Stimulation holiday rescues analgesia after habituation and loss of efficacy from 10-kilohertz dorsal column spinal cord stimulation

Abstract

IntroductionHabituation and loss of efficacy from spinal cord stimulation are commonly reported. This retrospective analysis investigated rescue of analgesia from spinal cord stimulation failure after implementing a strategy called a stimulation holiday, during which spinal cord stimulation is interrupted for a defined period and subsequently restarted.MethodsA 6-year review (June 1, 2016–May 13, 2022) from a tertiary care center was conducted on patients who underwent 10 kHz frequency dorsal column spinal cord stimulation for ≥3 months, experienced loss of efficacy (≤30% pain relief or patient self-report of lack of meaningful pain relief), subsequently underwent a stimulation holiday, and then restarted spinal cord stimulation. The primary outcome was comparison of pain relief and responder rate (≥50% relief in pain intensity) before and after stimulation holiday.ResultsOf 212 patients, 40 (18.9%) experienced loss of efficacy at a mean follow-up period of 452.7±326.4 days after stimulator implantation and underwent stimulation holiday. Pain relief was significantly higher 1 month after stimulation holiday (39.4%±28.6%) compared with before stimulation holiday (8.7%±13.0%; mean difference 30.6%, 95% CI 21.9% to 39.3%, paired t-test p<0.001). A significantly higher responder rate (≥50% relief in pain intensity) was identified after stimulation holiday (57.5%) compared with before stimulation holiday (0%; Fisher’s exact test p<0.001). Associations of superior pain relief and responder rate remained significant at 3 and 6 months after stimulation holiday.DiscussionPatients who experience loss of efficacy from spinal cord stimulation habituation could attempt a stimulation holiday rather than abandon therapy. Rescue of analgesia may be achieved after implementing a stimulation holiday and restarting spinal cord stimulation.

Implantable Peripheral Nerve Stimulation for Peripheral Neuropathic Pain: A Systematic Review of Prospective Studies

“…Although additional research is needed, this emerging therapy may have the potential to significantly change practice patterns and could substantially impact patient satisfaction and quality of life in patients suffering from intractable chronic neuropathic pain. Finally, loss of efficacy from neuromodulation interventions has been described and strategies to salvage efficacy from implanted neuromodulation devices warrant future investigation [ 51 ].…”

Long term outcomes of occipital nerve stimulation

“…In this review, evidence of habituation was investigated by evaluation of the initially documented post-permanent ONS stimulation response (typically 3 months after implantation to allow for recovery from operative pain) and the final recorded long-term response. We had used a minimum follow up of 24 months due to the long-term efficacy studies observed in SCS, proposed operational definitions of chronic pain remission following neuromodulation, and the observation that habituation typically occurred more than 12 months after implantation in prior SCS studies (9)(10)(11)(12)(13).…”

“…Human studies in spinal cord stimulation (SCS) have demonstrated that habituation may occur from 3 months postprocedure to 12 months follow up as evidenced by the results of the ACCURATE randomized control trial. Evidence for habituation has been reported to continue beyond 12 months of treatment by D'Souza et al (8,9) Studies of long-term efficacy in SCS have shown sustained pain relief up to 24 months following spinal cord stimulation implant (10)(11)(12). Based on these findings it has been proposed that patients with sustained pain relief for greater than 24 months with neuromodulation could be considered in "remission" of chronic pain (13).…”

Neuromodulation and Habituation: A Literature Review and Conceptional Analysis of Sustaining Therapeutic Efficacy and Mitigating Habituation

“…The biological etiology of habituation is not well understood. Many physiological, pathological, and psychological components have been suggested, with neuronal plasticity being a major contributing factor [19,61,62]. The onset of therapy habituation is influenced by time, type of SCS device, and the patient's pain condition [63].…”

“…Another rescue strategy that has proven to be effective is incorporating a "stimulation holiday," during which SCS therapy is discontinued for a period of time prior to restarting [61]. D'Souza et al reported that 57.5% of patients that underwent a stimulation holiday (17.3 ± 20.6 days) after experiencing a loss of efficacy with HF-SCS had ≥50% relief in pain intensity with maintenance of pain relief for 6 months [61].…”