Scott Webb (Host): Spinal cord stimulation or SCS is really nothing new having been around for some time. But the new and improved version of SES is nothing short of mindblowing. And here today to help us understand the advancements in SES is Dr. Cortez Singh. He's an interventional spine and pain medicine specialist at the centers for advanced orthopedics orthopedic associates of central Maryland in practice for over 50 years.

Hi, I'm Scott Webb and I've Got a Bone to Fix With You. So Dr. Singh, thanks so much for your time today. We've got a lot to get to, and I want to hear about this spinal cord stimulation, SCS as it's known. So just have you start here. Can you explain to the audience what spinal cord stimulation is and with the understanding of course, it's better known shorthanded as SCS.

Gurtej Singh, MD (Guest): Thank you so much for the opportunity today to be on the podcast and connect with the listeners out there. Spinal cord stimulation, is a form of pain management where we place two small wires into the back of the spine. And before patients get nervous about that, I really kind of redirect them, and I say, do you know somebody that has a pacemaker or defibrillator and most patients know that, you know, two wires go around the heart and it helps the heart to electrically beat. And so in a very, very similar way, we place two wires into the back of the spine, that will help to electrically decrease the painful signal, whether that's coming from the back after back surgery, whether it's coming from down the leg because of a pinched nerve or similarly in the neck. And so the brain receives a decrease of that pain signal and we're able to significantly improve patient's quality of life.

Host: And that's the goal, right? That's the dream, quality of life, the best quality of life that doctors can help provide for patients. And that analogy really helps actually, I can really sort of picture it now. So, who's an ideal candidate for SCS?

Dr. Singh: So, there are many ideal candidates for patients with this technology. The traditional patient has always been the one that had prior spinal surgery. So, prior neck surgery with constant neck or arm pain, prior back surgery, or multiple revision back surgeries with continued back and leg pain. In addition, there are patients who experience specific nerve traumas. So, I have a few patients, maybe they had fractured their leg and then that fracture caused nerve injury and they have a chronic nerve pain into the foot. And we refer to that as complex regional pain syndrome, which was known as CRPS or the old term, which was reflex sympathetic dystrophy or RSD. So, those are also patients. The newer patient are patients with chronic pelvic pain, as well as patients who have what's called peripheral neuropathy, specifically those that are either chemotherapy induced or that come from diabetes.

And so these patients aren't the traditional spinal cord stimulator patient from years past. But with the new technology of how stimulation works, we're finding that we're able to treat a larger group of patients, not just simply those that had previous spine surgery.

Host: And I'm glad you mentioned the new technology, cause I wanted to ask you so right on cue there, Doctor. Cause I know over the past few years there's been this big change in SCS technology and maybe you can explain the change and maybe why patients who have used the old technology SCS really should consider trying the newer technology.

Dr. Singh: That's a phenomenal question. Thank you. Back when spinal cord stimulation was first developed about 30, 40 years ago, we would electrically pulse the back of the spine. And so we would refer to this as tonic stimulation or patients would say, I feel a tingle in my back and I feel the tingle go down my leg where I have the leg pain.

And so, we would previously place the leads, or the electrical wires, we would place them in the area of the spine that would match up to their back pain or match up to their arm or leg pain. And then we would activate the tingle and then patients would let us know after a trial period, if that decreased their pain, improved their sleep, added to their function and their quality of life. Over probably the last five years, all of the major companies on the market have moved away from that tingling sensation. And what we found was, you know, a patient would get the old system placed. They would do really well for anywhere from two to 10 years. But as the body, as that spinal cord and the brain kept feeling that tingle, it would continue to adapt.

And unfortunately, these patients would come back and say, you know, I've been doing great for the last three years and all of a sudden, now the stimulation doesn't work. So, we have advanced the way in which we pulse the back of the spine. Patients now don't even feel the tingle anymore. And what has happened is you're able to pulse the spine in different ways, targeting different neurons and different nerve cells. And then that translates better information to the brain. And even in some situations, we're targeting areas of the brain that we've been able to map on an MRI and know that those areas are painful signals in the brain. So, the evolution has been tremendous over the last five years and patients who had the old system, or maybe they still have the old system; this is a great conversation to go and have with a pain specialist who specializes in spinal cord stimulation.

Host: Well, you know, Doctor, I'm just shaking my head, thinking, you know, this is so amazing. And I'm wondering if you can share a patient testimonial, sort of a patient example, if you can.

Dr. Singh: Absolutely. I saw a gentleman in his seventies who has had three spinal surgeries. And then had the older technology system trialed and then implanted. And unfortunately, after a few years, the battery died. So, then they replaced the battery. And over the last five years, unfortunately, it just hasn't worked as well. He still remains an excellent candidate. So, when we talked in the office, about trying other medications, trying physical therapy, again, even trying other injections, you know, he felt sort of disappointed because he had already been through all those things. So, I addressed with him the new technology of spinal cord stimulation, for which he was very excited because the original technology had worked for those few years. So, in a few weeks, the two of us are going to get together as an outpatient procedure. And I'm going to place the two wires in the correct location and run him under the new technology. So, he's very excited and I think he's sort of the prime example that patients who have had stimulation in the past, or I also see patients who they know a friend who had one in the past. And so they're already discouraged because the friend, it didn't work well in the past. So, the best thing I could share with the listeners are, you know the old Buick versus the new right? You want the new technology. You'd want the backup navigation screen. Whereas yeah, the old they ones, they had their place back in the eighties and the nineties and early two thousands, but that's not what we're doing anymore.

