Physicians strive to find ways for their patients to live healthy, active lifestyles, and that is what attracted Dr. Dave Eichman to the specialty of spinal cord stimulation. 

In this episode of Back Talk, host Dr. Sanjiv Lakhia and his guest, Dr. Eichman, cover what makes a patient a good candidate for the treatment, what to expect from it, and some potential pitfalls. 

“The unique ability to test the device before committing can help patients feel more confident in their choice. “[Once] you've had the surgery done, there's no going back. But with the stimulator, there's a five-to-seven day trial period where you come in, like you're gonna have an injection performed,” Dr. Eichman says while explaining a unique aspect of this treatment. “You just get to try it out, see if you can walk further, stand longer, sleep better, use less pain medicine. Are you comfortable with it?” 

The technology behind spinal cord stimulation has made significant progress since it first became available almost 50 years ago. In the past ten years alone there have been major improvements in the therapeutic modality of the device, so patients have more choices in what the treatment feels like to them. The devices are also now MRI-friendly, giving patients more imaging choices than they traditionally had if they had chosen to pursue this treatment. 

Tune in to this episode of Back Talk to hear how spinal cord stimulation can improve the lives of patients living with recurring nerve pain. 

💡 Featured Expert 💡

Name: Dave Eichman, MD

What he does: As a clinician, Dr. Eichman enjoys caring for patients by using critical thinking, patience, and perseverance. He specializes in pain management with a special interest in spinal cord stimulation, peripheral nerve stimulation, MILD procedure, and Botox for migraines.

Company: Carolina Neurosurgery & Spine Associates

Words of wisdom: “My interest has been in trying to make people's lives as bearable as possible. There are a lot of people that, unfortunately, are dealing with conditions that make it difficult for them to function throughout their day. So I've developed an interest in trying to make their lives better.”

Connect: Website | LinkedIn

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at CNSA.com.

Welcome. You are listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery and Spine Associates, where cutting edge nationally recognized care is delivered through a compassionate approach. This podcast is for informational purposes only and not intended to be used as personalized medical advice. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakia.

Welcome to another episode of Back Talk Doc. Today we're going to dive deep into an evolving technology that can help people who are suffering with chronic pain and that is spinal cord stimulation. I'm very pleased to be interviewing my colleague, Dave Eichman. Dave, welcome to the show.

Great. Thanks for having me.

Let me introduce you to everyone. Dr. Eichman is a board certified anesthesiologist and he's done a fellowship in pain medicine. His educational background, he did medical school at Wake Forest University and residency in anesthesiology at Wake Forest University School of Medicine. And he did a fellowship in pain medicine at Beth Israel Deaconess, Harvard Medical School, Boston, Massachusetts. And of course his undergrad was at North Carolina State University. He is a Carolinian through and through. His specialty interests really include helping people with their chronic pain through spinal cord stimulation. He does peripheral nerve stimulation, radiofrequency ablation, Botox from migraines, and pretty much anything people need to help them deal with their chronic pain and injuries. And today, like I said just prior, we're going to dive deep into the topic of spinal cord stimulation. But before we do that, Dave, why don't you go ahead and give the listeners a little bit background about who you are, where you're from, and how you found your way into the field of pain management and spine care.

As you had said earlier, I've pretty much grown up in North Carolina and did my training at Wake Forest University for both med school and for residency. And for me, pain became an interest whenever I was a third year medical student, I met a patient that had both known as complex regional pain syndrome. I just found the disease process very fascinating and that led me into the field of pain management. After my residency in anesthesia, I went to Boston to do the fellowship and pain management itself and learned a lot more about different things available to help people with pain and how to help them cope with it. And that's where I learned more about spinal cord stimulation. And I think my interest have been in trying to make people's lives as bearable as possible. There's a lot of people that unfortunately are dealing with conditions that make it difficult for them to function throughout their day. And I've developed an interest in trying to make their lives better.

I failed to say this earlier, but you practice predominantly out of our office in Greensboro, North Carolina. Is that correct?

Correct, yes.

Okay. And how long have you been in the field of anesthesia pain?

I finished my fellowship in 2010, we're looking at about 12 years now or so. Prior to joining the facility here in Greensboro, I was with an anesthesia and pain practice in Hickory, North Carolina for about 11 years. About 12 years total independent practice.

That's a lot of experience. As you know, on this podcast I focus predominantly on back pain and I try to look at it from every angle I can, since I feel like there's not a one size fits all solution. Spinal cord stimulation was something I was introduced to when I was in residency and at the time it was presented mainly as a technique to help eliminate chronic nerve pain in an affected extremity. Though I know things have evolved. Let me have you open up, explain to patients, people, anyone who's listening, what exactly is a spinal cord stimulator and how does it work?

