I’m Dr. Thomas Pontinen with Midwest Anesthesia and Pain Specialists here in Chicago, and today we’re discussing a highly effective pain relief technique called neuromodulation.

Neuromodulation is a device that’s implanted under the skin that can be done either in the spine itself in the epidural space, which is called a spinal cord stimulator, or in the periphery, what’s called a peripheral nerve stimulator. That’s generally in an arm or a leg, like a shoulder or a thigh. What it does is it uses electrical currents to help block the pain signal from wherever it is, whether it’s your knee, your back, even your neck, from coming up the spinal cord into the brain.

So even though that stimulation may be there and the pain may still be there, it isn’t registered by your brain. It works like a pain medication would work in a similar way. The nice thing about it is it doesn’t use drugs or medication, so there are really very little side effects associated with its ongoing use.

The batteries have developed in a way that you don’t need to recharge them, or if you do, it’s very infrequently, maybe once a month. And that’s just done through the skin. So you take a plate, and if it’s in your back, you put a strap around it for a few hours or overnight, and that’s maybe once a month.

In the peripheral nerve stimulators, those devices are very small, the size of the end of your pinky. So that’s just implanted under your skin and it’s communicated with through a remote control that will stimulate the leads, let’s say on either side of your knee. That can help with knee pain, or especially if you’ve had a knee replacement and you’re still having pain in the knee and you can’t operate in there because your joint is replaced, you’ll be able to stimulate those nerves and block that pain signal to help your knee stop hurting.

We use it primarily for pain conditions in the neck or back and then radiating into the arms or legs. We use spinal cord stimulation, which is where the lead is placed in the epidural space, the same space you’d have an epidural as a pregnant woman.

It’s internalized though. There’s nothing coming out of the skin. You have a trial first. That’s done through a needle and the lead is threaded into the epidural space, covered with a dressing. You have it for a week to test it and see if it’ll work first before you’d implant the battery. If it doesn’t help you significantly, then you don’t do the implant and it just comes out and you put a Band-Aid over the hole like you never had it. But if you do like it, then you come back usually about a month later and then the battery is implanted through an incision.

That spinal cord stimulation also can help with peripheral neuropathy. A lot of people have diabetic neuropathy or they have pain and the tingling in their feet and legs, and spinal cord stimulators can also help with that, which is traditionally really difficult to treat because there are very few injections or other procedures that can help with peripheral neuropathy.

Peripheral nerve stimulators, I mentioned, help with more extremity pain. So shoulder, knees, those are the most common, but even certain types of headaches. You can implant it under the scalp at the base of the skull. It can help with certain other types of back pain that are around the side of the back, rib pain, so if you have a rib injury, it’s called intercostal neuralgia, you can implant them there. Really now with new technology, many types of pain conditions that either the spinal cord stimulators or peripheral nerve stimulators can help with.

With the trial, those are just done through a large needle that’s threaded through the needle, kind of like having an IV placed for a week. And that’s a half an hour procedure time.

You can actually do that awake in the office. We usually provide light sedation through an IV just to make sure the patient’s comfortable. But it’s a half an hour, you go home the same day. You should feel relief right away. Sometimes you’re sore from the needle for a day or two, but the pain relief starts right away.

You’re in constant contact with the rep every day. You get their cell phone number, they’re talking to you every day, and you monitor how you’re doing and changing the programs and so forth. You come back to the clinic the next week, it’s removed. It doesn’t hurt when you take it out. It’s like taking an IV out. It just slides out, you put a Band-Aid over the hole, that’s it.

If you want to move ahead with the permanent placement, you’ll generally come back after at least a couple of weeks, maybe a month on average. For a spinal cord stimulator, there’s two incisions about an inch or two in length, one in the mid-back, one just off to the side in the soft tissue above your waist over to the right or left side in the back where the battery is implanted. That takes about two hours. That procedure, you’ll be given sedation, you’ll be asleep and comfortable for that, and then you go home the same day.

The recovery for that is usually soreness over the incisions for anywhere from a few weeks, maybe a month or so, as your body just gets used to that flat disc of a battery in it. It’s a small disc. The latest one that came out is really maybe about a centimeter in thickness and a small diameter, about the size of maybe a small oyster.