Host: Yeah, I think some people will miss just being able to use the word tingle. I really enjoyed how many times you've dropped that word in. But as say, we don't, we don't need the tingle anymore. It's a tingleless technology, which is really amazing. And I know there's been some new FDA indications for the use of SCS, this new technology. Can you explain what these new indications are?

Dr. Singh: So, two of the newer indications from the FDA are chronic pelvic pain, as well as painful diabetic peripheral neuropathy. And so, patients with chronic pelvic pain, typically it's female more than male, but they'd see their GYN. They see a urologist, they get multiple different injections, pudendal nerve injections. They tried to burn the nerves with radiofrequency ablation and unfortunately, you know, pain deep pelvis is incredibly debilitating for patients and they lose a lot of meaning in their life, and a lot of quality.

It's a strain and a stress, not on them, but also on their family, their loved ones. So, with various types of spinal cord stimulation, one is able to target just the nerves in the deep pelvis. The other indication, which is painful diabetic peripheral neuropathy, and that's a whole mouthful, but essentially we know lots of patients who have diabetes, typically Type 2, their sugars, you know, weren't well controlled and now they've got pain and stabbing sensations and fire feelings in their feet and in their toes. So again, this is a nerve problem. And spinal cord stimulation has been very well documented over the last 40 years to help with nerve pain. So, this population of diabetics is unfortunately growing. And obviously with the growth of more diabetic patients will have more patients who have painful diabetic foot pain. So, this is a great indication for patients, given that it is a minimally invasive procedure, that can be done as an outpatient. There's no hospital stay. There's no overnight, there's no rehab. There's no nursing care. Patients go home the same day and can revolutionize the meaning and the quality of their life.

Host: Yeah, it definitely can. And you've mentioned nerves and nerve injuries a couple of times, and I'm sure you see patients who have focal nerve injuries and pain. So how do you treat those patients specifically?

Dr. Singh: Yeah. So there are ,two different types of spinal stimulation. One is the central, which is typically known as SCS and which we've been talking about so far, another is known as peripheral nerve stimulation or PNS. And so the technology with PNS has been known, for again, probably the last 20 to 25 years. But over the last five again, a lot of advancements have been made in the size of the wire, the ability to deliver the, the electrical lead under an ultrasound camera. So, for example, a patient that may have an amputation or somebody that has a crush injury. You know, if the nerve pain can be isolated to just one specific nerve, we can place a really thin needle under ultrasound to lay on top of the nerve. And then we slide the electrical wire, that PNS wire, and then connect it to the battery and patients can get focal pain relief as opposed to having something implanted into the back of their spine.

And so that becomes very exciting. When you look at patients who have chronic knee pain, whether that is, you know, the 70, 80 year old patient, who just is too old or has other health concerns and cannot have a total knee replacement or the individual who's already had the total knee replacement and unfortunately has a lot of chronic pain afterwards. And then there are other examples throughout the body. There's so many peripheral nerves, but I think, the knee example is the one that probably will resonate the most.

Host: Yeah, it definitely will. And I'm only 53 and I'm thinking, hmm. Maybe, maybe I should see Dr. Singh. This is a pretty awesome option versus having total knee replacement, maybe. You know, you, you got me thinking here, doc. I appreciate it.

Dr. Singh: Hopefully we can keep you out of that for a few more years, and I'm sure technology will grow even more.

Host: Absolutely. That's what I love about medicine and science and technology. It's just every time you blink, it's something new and I'm sure it's the same sort of for you. Like, as you say, I've heard you use the word excited a few times today, you know, doctors getting excited about the technology, about the future, which for patients, it means there's a lot of upside. There's a lot of reason for optimism and it really does sound like SCS has this tremendous upside. But i'm sure there are some concerns and risks that a typical patient would have. What are some of those?

the

Dr. Singh: Well, any time you place a needle into a patient, you know, there are risks for infection and bleeding. And obviously we take care of understanding a patient's medications, making sure they're not on blood thinners and making sure they don't have an active infection when we do these procedures. Any procedure that is placing something into the back of the spine, obviously, you know, you can run into complications.

They are and have been well-studied. And because we've been doing spinal cord stimulation for over 40 years, the literature clearly shows that these happen maybe one to 2% of the time. And typically, you know, it's an irritation of the nerve. Sometimes you can actually enter into the spinal fluid, which even if it happens, can be taken care of. And so the patient doesn't experience any long-term side effects. So, that being said, the safety behind it is tremendous, right? Here's a procedure that we're placing into the spine where the biggest risk is that it doesn't work. And so for patients, who are thinking about trying a spinal cord stimulator, the biggest thing to know is that there's always a trial first. So, you know, my pacemaker example from earlier, I give my patients a second example and that's how do most people go buy a car? Well, most of us will go take a test drive. And so I think patients who are listening here to as well as those who I see in my clinic, the thing I focus them on is are you willing to take a test drive?

