We are all familiar with pacemakers for the heart, but the devices are also used for a variety of health problems. Pacemakers for pain have been around for decades with limited success, but some patients are finding relief, if they are willing to be awake during part of the surgery.
“It was like a stabbing pain that just would never go away,” Ashlee Lipinski told Ivanhoe.
“There was so much pain. It was just debilitating,” Kim Lipinski told Ivanhoe.
Mother and daughter were both suffering with chronic pain.
Neurosurgeon Giancarlo Barolat is a pioneer in using pacemakers to help control chronic pain. Dr. Barolat has perfected the science of testing the devices while the patient is awake during surgery, so they can tell him exactly where the pain is coming from.
“They can tell me very precisely where they feel the pain and whether they feel the stimulation,” Giancarlo Barolat, MD, Presbyterian/Saint Luke’s Medical Center, told Ivanhoe.
Dr. Barolat implanted the pacemakers of Kim and her daughter Ashlee.
“I did not remember it what so ever,” Kim said.
An electrode is implanted on the nerves, or spinal cord, in an area strategically designated to relieve the pain. The electricity that passes through the electrode is generated by a pacemaker implanted under the skin.
The patient can adjust the electrical impulses with a remote control.
“I would say mine is 90 percent successful,” Kim explained.
The procedure does not cure pain, but has a 50 to 75 percent chance of providing relief and that’s enough for Kim and Ashlee.
Dr. Barolat says the pacemaker for pain can also help people with chronic headaches and back pain who have not responded to conventional treatments.
BACKGROUND: Chronic pain is a constant pain that does not go away. If you have been suffering from pain for more than six months, then your pain is defined as chronic. The pain can take a serious toll on a person mentally and physically. Commonly, chronic pain stems from an injury, headache, backache, or joint pain. It can also come from carpal tunnel syndrome, tendinitis, and sinus pain. (Source: http://www.webmd.com/pain-management/guide/understanding-pain-management-chronic-pain)
OUTCOMES: The emotional roller coaster of living with chronic pain can be difficult to deal with. When a person is continuously in pain, it becomes frustrating to perform daily activities and functions. Some emotional outcomes of living with chronic pain include depression, fatigue, stress, anxiety, and anger. A combination of these negative feelings may increase pain levels and reduce the amount of the body’s natural pain killers. The immune system may also be affected from chronic pain due to the emotional strain on the individual. (Source: http://www.webmd.com/pain-management/guide/understanding-pain-management-chronic-pain)
SYMPTOMS: Symptoms of chronic pain can include:
• Weakened immune system
• Changes in mood
• Withdrawal from activity
• Sleeplessness (Source: http://www.webmd.com/pain-management/guide/understanding-pain-management-chronic-pain)
NEW TECHNOLOGY: Pacemakers have been used for years, but now they are being used to control chronic pain. Peripheral nerve field stimulation (PNFS) is now providing relief to patients who suffer from chronic pain. Doctors place electrical leads under the skin where the pain is most frequent. The area is then stimulated by a power pack that is implanted. The patients will feel a slight tingle during treatment, which provides relief for surrounding muscles. Ashlee Lipinski has two sets of electrodes (leads) in her spine: one in the cervical spine (neck), to control her pain in the arms, and one in the thoracic spine to control her pain in the legs. All the electrodes are connected to one single pacemaker unit, which is implanted in a pocket under the skin in her buttock area. (Source: http://www.medicalnewstoday.com/releases/80533.php)
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Presbyterian/Saint Luke’s Medical Center
Giancarlo Barolat, MD, Neurosurgeon, Presbyterian/Saint Luke’s Medical Center, talks about a new pacemaker for patients in chronic pain.
Can you tell us about the pacemaker for pain?
Dr. Barolat: Well, this is not a new technology. This is something that has been around since the mid-70s. I started getting involved with it in 1976 when I was a resident in neurosurgery in Italy. At the time, we started to do just a few of those and then they stopped, but I was fascinated by it and so I didn’t want to stop. However, there was no way that I could continue to do that in Italy because of the way the medical system is and the structure. So, that’s when I decided to come to this country to pursue that. So, I came to this country in 1978 and I did a one year fellowship with somebody who was one of the very first ones to do that. I spent a year with him and I did a lot a lot of these early implants and those were not specifically for pain. Many of them were for patients that were paralyzed, or that have cerebral palsy, and some of these people have horrible contractions.
Is the implant used for different conditions?
Dr. Barolat: It’s used for many different conditions, not just for pain.
How does it work? How does it alleviate the pain?
Dr. Barolat: Well, we don’t know the exact mechanism. The same as we don’t know the mechanisms of aspirin for instance. We think that pain is an electrical short in the nervous system, where the nervous system starts firing all of these signals that are read by the brain as being painful. So, what we do with the stimulator, is we either block the pain signals or we change the pain signal so that the brain does not read it as pain. It reads it as a tingling sensation instead. So, either we block the signal or we modify the signal to where. It’s kind of like a noise cancelling headphone to where you still hear the noise, but it doesn’t bother you.