It's a device that is used to basically mask pain or alter the perception of pain. And what it entails is very commonly people may be familiar with an epidural steroid injection, when we do our epidural steroid injections, we essentially take some steroid medicine and place it into the spinal area in the epidural space to try to help quell any sensations of pain, a lot of times with pain that shooting down extremity. What the stimulator actually goes in that same space, it's where somebody would get an epidural steroid injection or for females if anybody's in a labor epidural place where people are having an epidurals place for pain during labor, instead of placing a solution there or a little tube that delivers medicine, we place a small wire under the skin beneath the bones that sends signals to mask somebody's pain or at times it can either make the pain just seem like it's not there or may replace the pain with a sensation of more a vibration or tingling type sensation's, more pleasant, as compared to the pain itself.

And the device if it's something that somebody has placed for permanent so to speak, it's all under the skin and nobody sees anybody with this device in place. It's basically worn all the time and has a little battery that can be adjusted to those sensations to replace the pain.

All right. Let me just recap that. The device itself sends an electrical input or electrical signal through the spinal cord to the brain to block the pain signals. Is that how you think about it?

That's one way of thinking about it, yes. Basically delivering the signals into the spinal cord itself where the signals are interrupting the transmission of pain.

Would this be akin to how when someone stubs their toe, they rub it really fast to help block some of the pain signals from traveling to the pain centers in the brain? What we've all known as the gate theory. Does the spinal cord stimulation work on the gate theory?

There is thought that that is one of the primary mechanisms of it. Basically activating the inhibitory pathways of pain so that they don't feel the pain, the burning type sensation that would typically be elicited from an injury.

What type of patient would you typically consider? This is certainly not a treatment that's offered up front in the world of back pain, correct?

Correct. There's two primary diagnosis for this. The first of which is somebody who has had surgery on their back and they still have pain even though the surgery may have been a great operation, but for whatever reason the nerves are still saying that they hurt. Those type of patients would be a good candidate for a spinal cord stimulator in that they've typically already done basic injections and they've had surgery and there's really nothing left to operate on, it's just that we need to quiet down those nerve signals. That's one type of ideal candidate. The other type is for a pain syndrome called complex regional pain syndrome, which is more of a nerve type pain condition that somebody has typically in an arm or a leg. And those are the two most utilized syndromes for this device.

Are there other, I would say non neurologic indications, meaning someone who has chronic hip or knee arthritis or orthopedic trauma that left them just with some residual pain?

If there's nerve damage, that could be a possibility, but most insurances won't cover it just for that. But as far as other conditions go, peripheral vascular disease is actual an indication for it as well.

Oh wow.

People that have lack of blood flow to a limb would be a candidate for. And the theory is to how spinal cord stimulation works for that is a bit unknown, but the thought is that somewhere just caused some vasodilation or dilation of blood vessels which causes increased blood flow. And there's actually some studies showing increased blood flow and experiments and also increased blood flow for people to have chronic chest wall pain that's not minimal to any sort of heart intervention.

I did not know that. That's very interesting. When you are talking about spinal cord stimulation for spine care, are we only referring to pain in the low back, potentially goes down the legs? Or are you applying this technology to patients with chronic neck pain or cervical radiculopathy radiating pain in the upper extremity?

You can use it for either. Most commonly it's going to be back pain cause that's what we see the most of. But there certainly are patients that we'll use it for neck pain. And what's associated upper extremity pains as well.

Does it change the approach if it's neck versus back in terms of where you place the leads?

Yes, that's a good question. For the back pain, the leads are typically going to be somewhere in the mid portion of the thoracic spine and for the neck pain it's going to be more in the upper portion of the neck or the cervical spine.

Okay, very good. Someone who's nonmedical and is listening, I think the take home point so far, this is an external device but it's placed under the skin so you're not wearing it outside, it's not a TENS unit. I like to tell people that it's somewhat like having an insulin pump in the body except this is more working on the neurologic system and the pain nerve pathways.

And other analogy is helpful is think of it as like a pacemaker because the batteries are very similar, some people call it a pacemaker for pain, whereas pacemaker you have a battery and wires that go to the heart, here you have a similar type battery with the wires that go on top of the spine.

Give us a little perspective on, just from your opinion, the evolution of spinal cord stimulation. Where it first started and what's been some of the advances that you've noticed over the last five to 10 years with it?

