Neurosurgical Advances in Pain Management

Christopher J. Winfree, M.D., F.A.A.N.S.

Director, Center for Neurosurgical Pain ManagementDirector, Center for Peripheral Nerve Surgery

Christopher J. Winfree, M.D., F.A.A.N.S.

Director, Center for Neurosurgical Pain ManagementDirector, Center for Peripheral Nerve Surgery

Department of Neurological Surgery

Columbia UniversityMedical Center

Department of Neurological Surgery

Columbia UniversityMedical Center

DisclosuresDisclosures

No ties

Companies

FDA approval

No ties

Companies

FDA approval

Spinal Cord Stimulation (SCS)

Peripheral Nerve Stimulation (PNS)

Facial Pain

Occipital Neuralgia

Headache

Ablative Procedures

Spinal Cord Stimulation (SCS)

Peripheral Nerve Stimulation (PNS)

Facial Pain

Occipital Neuralgia

Headache

Ablative Procedures

Spinal Cord Stimulation (SCS)Spinal Cord Stimulation (SCS)

Tonic2-1000 Hz

High Frequency10,000 Hz

Burst40/500 Hz

High Density1200 Hz

Back and Leg Pain

Success = 50% VAS reduction

1 Year

50-55% success with Boston Scientific tonic

Back and Leg Pain

1 Year

50-55% success with Boston Scientific tonic

Back and Leg Pain

2 Year

49% success with Boston Scientific tonic

Back and Leg Pain

2 Year

49% success with Boston Scientific tonic

HD at least as effective as tonic

Eliminated uncomfortable paresthesias

Could salvage otherwise failing therapy

Could salvage some patients who lost tonic efficacy

HD at least as effective as tonic

Eliminated uncomfortable paresthesias

Could salvage otherwise failing therapy

Could salvage some patients who lost tonic efficacy

Back and Leg Pain

1 Year

80% success with Nevro HF10

Back and Leg Pain

1 Year

Back and Leg Pain

2 Year

73-77% success with Nevro HF10

Back and Leg Pain

2 Year

73-77% success with Nevro HF10

Axial Neck and Arm Pain

1 Year

Axial Neck and Arm Pain

1 Year

Back and Leg Pain

6 months

61% success with BURST

50% success with tonic

Back and Leg Pain

6 months

61% success with BURST

50% success with tonic

HD Stimulation

Putting It All TogetherPutting It All Together

Evidence to support all the waveforms

All have comparable workability / interchangeability

HF10 has the best evidence (N, A, LB, L)

HF10 has the biggest IPG, most expensive, no tonic

HF10 no paresthesia mapping, needs monitoring

BURST engages the medial pain pathway

Boston has option to mimic all 4 waveforms

Consider IPG-free for certain patients

Evidence to support all the waveforms

All have comparable workability / interchangeability

HF10 has the best evidence (N, A, LB, L)

HF10 has the biggest IPG, most expensive, no tonic

HF10 no paresthesia mapping, needs monitoring

BURST engages the medial pain pathway

Boston has option to mimic all 4 waveforms

Consider IPG-free for certain patients

Peripheral Nerve Stimulation (PNS)Peripheral Nerve Stimulation (PNS)

Limited equipment options

Hardware complications

Reimbursement

Lousy evidence

Limited equipment options

Hardware complications

Reimbursement

Lousy evidence

Peripheral Nerve Stimulation (PNS)Peripheral Nerve Stimulation (PNS)

Percutaneous, Ultrasound-GuidedPeripheral Nerve Stimulation

PNS can be a good option

Pain in a distinct nerve distribution

When SCS not feasible

No spinal access

Multiple previous spinal infections

When no IPG is desired

Limited waveform choices

PNS can be a good option

Pain in a distinct nerve distribution

When SCS not feasible

No spinal access

Multiple previous spinal infections

When no IPG is desired

Limited waveform choices

Facial PainFacial Pain

Trigeminal neuralgia, Type 1

Trigeminal neuropathic pain

Postherpetic neuralgia

Trigeminal deafferentation pain

Make correct facial pain diagnosis (TN1 v. others)

Drug therapy (AC, AD, Bac)

Image TN1 for vessel – refer to neurosurgery

For the rest, PNS, SCS, etc.

Make correct facial pain diagnosis (TN1 v. others)

Drug therapy (AC, AD, Bac)

Image TN1 for vessel – refer to neurosurgery

For the rest, PNS, SCS, etc.

Occipital NeuralgiaOccipital Neuralgia

History

Occipital NeuralgiaOccipital Neuralgia

HeadacheHeadache

Make correct pain diagnosis (ON v. HA)

Drug therapy (AC, AD, Bac, Bot)

ON with Tinel – nerve entrapment, decompression

For the rest, PNS, ablations, etc.

Make correct pain diagnosis (ON v. HA)

Drug therapy (AC, AD, Bac, Bot)

ON with Tinel – nerve entrapment, decompression

For the rest, PNS, ablations, etc.

Salvage TherapiesSalvage Therapies

Spinal Infusion PumpSpinal Infusion Pump

Ablative ProceduresAblative Procedures

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