Neurostimulation has shown great results for patients with chronic pain for whom drug therapy is not the best approach. Duke neurosurgeon Nandan Lad, MD, PhD, implants the devices.

Life was good for David Brandel before his auto accident -- playing golf and softball, riding horses and motorcycles -- and he was at the top of his career making custom petroleum pumps for oil refineries.

That all changed in the predawn hours of April 2010, when a car pulled out in front of him. The accident injured his lower back to the extent that he needed spinal fusion.

Brandel attempted to return to work, but he could no longer sit leaning over a workbench.

With his job and his active hobbies gone, he and his wife moved from Colorado to Durham in May 2011 so she could take a job in nursing. Meanwhile, Brandel’s worsening pain was spreading to his limbs, and that led him to Duke orthopaedic surgeon Joe Minchew, MD.

Brandel also had ankylosing spondylitis, an inflammatory spinal disease in which vertebrae eventually fuse together. Minchew knew there was no surgical solution for Brandel, so the physician sent him to Duke Pain and Palliative Care Clinic.

There, they recommended that Brandel try neurostimulation -- a form of pain management that blocks the pain signals themselves, so that the brain wouldn’t be able to register them as pain.

Neurostimulation involves surgically implanting a pair of wire leads in the body, with one end implanted in the epidural space around the spinal cord. The other end is attached to a stimulator box (a device similar in size and function to a pacemaker), which sends out electrical impulses. The device essentially intercepts pain signals and turns them into a gentle tingle.

After a test of the therapy, surgeon Nandan Lad, MD, PhD, implanted the electrical leads and the stimulator box into place in early February 2012.

A month after the surgery, Brandel felt well enough to walk around car shopping, and he takes his dog on a short walk every day. Previously, just standing for a few minutes was miserable. Now, he has reduced his use of painkillers and actually looks forward to walking.

“I spent a good part of the day outside,” he says of an unseasonably warm March day. “It’s getting better.”

Catch the buzz

A paddle-shaped lead is used for permanent implantation; a rounded wire for testing before surgery.

Chronic pain is different from acute pain -- instead of being a signal that informs the body of an illness or injury, it’s more like a car alarm that’s been triggered but never turned off -- constantly sending out distress calls when the danger is no longer there.

Neurostimulation is ideal for people with chronic pain that has become unmanageable with injections or oral medications. Often, their pain results from prior neck or back surgery, and gradually radiates out to arms or legs.

Neurostimulation also works well for complex regional pain syndrome, a condition with symptoms that include alternating hot and cold sensations, burning pain, and muscle spasms.

Lad says it works by blocking pain signals and stimulating the nerve fibers in the spinal cord that carry vibration and position sense. Debilitating pain becomes an occasional my-foot’s-asleep tingle. Voltage settings are adjusted with a wireless remote control, and batteries are rechargeable wirelessly as well.

Patients who are candidates for the treatment first take it for a test drive.

In an outpatient procedure, a physician inserts the leads into the spinal space through a needle, and the patient wears the wires and stimulator pack externally for three to five days.

“It’s one of the few surgeries you can try before you actually have it done, which is nice,” says Lad. The trial is deemed a success if the patient has at least a 50 percent reduction in pain, an improvement in quality of life, and a decreased use of pain medication.

“It’s not going to remove 100 percent of their pain,” says Lad. “But if those three criteria are met, we consider it a success and set our expectations for the permanent implant accordingly.”

The Right Therapy

Lad works with a multidisciplinary team including neurosurgeons, neurologists, physical medicine and rehabilitation specialists, pain management anesthesiologists, psychologists, biofeedback clinicians, physical therapists, acupuncturists, and chiropractors to provide the best possible treatment options for patients with chronic pain.

Because of Duke’s careful screening, approximately 75 percent of patients who undergo a trial will receive surgery to implant the neurostimulator. The wires run just beneath the skin, and the stimulator box is placed just above the buttocks.

Disadvantages are few, and include the risk of infection present with any surgery. There is also the possibility of “lead migration,” where the electrical contacts move away from the proper area of the spine, but this is minimal with paddle-shaped leads. If it does happen, doctors go back in to reorient the lead.

David Brandel still experiences pain, but it has decreased to the point where he is eagerly anticipating a family camping trip in August. “The stimulation is helping a great deal,” he says. Life is starting to get good again.

The Hurt Blockers

The path to neurostimulation therapy begins at a pain management doctor, goes to a neurosurgeon, and returns to the pain doctor for long-term care. Duke Neuromodulation Clinic in Durham is a great place to start Call 919-681-4986 for appointments.