A Review of Clinical Data on Salvage Therapy in Spinal Cord Stimulation

Abstract

Background: Since its introduction in 1967, neuromodulation through spinal cord stimulation (SCS) or dorsal root ganglion stimulation (DRGs) has advanced significantly in both the technology and indications for use. There are now over 14,000 SCS implants performed worldwide every year. This review focuses on mechanisms behind the loss of efficacy in neuromodulation and current data on salvage therapy, defined as the conversion of a neuromodulation device to an alternative SCS or DRG stimulation, in the event of loss of efficacy or failure of a trial. Study Design: A narrative review of clinical studies regarding habituation, explant data, and salvage therapy with SCS. Methods: Available literature was reviewed on spinal cord stimulation technology and salvage therapy. Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measures were to understand the mechanisms of loss of efficacy, provide a review of explants due to failure in treatment, and summarize the data on current salvage therapy in SCS. Results: A total of eight studies and four abstracts/poster presentations were identified and reviewed. Of the eight studies, only one was a randomized controlled trial. Conclusions: There is limited evidence for the appropriate treatment alternatives, but from data currently available the conversion from conventional tonic stimulation to burst, high frequency (10 kHz), multiple wave forms, and/or DRGs may be appropriate in select patients and will require further research to determine the most appropriate first line salvage in the context of the underlying pain pathology.

Neuromodulation With Burst and Tonic Stimulation Decreases Opioid Consumption: A Post Hoc Analysis of the Success Using Neuromodulation With BURST (SUNBURST) Randomized Controlled Trial

“…Studies should also investigate the mechanism of action of analgesia and decreased opioid consumption after burst and tonic stimulation. Finally, studies should examine whether burst stimulation is a good option for salvage therapy in nonresponders to tonic stimulation (30).…”

Dorsal Root Ganglion Stimulation for the Treatment of Non-Complex Regional Pain Syndrome Related Chronic Pain Syndromes: A Systematic Review

“…It is known that habituation phenomena with SCS manifest across time in various patients and pain conditions. There is early and limited evidence that suggests that DRGS may prove to be a beneficial salvage strategy in patients that lose SCS efficacy in the long term (15,16). In our review, we found: (10/28) mentioned failed conventional management without detailed description of specific treatments (17–25), (7/28) failed to mention the failure of early management (26–32), (3/28) reported patients failing pharmacological management only (33–35), and (9/28) detail specific failed early management therapies prior to DRGS treatment (25,36–43).…”

The Evolving Role of High‐Frequency Spinal Cord Stimulation as Salvage Therapy in Neurostimulation

“…Patients undergoing explantation of their t‐SCS devices is not uncommon; up to 30% of patients undergo explantation over the course of over a decade 23 . There is no consensus on what the next best option should be for this significant patient population, who are often left with suboptimal pain control 24 . The results of this single‐center, small retrospective investigation suggest that 10‐kHz SCS therapy can effectively reduce chronic pain intensity and increase functionality in those individuals with FBSS and CRPS who had a limited long‐term response to t‐SCS therapy.…”