG-S therapy at SPNY can be found here. With each success story and the variety of conditions we have been able to treat with DRG-S, we believe the potential uses for this therapy have only begun to scratch the surface. At SPNY, we take a more aggressive approach with DRG-S and consider it a front-line therapy for the treatment of chronic pain in many cases. If you are experiencing chronic pain that has failed conventional therapies, make an appointment today to meet with one of our DRG-S expert physicians to discuss if you are a candidate for this promising and exciting new therapy. VIEW IMAGE Energy Delivered to the Neural Structures DRG-S uses far less electrical energy for effect when compared to other forms of spinal cord stimulation (SCS). Research performed by the physician researchers at the Spine & Pain Institute of NY on programming optimization have substantially reduced the amount of electricity delivered to the nerve tissue. There are inherent anatomic and physiologic advantages to stimulation at the DRG rather than on the dorsal columns. Newer types of SCS have been introduced recently which have led to better outcomes, including Burst DR-SCS and High frequency SCS. With these systems, the leads are placed on the dorsal columns, but it is believed the effects are through alternative mechanisms potentially independent of the dorsal columns. These newer methods of SCS provide subthreshold stimulation, or in other words they do not require the tingling sensation to block pain sensation. Patients tend to prefer the subthreshold, paresthesia-free stimulation when compared to traditional, tonic SCS.1,3,4 When the electrical energy is delivered to the patient, it is not delivered in a constant manner. There are three parameters that can be manipulated: The frequency measured in Hertz (Hz)- This is the number of times per second the electrical energy is activated. The pulse width (pw)- This is how long each individual pulse is delivered for. And, the amplitude measured in milliamps (mA)- This is the strength of the electrical energy. The cumulative amount delivered to the patient is measured in a unit called microcouloumbs per second (uC/s) which is the product of frequency (Hz)*pulse width(pw)*amplitude (mA).5 Our research team performed studies demonstrating maintained efficacy with DRG-S at settings that were 4 times lower than previously reported. Additionally the SPNY team performed further research using cyclic ‘on’ ‘off’ paradigms to further decrease the necessary electrical charge to our nervous tissue by 2/3.6 In essence, although demonstrated in small studies, DRG-S has vast improvements not only in pain, but in function, quality of life, and psychological status. The physicians of the Spine & Pain Institute of NY have seen the clinical improvements and use Dorsal Root Ganglion Stimulation as a primary method of neuromodulatory therapy for pain. VIEW IMAGE Dorsal Root Ganglions Stimulation for Peripheral Vascular Disease DRG STIMULATION FOR PVD NEUROMODULATORY OPTIONS SPNY RESEARCH REFERENCES Peripheral vascular disease, or PVD, is a systemic disorder that involves the narrowing of peripheral blood vessels, most commonly caused by atherosclerosis. Peripheral Vascular Disease (PVD) is a major cause of morbidity and mortality globally, with significant financial burdens on healthcare resources 1. Peripheral Arterial Disease (PAD) affects 10-15% of the population and ~20% of people >60 years old, and a 2010 estimate was over 200 million affected globally 2. In PVD, the diameter of the blood vessel is reduced, limiting the amount of oxygen that circulates to the arms and legs. Symptoms typically start with pain and discomfort while walking, and in severe cases, it may progress into critical limb ischemia, a severe stage of PVD that can result in ulcerations or potentially amputation. Peripheral vascular disease is most commonly caused by smoking, high blood pressure, elevated cholesterol levels, and/or type 2 diabetes. Patients with PVD may experience no symptoms at first, and when symptoms begin to appear, they tend to be irregular and occur more often when a patient is active—especially when walking. A patient may experience pain, cramping, and/or discomfort in their legs and feet. Other symptoms can range from achiness, to burning and fatigue, to cold, painful feet, to presenting with non-healing ulcers. If a patient’s peripheral vascular disease continues to progress, symptoms will probably occur with greater frequency and may manifest even when the patient is not walking or otherwise being active. Other signs to watch for include • Changes to the skin on the legs and