Faculty Bibliography

Case Description: Patient with a history of chronic low back pain secondary to lumbar spinal stenosis status-post two lumbar laminectomy/fusions, now with failed back surgery syndrome. Pain is constant with radiation down posterior thighs. Physical exam reveals tender thoracolumbar paraspinals and lumbar facets, without radicular signs. MRI reveals degenerative disc herniations, stenosis and stable post-surgical findings. Patient unable to tolerate physical therapy due to pain. Medication regimen includes naproxen, hydrocodone, gabapentin and duloxetine. Three lumbar ESIs provided only temporary relief. Patient underwent unsuccessful trial of low-frequency spinal cord stimulation (SCS), with complaints of increased pain and decreased functional mobility. One month later, high-frequency SCS was trialed, with complete resolution of pain reported by the patient. Following permanent implantation, patient discontinued naproxen and has decreased hydrocodone dose by 25%.
Setting(s): Outpatient Pain Practice Patient: 62-year-old female with chronic low back pain Assessment/Results: 62-year-old female with chronic low back pain secondary to spinal stenosis and failed back surgery syndrome, who was functioning below baseline despite dependence on opioids. Pain was refractory to conventional SCS with low-frequency stimulation, however high-frequency SCS provided immediate pain relief as well as decreased dependence on opioids.
Discussion(s): Chronic back pain continues to plague our nation's health and economy. Many patients are unable to tolerate recommended conservative treatments such as physical therapy, while surgical interventions are often not desired or not effective. Neuromodulation offers a minimally invasive treatment option which has proven to decrease pain and allow for decreased opioid dependence. In this case, high-frequency stimulation proved more beneficial than the conventional, lowfrequency stimulation.
Conclusion(s): Spinal cord stimulation may provide relief and allow for decreased opioid dependence in patients with failed back surgery syndrome. In cases refractory to conventional, low-frequency spinal cord stimulation, physicians should be aware that a trial of high-frequency spinal cord stimulation may be warranted