So your body gets used to it. You don’t notice that it’s in there after a while.

With the peripheral nerve stimulator, that’s even easier because it’s in the thigh or the upper shoulder most commonly. And that size is about the end of your pinky finger, the device itself. So only one incision is made about a centimeter or so in length, and that’s inserted through that centimeter incision. That heals up really within a few weeks at the most.

That one, because the device is so small, is even easier to adapt to, and it’s very rare for patients to have much discomfort after the device for the peripheral nerve stimulator is implanted.

For the first, sometimes it’s a few weeks, sometimes it might be a month or so, you want to avoid certain strenuous activities like heavy lifting, bending, doing squats at the gym, or if you’re very athletic, strenuous and tense activity, especially involving weights and flexing and extending at the spine. You want to be careful.

For peripheral nerve stimulators, that’s not as much of a concern because those leads aren’t going to move as much when they’re anchored in the extremities. But for the spinal cord stimulator, yes.

Eventually though, there aren’t any restrictions. Once those leads scar in, you’ll be able to do everything normally, swimming, anything in the water, any kind of exercising, running, anything like that won’t be limited with the stimulator.

It’s really until the battery dies, which on average with current technology is about seven years. Depending on usage, it can last 10 years. And then you need to get it replaced. That would just involve coming back in and having a similar procedure as the implant itself. That would be removing the battery by opening the incision, reconnecting the leads, and then placing the battery back.

But again, that’s only every 7 to 10 years.

As you have the device on, it should provide relief assuming that you don’t have an injury that changes the anatomy or something that would change your pain pattern entirely. But if you do, you can always change the programs. You meet with the rep, it’s a lifetime of interaction with the device company rep, and they’ll always be available for you to call their cell phone really anytime. They have people employed only to interact with patients and answer questions.

The worst-case scenario is if, let’s say you have back pain and you have a stimulator for a number of years and then you’re in a car accident or you have something happen that damages the spine from an anatomical standpoint in a much more severe manner and you end up needing a surgery because a nerve is compressed. The surgeon can just remove the stimulator easily during the surgery. Or if something changes and for whatever reason you don’t want the stimulator anymore, it is removable.

So say 10 years go by and something changes and you decide to get surgery. We can remove them. You don’t have to, but it’s just a battery, a flat disc under the skin. It involves making an incision and removing it.

That’s what I remind people as well: it’s not a permanent device that’s fused to your spine or that’s not removable. It is actually removable. So I think of it as like a long-term temporary solution. And psychologically, people like that because they don’t like something that, “Oh, what if it changes or doesn’t work, it’s fused to me or it’s internalized in a way that it’s not removable?” Well, that’s not a concern because you can actually take them out 10 years from now for whatever reason if you don’t want it anymore.

Some of it you can actually update, kind of like your iPhone updating its new iOS. You can do that with stimulators too, where you can upload the new programs and the improved technology without having to exchange the device.

Unless you’re extremely thin, you won’t be able to see it. There’ll be a small incision over there, but the incision heals like a thin surgical scar that you won’t notice unless you’re really looking closely at that area of the body. We can also implant it in different areas. So if someone wanted it placed higher or in a certain area that they think is less visible, we can try to do that.

For the most part, the stimulators, at least the spinal cord stimulators, are in an area that’s most comfortable for the person. So it’s below the rib and above the hip bone, right here. And that’s the area where it’s not going to be pinched against a bed or a chair when you’re sitting or laying down between the bone and the skin. Those are the areas that you really should not feel the device unless you’re feeling it with your hand. And if you press with your hand, you can feel it, but like sitting against a chair or laying in bed, you won’t notice it in your back.

I just think new technology is cool in general, but especially when it’s only to help other people and really change people’s lives. The people who get these devices have tried all kinds of things, including surgeries, injections, medications, physical therapy, everything else. And this is kind of a last resort option.

And to see how it can help people and really literally change people’s lives just through this element of technology, I think, is really cool.