feet, which can become thin and/or shiny • A purplish tinge to arms and legs, or toes that become blue • Wounds and ulcers appearing on the feet and legs • Thinning of hair on the legs Therapy typically includes changes to diet and exercise, smoking cessation, and, if appropriate, medications including blood thinners to dissolve clots, statins to reduce cholesterol, and vasodilators, which widen the blood vessels. In the majority of cases, lifestyle changes, medical management, and intravascular based procedures such as stents can treat the majority of cases. However, critical limb ischemia leads to the final step in treatment, amputation. Prior to this point, after thorough intravascular and comorbidity optimization, neurostimulation should be considered to treat symptoms, improve quality of life, and prevent limb amputation. VIEW IMAGE DRG-S for Low Back Pain and Leg Pain Effective treatment for chronic low back pain (LBP) is considered the ‘holy grail’ of neuromodulation. Spinal Cord Stimulation (SCS) was introduced in 1967 to treat chronic pain. Over the years it has shown mixed results for LBP, with limited improvements in pain and function, and loss of efficacy over time. Dorsal root ganglion stimulation (DRG-S) was developed as a treatment for nerve-related pain syndromes and has proven to be superior to SCS for complex regional pain syndrome (CRPS), which typically affects the hands or feet. As utilization of DRG-S increased, so did our understanding of its underlying mechanisms of action. One such mechanism of action is a result of the stimulator device sending inhibitory signals into the spinal cord. Based on this principle, the team at the Spine & Pain Institute of NY pioneered the treatment of low back pain with DRG-S at the T12 spinal level1. Their publication on a case series of patients using DRG-S at the T12 level for intractable low back pain was better than previous studies with other forms of neurostimulation for low back pain. The study included patients who had failed extensive treatments and included several patients who had multiple spinal surgeries. They reported not only excellent pain relief, but also great improvements in physical function and psychological testing that were not previously seen with neuromodulation therapy. The results of the study are shown on the right, here, and below. In our clinical experience, these results are readily reproducible and have been maintained over time. After experiencing continued impressive results with DRG-S for low back pain, we decided to dive deeper into exactly why and how this device works in this manner. After a year’s long quest and an exhaustive review of the published literature relating to nerve transmission and back pain, the team authored ‘The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations from Dorsal Root Ganglion Stimulation Treatment’. This evidence based paper details our theory on why DRG-S works at T12 for low back pain, and more importantly outlines how low back pain is transmitted in the spinal cord2. VIEW PAPER After experiencing continued impressive results with DRG-S for low back pain, we decided to dive deeper into exactly why and how this device works in this manner. After a year’s long quest and an exhaustive review of the published literature relating to nerve transmission and back pain, the team authored ‘The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations from Dorsal Root Ganglion Stimulation Treatment’. This evidence based paper details our theory on why DRG-S works at T12 for low back pain, and more importantly outlines how low back pain is transmitted in the spinal cord2. To better understand this complex subject, which for many may be challenging to fully grasp, the major points have been illustrated in this animated graphic. Since that time, the team has expanded the use of DRG-S by placing additional leads at S1 along with T12 as an off-label treatment for low back and associated leg pain. Our results continue be superior to our doctor’s experiences with other forms of neurostimulation for similar pain conditions. Our doctors have collectively published over 20 articles in peer reviewed medical journals on DRG-S and are considered thought leaders and pioneers of DRG-S therapy. While results from our practice with DRG-S are quite impressive and have been published and shared with the medical community, the team also recorded patient testimonials to further illustrate the great improvements seen with this therapy. The testimonials can be accessed on our Youtube page. DRG-S LOW BACK PAIN OUTCOMES DRG-S COMPARED TO SCS FOR LBP Multiple studies have published