It's been around for a long time. I'd probably say close to 40 or 50 years or so. I think neurosurgeons are the first to start utilizing it. Devices have come a long way. Think initially it'd be a wire, those place under the skin, you have a battery on the outside that would transmit the wire and now everything is underneath the skin. And we talk a little bit about these systems where people can feel the vibrating sensation or the prestigious, more medical term that'll be used to replace the pain. And for a while that's pretty much the main modality of treatment. But now the systems have evolved so that people are now getting the same therapy without necessarily feeling the vibrations. There were some people that really didn't like those TENS unit types sensations, vibration sensations that were replacing their pain.

And that's been a good evolution in the system itself. For a while, another issue was that they were not MRI compatible. Now about every system out there is MRI compatible to some extent. Patients aren't limited on what type of imaging they can have done. And that's been really neat to see because that opens up the windows for more patients that we're able to treat from that perspective. And there's different stimulation patterns out there that has changed. Each company has their own type of stimulation that they can present to a patient. I think the past 10 years, the two things I've seen that I think have helped patients the most are, one, changing from the vibrating type sensation being delivered as the only therapeutic modality from the stimulators and, two, the MRI compatibility.

That's certainly a game changer. Very difficult for people when they have a device that's not MRI compatible. The idea that you cannot have an MRI at any point the rest of your life, that could really become an issue down the road. That's been great to see and observe. Now the process itself, talk people through a little bit. Let's say someone's in your office, they've gone through maybe a lumbar fusion and a revision and it's been five, 10 years and they've been having just some residual pain that's down their leg, burning pain, they've gone through a lot of therapy, maybe medications as well and they're interested in this technology. What's the process for someone who's interested?

First thing is does their pain pattern fit something that stimulation would cover? And I think for patients that have a burning pain in an arm or a leg, those tend to be ideal candidates, especially if they've had surgery done previously and the surgeries has corrected any problem that was there, the nerves just don't know that they're not supposed to be causing pain anymore. That makes them a good candidate and the insurance would cover that. Once we've determined that, "Hey, you've got a pain process that this device can help and also it looks like you've got something that your insurance will cover," then we start down the path of seeing if the device is going to be good fit for the patient. The main steps are, one, a psychological evaluation. Now it may seem a little absurd to some individuals, but that's more or less just something that's part of most insurance protocols to have the device trialed and then implanted.

And we'll talk further about that in a second. And mainly what we look for in the evaluation that you'll have an independent psychologist, just ask the patient some questions, making sure there's no overlying other problem that could interfere with their ability to interpret the device or appreciate the device's effectiveness. And also to make sure they understand the process of going through with the device and having it placed permanently. And they also have good expectations as to what it can do for them. And one of the key things here is I think people should understand that it's highly unlikely that's going to take away a hundred percent of their pain. We look for 50% or more benefit. And the benefit is can you walk further? Are you sleeping better? Are you standing longer? There's just some significant quality of improvement, quality of life improvement that you're able to get from the device. And what they'll try to interpret with the psychological evaluations, your understanding of the device and making sure there's nothing else that may interfere with your ability to interpret how it's doing for you.

Once that part's done and everything looks okay, you actually get to try it out, which is something we haven't really talked about. It's a cool thing. As compared to most surgeries that are out there, once you commit to the surgery, you have the surgery done, that's it. You've had the surgery done, there's no going come back. But with the stimulator there's a five to seven day trial period where you come in, like you're going to have an injection perform and the stimulator at that point it just stuck underneath the skin and the battery that goes to is outside the skin. Now all this is under bandaging so that we keep it sterile and it can go under your shirt so nobody necessarily sees what's going on. But you have about a five to seven day period where you just get to try it out, see if you can walk further, stand longer, sleep better, use less pain medicine, are you comfortable with it?

After that trial period, the device comes out, whether that goes well or not. And that's just a decrease in the infection risk. The device comes out and you say, "Hey, I like this," or, "I don't like this." And based on that decision then you would go and have it placed permanently or we would go back, have the wires placed again underneath the skin and bury everything underneath the skin, so that's basically not seen by anybody and it'll be there for as long as you want to have it there.

Talk a little bit about maintenance and follow up with the spinal cord stimulators.

Once it's done and implant it permanently, so say somebody goes through, they have it placed permanently so that everything's under the skin, there's typically not a whole lot of maintenance aside from charging the battery. And the battery will need to be charged every couple of days. And that's just going to depend on what the usage is and the type of the system. And then sometimes there's some programming. When you have these devices placed, there's a representative from the appropriate company that adjusts the stimulation to a level that you're comfortable with so that it covers your pain and a fashion that you like. Once all that's set up, there's really not a whole lot to do. Now the caveat to that is you have a battery in there. And just like every other battery out there that has a lifespan. And a lifespan is typically somewhere between seven to 10 years. After seven to 10 years these batteries would need to be replaced, which involves a very minor outpatient surgical type procedure.