These devices literally talk to the nerves in a way that works because nerves transmit signals using electricity and electrical shifts along the nerve. So when you figure out basically how to communicate with these nerves and speak the language of a nerve, you can learn to settle down those transmissions along those pain fibers.

It’s just so cool how we are developing technology like this that directly translates to pain relief in life.

Overall in the field of pain management, there are things coming out like this. Peripheral nerve stimulators have really only become more mainstream in the last few years, along with some other devices that we’re using that are consistently coming out. It just gives us more tools.

To help someone who came here previously, even five or 10 years ago, there isn’t much you could have done for them. But now, any patient who walks in the door, I’ve got a list of things that we can try. Many of them didn’t exist five or 10 years ago.

This is covered by every major insurance, including Medicare, every commercial insurance, private insurance, both the spinal cord stimulators and the peripheral nerve stimulators. And it’s a very widely accepted, widely studied area. So it’s not like new experimental technology. Spinal cord stimulators have been around for decades and they just continue to improve. They’re implanted every single day. I don’t know the exact data, but I would assume hundreds, if not thousands of patients a day across the country.

It’s a very common technology. There’s plenty of information online that patients can look up and research themselves. But yes, if you have really any kind of standard medical insurance plan, there’s a very high chance that it’ll be covered for this procedure.

We do probably two or three of these a week as a practice, so it’s become a very common way of treating people.

I have patients who are pretty consistently in tears of happiness because they’re like, “I’ve forgotten what it’s like to go through a day without pain or minimal pain.” They’ll say, “I haven’t slept through the night in years. I was actually able to sleep through the night without waking up all the time in pain.” I was able to, you know, any kind of basic things like just walk my dog or play with my grandkid or go back to work on these things.

I don’t like to overpromise anything because there’s always a possibility that it won’t help, and that’s why we do the trial first. But we have about an 85% trial conversion rate in our practice. That means that 85% of the people who do the trial do the permanent implant, meaning that it provided them enough relief to move forward with that.

This is significant. You still probably will have some pain because sometimes people actually ask that. “What if I can’t feel pain? What if I’m injured? If I step on a nail or break my ankle or something, am I going to know?”

And I tell them, no, you will. It doesn’t take your body’s ability to feel pain away entirely. It just dulls it. So that kind of nagging baseline pain that’s always there, and then the sharp twinges you’ll get with certain activities, will just decrease, almost like when you take a pain medication, the pain improves. But if you injure yourself, you’ll know it.

You’ll still feel those ups and downs and you’ll still have elements of pain, but it won’t be so severe that you’re unable to function.

One way of telling how severe a pain is, is if you are unable to remove it from your conscious mind, where it distracts you from things. It’s always kind of bothering you and you can’t enjoy day-to-day activities because that pain, you’re unable to suppress it into your subconscious.

So the goal with the stimulator is to be able to do that more often, and that allows you to essentially enjoy life and learn and train your mind to be able to suppress it in the way that you don’t feel the clothing on your skin unless you consciously think of it. Then you’re like, yeah, I do have some pressure, you know, like from my shirt or my pants. But then when you’re thinking about something else, you’re not constantly thinking about that sensation.

So the goal is to be able to help your mind put that form of thought into your subconscious.

You can go on our website, mwpain.com, and make an appointment and reach out to us. The easiest way is if you go on Google Maps, you can put in MAPS Centers for Pain Control and our eight locations will show up. If you’re in the Chicagoland area, there’s likely a location relatively nearby.

Our website has information on specifically spinal cord stimulation or neuromodulation in general that you can learn more about.

We take all major insurances. There’s a very high likelihood that we would be able to see you. And there are so many different forms of treatment.

I would say 95% chance we do have something that you either are unaware of or you haven’t tried yet that we would be able to at least, maybe not eliminate your pain, but decrease it to a level where it’s not always nagging you. It’s not preventing you from doing things you enjoy.

It may just be being able to walk your dog, sleep through the night, go grocery shopping, and carry your grocery bags from your car without significant pain. Those are the realistic goals that we have, and almost always can succeed to an extent with someone who is motivated to get better.