positive results using DRG-S therapy for low back pain. For instance, DRG-S was utilized at the L2 level to treat discogenic low back pain following failed back surgery. The graphic below shows the changes in patient reported survey scores used to measure treatment response before and after DRG-S therapy in each study. Collectively, improvements with DRG-S therapy in VAS (visual analog scale) which measures pain severity, ODI (Oswestry disability index) and SF-36 Physical which measure physical function, EQ-5 which measures quality of life, and SF-36 Mental which measures psychological improvements were consistent with or superior to prior spinal cord stimulation studies. If you are interested in learning more about DRG stimulation for low back pain and leg pain, or have failed other forms of neuromodulation, please feel free to reach out to our physicians at the Spine and Pain Institute of NY to learn more. 1. Chapman KB, Groenen PS, Patel K V., Vissers KC, van Helmond N. T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: A Case Series. Neuromodulation Technol Neural Interface. 2020;23(2):203-212. doi:10.1111/ner.13047 2. Chapman KB, Groenen PS, Vissers KC, van Helmond N, Stanton‐Hicks MD. The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment. Neuromodulation Technol Neural Interface. Published online April 23, 2020:ner.13150. doi:10.1111/ner.13150 VIEW ON YOUTUBE EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES EDUCATIONAL RESOURCES TYPES OF PAIN Let's live pain free. Is Pain Management Right for You? Depending on many factors, such as the type of pain and your general health, there are numerous options for treating your pain. Some patients are surprised to learn that a treatment that previously failed to provide relief may be effective when combined with a multi-treatment approach. Our specialists treat complex pain issues. There are many different physical and neurological disorders that contribute to pain, and we treat all types of pain including: LEARN MORE ABOUT PAIN MANAGEMENT Practice Policies We are pleased you chose The Spine and Pain Institute of New York for the diagnosis, treatment and management of your pain. To acquaint you with our office policies, we provide the following information. PRIOR TO PROCEDURE FORMS *If your insurance requires a referral for a visit to a specialist, you must obtain this referral from your Primary Care Physician prior to your visit. INITIAL CONSULTATIONS Please bring the following relevant information to your consultation. Photo ID Insurance Information Referral* Diagnostic Studies & Reports (MRI/X-Rays) List of Medications INSURANCE & BILLING We accept most insurance programs and their subsidiaries. If we do not participate in your insurance plan, please contact Billing to find out if other arrangements are possible. Text us via Klara using the messaging option to the bottom right of this page! Just detail your concern or question, and a member of the team will reply via return text message or phone call. Insurance co-payments are due at the time of arrival. We accept cash, checks and credit cards. APPOINTMENTS If you are a new patient, please arrive 15 minutes prior to your appointment to allow time to register. If you are running late or need to reschedule, please contact us as soon as possible to make us aware. Unfortunately, if you are more than 30 minutes late for your appointment time, we will have to reschedule. PROCEDURES If you are scheduled for a procedure or plan on having one in the future, please read the attached important instructions to follow prior to a procedure.You will be called prior to your procedure and notified about the following information as well. MEDICATIONS & REFILL REQUESTS Please discuss your medication needs, including refill requests, with your provider at the time of your appointment. Medications should be taken only as prescribed. Please do not request early refills of your medications. Patients are responsible for lost or stolen medications and prescriptions once they leave the office. AFTER HOURS EMERGENCIES Our regular phone lines are transferred to an answering service after normal business hours. Please proceed to the nearest emergency room for after-hours emergencies. MANHATTAN 860 Fifth Ave New York, NY 10065 212.724.7246 NEW JERSEY 1 Bay Ave. 2nd Fl. Suite 1 Montclair, NJ 07042 718.667.3577 STATEN ISLAND 1360 Hylan Blvd. Staten Island, NY 10305 718.667.3577 STATEN ISLAND 1534 Victory Blvd. Staten Island, NY 10314 718.667.3577 BROOKLYN 1513 Voorhies Ave. Brooklyn, NY 11235 718.427.2110 DOWNTOWN BROOKLYN 188 Montague St. 3rd Fl. 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