Where is it placed?
Dr. Barolat: There are different target areas where you can place it. You can place it either on the little nerves under the skin where the pain is; you can place it on the big nerves that are coming up from the limbs; you can place it on the spinal cord in the spine; or you can place it on the brain.
Let’s talk about it when it goes in the spine. Are there hundreds of nerves in the spinal column or are there just a few to select from?
Dr. Barolat: There are thousands and thousands of nerve fibers that go into the spinal cord. There are a definite number of entry points into the spine. So, there are 5 in the lumbar, 12 in the thoracic, and 8 in the cervical. These are called the nerve roots. Then, inside of the spine, there is the spinal cord and in the spinal cord, there are thousands of micro nerve fibers that travel together.
So, during the actual surgery when you have them opened up, do you wake them up?
Dr. Barolat: Yes, we wake them up. Usually, the patient doesn’t feel any pain because before I wake him up, I put a lot of local anesthetic in the incision. So, when the patients wake up, they don’t feel any pain really from the surgery, but they can feel their pain and they can feel the stimulation. They can tell me very precisely where they feel the pain and whether they feel the stimulation overlapping the area of the pain. Sometimes it takes a long time to get these things and sometimes it takes a short time. If I run into somebody whose nervous system is not following the rules, I might be there for hours trying to figure it out.
So, you are tweaking it, correct?
Dr. Barolat: Tweaking, adjusting, moving it a millimeter to the right, a millimeter to the left, a millimeter up, a millimeter down until the patient says you hit the right spot. Then, we know we have it in the right spot. So, it takes a lot of patience and you have to be willing to spend the time. If you try to do this thing in a rush, it’s not going to work.
What’s the success ratio?
Dr. Barolat: When somebody has a chronic pain condition that has been present for at least six months, the chances of curing it are almost zero. However, the chance of reducing the pain varies between 50 and 75%.
Is it generally sort of a last resort for people?
Dr. Barolat: It is because before you want to try other treatments like physical therapy, psychological, relaxation, all of those things. Then, you try the medications, but the medications themselves can be a huge source of problems and the medications that are most commonly used for chronic pain are narcotics. If you take narcotics for a long time, that adds another whole set of issues that could be even more damaging than the initial pain situation.
What kind of reactions do you see in people after they experience the pacemaker and they have some relief?
Dr. Barolat: Awesome reactions. That’s what makes this all worthwhile for me because it’s a lot of work and effort, but I save people’s lives. I had a patient last month who came to me and I had put a stimulator 6 months earlier and he was doing great. He came to me and he said, “I never told you this, but before you put this stimulator in, I tried to kill myself three times, but I never had the courage to do it. Now, I’m fine. I don’t need to even think about that stuff anymore.” So, it’s great. Not everybody, but some people get the relief within seconds. I had people in the operating room, start crying when we turned the stimulator on. They would say, “this is the first time in 5 years that I have no pain.” So, sometimes it’s dramatic.
Can you explain how it works?
Dr. Barolat: The stimulator is basically made of two parts; one is the pacemaker and another part that contains the battery. It’s a lithium battery that lasts about 10 years and then the electronics. The second part is the electrodes and there are two types of electrodes; one is called the percutaneous electrodes, these are placed through a needle and then there is another type called the paddle lead and this one has to be placed through surgery. You have to open up the spine and put it in the spine and there are advantages and disadvantages to one or the other. So, sometimes you chose one and sometimes you chose the other depending on the application. The electrodes are placed inside of the spine, in the epidural space and that’s where all the nerves are. So, if it’s a percutaneous electrode, you put it through a needle. It’s like during an epidural for delivery. So, you put the needle there and you place this thing in. However, for the paddle lead you have to place it through surgery, so you make a small opening in the spine and then you place it right inside of the spine right on the nerve. So, this one is a little more difficult to place, a little more invasive, but once you it is placed it stays in better because it is a flat surface. This one is easier to place, but sometimes tends to move a little because it’s just a little wire in there.
Is the pacemaker then providing a continuous current?
Dr. Barolat: So, the patient has a little device like a cell phone that controls this inside, so they can turn it on and off, and they can make it weaker or stronger. They can change all of the settings pretty much like you do with a TV. It can’t open the garage door, but you can do a lot of stuff with it. So, the patient has full control over the device and that’s one of the things that make this treatment different from any other treatments. With this one, you now have your own device that you can control, so you are in charge of your own pain.
What about charging the battery?
Dr. Barolat: There are two types of batteries. There is one type that cannot be recharged and once it’s finished, it’s finished then you have to replace the unit. Then, there is another type where the battery is rechargeable and so that triples the life of the battery and also allows the pacemaker to be smaller. So, most of the ones we put in today have a rechargeable battery. It’s not a big deal. People have to recharge about every 2 weeks and all they have to do is put a little antenna on the skin for about 2 hours and that recharges the device inside.
While they are doing that, they can walk and they can do things. They don’t have to be sitting. They can be active.