Excellent. There is support for people who have it put in, there's the representatives from the vendor and then of course there's support from the clinical staff. Not a lot of maintenance that people have to consider.

Correct. Yeah.

And what scenarios have you seen or observed that spinal cord stim just hasn't worked out or there's been just challenges? What are some things maybe some downsize or pitfalls to spinal cord stim?

I think sometimes there may be unrealistic expectations in that the patient may think that it's going to take away all of their pain. And sometimes patients may be a little bit over optimistic with their trial. The trial may go and they think that it did a whole lot better for them or wanted to do a whole lot better for them than actually did, some false expectations. Another instance is somebody that has pains all over the place, so say they have that shooting pain in their leg but they've also got various other arthritic pains and different extremities like maybe their elbows or their hands or their thumbs or something or also bottoms. The stimulator is not going to be able to cover all of that.

Another case is somebody who truly needs a surgery but doesn't want to have the surgery done. And those are some times where the part of their body that needs to be corrected, whether it's like a disc or something that's pinching on a nerve that needs to come off of it, when those things need to be corrected and they're not, that's when I often see the device will fail because they just can't quite overcome that intense pain.

Now let me give you two examples and you can give me your thoughts if it's applicable or not. First would be individuals who have lumbar stenosis and what we call claudication, aching heaviness in the legs with activity. And then the second would be individuals who have predominantly back pain without that nerve pain down the leg.

There are some data showing success in each of those scenarios. That being said, for the first scenario where somebody has spinal stenosis with claudication symptoms, my personal experience is that they don't do as well with stimulation because it gets to a point where that just worsens over time and the stimulation can't fix that. It can't fix that spinal canal getting really narrow and the device just fails. The second one is where patients have pretty much predominantly, what's known as axial back pain, so pain that doesn't shoot, it's just right in the middle of your back. And I will say that I'm seeing more success with that now than I had in the past. That's probably a 50/50 success rate for me.

And there's just some merging treatment options and I've done episodes on, if you're listening and you haven't heard some of my other episodes we've done in interviews on radio frequency ablation neurotomy, that's one to check out. I've done an interview with Dr. Samach on the intracept procedure. There's basically a movement towards how do you identify the pain generator and is there a way to silence it or turn it off? And this is another one, I've definitely seen clinically more utilization of spinal cord stim for patients with axial back pain, at least in the community. As to whether or not that's been good from an outcome perspective, it's hard to assess. And I would ask you this, do you still advise your patients that even when you do this procedure and it's successful, that they still need to maintain healthy, functional, active lifestyles?

Yes, definitely. Healthy, functional, active lifestyles keep the weight down. Part of the reasons why we do this so they can be more active and functional.

And that's part of the trial. You're assessing that during the trial too?

As best as you can over the couple days that you have to do that. If they're walking further, if they're able to decrease their medication requirements. Those are some of the things that we look at as well. I think the other thing with the device is that there's some patients where they may not be candidate for some of the other procedures that are out there. I think for the axial back pain does allow some window of opportunity for them. But either way though, we still want them to be as active as possible and lead a healthy lifestyle, there's other benefits of that as well.

Awesome. And I think that's a really good segue towards the end of the interview. Dave, you covered a lot, patients, if they're listening and intrigued, we covered the indications, what to expect, talked about the trial and some of the pitfalls. And I'll leave you with, I always enjoy talking with my colleagues about their own health habits and healthy lifestyle intervention. What are a couple things that keep you healthy, keep you active and energetic?

I try to exercise as routinely as possible. For me, it's going for a run because I'm typically in a time crunch. I have time to fit a run in. And then just trying to eat a healthy diet too, and watching how much red meat I'm eating or how much sweets I'm eating. And that's going to be the tough time of the year for us with all of these holidays coming up. I think trying to eat as healthy as possible and getting some exercise. And I think the other part that we need to remember is also our mental health as well, whether it's a meditation or a deep breathing exercise to just help release some stress from that fashion too.

I love that. In fact, the podcast episode I just recorded before this one, will post, was a 10 minute guided meditation that I recorded for people with chronic pain. There's all different ways. Spinal cord stim is about, I don't want to say manipulating, but changing the nervous system response to pain. You can do it directly with interventions like that. There's data that you can do it with meditation, hypnosis, there's all different ways to go about it. And in my experience, the more comprehensive approach that one takes towards our health, the better the outcomes. All right. Very good. Thank you so much for your time.

You're welcome. Enjoyed it.

Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.