Right? There's no commitment. Nothing is left inside. It takes anywhere from four to 10 days, depending on certain variables. And at the end of that trial, the wire is very easily removed and you get a band-aid and so then the patient can make a decision. Well should I buy the car show, not I not buy the car. How much did it help my pain? Did I sleep better? Was I less cranky? Was I able to go see my grandkid, you know, play soccer? So, you know, while there are risks, you know, at the end of the day, because we've been doing this for well over 30 to 40 years; in well-trained hands, it is exceptionally safe. And when you back that up with knowing a trial comes before any type of implantation, really does put a lot of patients at ease.

Host: I'm sure that it does. And I think that I have the million dollar question for you. Are the trials covered by insurance?

Dr. Singh: Fortunately they are. And if the trial is successful, the implantation, which is the second step of, of the stimulator, is also covered as well. And obviously each insurance is gonna have different criteria, and you know, most of the physicians who are passionate about spinal cord stimulation, have understood, okay, with this insurance, here are my criteria and different insurance has a little different criteria. So, we navigate the patient so that they meet criteria and therefore their insurance does cover it. That'd be a lot better that way than them with a huge bill at the end.

Host: Yeah, absolutely. And I think one of the other concerns, even just for me, would be if I did something like this, whether it was the trial or went with the full implant, would I still be able to exercise?

Dr. Singh: Oh sure. Now during the trial, we may hold you off on, on full vigorous exercise. Right? We would just want to know, is this working and because it is not, you know, stitched into you, those leads could move. And we try to avoid that. But after you get implanted, after the incisions heal and we restart the device, we do, we allow patients to go back to their usual daily activities. They can walk, they can jog, they can swim, go in the ocean. Many of my patients go back to playing golf. You know, typically these patients tend to be on the older side, so maybe into their sixties and seventies, or, you know, they've had multiple spine surgeries. They may not be as active as maybe you and I are right now, but that being said, those who want to get back to that activity almost always do.

I've, you know, there are indications on all the devices, even for things like skydiving and scuba diving. So, you know, there really is very, very few, if any restrictions on patient's activities afterwards. What's also nice, many of these devices are MRI compatible. So, in the past you have to actually take it out to get a patient, an MRI. Now, put their own device with their remote control into an MRI safe mode, they can have the MRI and then they can restart their device all on their own. And that's, I think where, you know, it really does become remote control therapy.

I mean, patients ask questions about going through the airport, that's never a problem. You'll always get a medical card, just like if you had a knee replacement or something like that. So, you will get a medical card, for having the device inside of you, but flying is not a problem.

Host: I mean, really? It is just so cool. I love it. I am so glad to have had this time with you today to really better understand. Cause I think I had a pretty good understanding of the older SCS technology, but the new and improved version, the new Buick versus the old Buick, as you were saying earlier, amazing. And just SCS therapy in general has been around, as you say, for 30, 40 years. Why do you think that this type of therapy isn't more widely used?

Dr. Singh: You know, I've had very interesting conversations with my colleagues who are both spine surgeons, as well as my colleagues who are family medicine and internists. And a lot of them cite some of the issues with the old technology. And that is, you know, the patient would do great for a couple years. And then when it stopped working, they would come back, their pain would come back. They'd have to go back on their narcotics or opiates. The spinal surgeons would have to go in to remove the device. And once that got out, you know, then everybody has that sort of negative appeal to it.

Nowadays, almost every well-trained pain physician can trial the device. Implant the device and if needed, pull the device out. So, patients aren't needing to see a spinal surgeon as much almost if at all, because it's such a minimally invasive procedure. A great conversation I had with some of my internist colleagues were, you know, that it's not a device that cures their pain. So, patients will still have some other pain. Maybe they get back into their activities, and all of a sudden their knee arthritis kicks up. Well, spinal stimulation is for nerve pain and knee arthritis is a mechanical joint issue. So, you know, it is also on the pain physician to sort of follow through and be able to help them manage the patient through their knee issue, which is a different mechanism when compared to spinal stimulation. So I think that's where, you know, in the past, that was the issue. I think now with these new indications, these new indications are not indications that surgeons can deal with, right? I mean, you can't surgically fix diabetic nerve pain. And so this is where I think there will be a little bit of a revitalization of the technology.

Host: Yeah, I sure hope so. And I see what you mean. Like there's some things you can fix and some things you can't, but even the wealth of things that we've talked about today, even though some of these things can't be fixed per se, I'm using air quotes, they can be treated and the newer technology SCS, with the FDA indications that we've discussed here today. Really amazing. Thank you so much for your time today, Doctor and you stay well.

Dr. Singh: My pleasure. Thank you to everyone who's tuned in today.

Host: That was Dr. Gurtej Singh, a Physical Medicine and Rehabilitation and Pain Management Specialist and Baltimore magazine, top 50 doctor, five years running from the Centers for Advanced Orthopedics Orthopedic Associates of Central Maryland.

Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast and that's all for today. I'm Scott Webb and that was a Bone That's Fixed.