Two women talking at computer
Filomena Mazzella (L), Clinical Nurse Coordinator, and Meaghan Pool, Patient Flow Coordinator, discuss care plans for patients of the Spinal Cord and Peripheral Neuromodulation Clinic at Toronto Western Hospital. (Photo: UHN)

When you're a patient with chronic neuropathic pain, you can often encounter many dead ends in pursuit of relief.

The challenges are numerous when looking for treatment or management of chronic pain and, for patients who live with the condition for many years, it is often an exercise in trial and error – meeting different doctors in various specialties, shuttling around to many services, sometimes getting lost within the system when potential options don't lead anywhere.

One possible treatment is neuromodulation – where a stimulator is implanted in the spinal cord to deliver pulses that override the pain signals sent to the brain (see box below).

Toronto Western Hospital (TW) is a leader in neuromodulation treatment for neuropathic pain. But the wait list to access the service was continuing to grow, meaning outcomes and quality of life could worsen for patients as their pain duration lengthened.

And, after waiting to be assessed, patients might also find out they weren't a candidate for neuromodulation, leaving them back at square one to find an alternative treatment.

That's why TW brought together its various departments for pain to form one program: the Spinal Cord and Peripheral Neuromodulation Clinic (SCPNC) at UHN.

The SCPNC is part of UHN's Comprehensive Integrated Pain Program – Interventional Pain Service (CIPP-IPS) and linked to the Toronto Academic Pain Medicine Institute (TAPMI) network. It launched last June.

The SCPNC – which combines disciplines that all treat pain patients – involves the departments of Anesthesia and Pain Medicine, Neurosurgery, and Physical Medicine & Rehabilitation (PM&R). TW is one of only five hospitals in Ontario to offer this service and the first in Canada to offer a collaborative neuromodulation program for pain involving three departments.

The program addresses an unmet need for patients with severe neuropathic pain who hadn't been able to obtain relief despite trying medications, physical and psychological therapy, and other treatments.

The team is comprised of pain physicians, neurosurgeons, anesthesiologists, psychologists, sleep physicians, nurses, and patient flow coordinators, who assess patients, often on the same day, and provide expertise to identify a treatment plan to achieve the best outcome for a particular case.

"Traditionally, pain medicine, neurosurgical services, PM&R, and psychology tend to work in isolation and refer patients back and forth," says Dr. Anuj Bhatia, Anesthesiologist and Medical Director, TW Pain Service who helped start the program. "This way, everyone is brought together for a holistic assessment and if the patient isn't a candidate for neuromodulation, then they are already connected with other specialists who can put together a treatment plan.

"I really commend TW's management team for bringing the teams to the table to make this happen and providing the support so we can better help our patients."

Clinic Sign
The Spinal Cord and Peripheral Neuromodulation Clinic (SCPNC) combines disciplines that all treat pain patients. (Photo: UHN)

It's benefitting patients like Shelley, 64, who had been affected by neuropathic pain since the 1980s after a work-related injury when she was an occupational therapist (OT).

"I had surgery to relieve bone pressure on a nerve in 1981," Shelley recalls. "But the procedure did not alleviate the pain entirely and I was unable to return to my job as an OT.

"I have since been managing my pain with the help of alternative healthcare providers for years."

Shelley managed the pain as best she could. Then, in the summer of 2016, things started to get worse. She began to experience new waves of pain and more than usual discomfort in her legs and feet after too much standing or sitting.

"It felt like I had a migraine in my back," Shelley says. "My pain changed and became completely intolerable and unmanageable.

"I finally had to try pharmaceutical treatments as an adjunct to the alternative therapies."

But the medication only provided so much relief and Shelly soon began to seek out help, even considering travelling to the United States for treatment.

Finally, she was referred to the SCPNC and was one of the first patients to be assessed at the clinic.

"Dr. Bhatia and other members of the team have a real sincerity in their approach to patients with pain," she says. "They were meticulous in understanding my case and working to find the best solution for me."

Shelley wasn't a candidate for neuromodulation surgery, but since she was assessed through the SCPNC, other specialists within the program were able to put together a care plan for her.

Shelley was prescribed other medications that could be more effective to manage her pain with fewer side effects. She was also connected with Dr. Aliza Weinrib, a pain psychologist with the SCPNC, for support.

"Dr. Weinrib has been a wonderful support," Shelley says. "The strategies she has provided have been invaluable and the pain seminar she recommended I attend was very helpful.

"She is a great adjunct to Dr. Bhatia's team."

Shelley also practices her own self care, continuing to utilize alternative therapies as well as doing pilates and aquatics.

For many neuropathic pain patients, including Shelley, the pain will probably never fully go away. But it can become more manageable. Shelley now has a check up with Dr. Bhatia every three to five months and can access any services through the SCPNC as needed.

"Compared to the summer of 2016, the pain has definitely changed," she says. "Finally getting some help was a big relief."

Two skeletal images
Spinal cord models in the clinic help educate patients receiving the neuromodulation implant on how the device works. (Photo: UHN)

Neuromodulation: From invasive back surgery to a simple epidural

One way to treat chronic pain is through neuromodulation where a device, about the size of a stopwatch, is surgically implanted in the epidural space around the spine. The device is then programmed to deliver a controlled electrical signal to the spinal cord. The electrical impulses deliver a tingling sensation to the brain while also blocking pain signals that the patient experiences, essentially overriding the pain sensation.

Though the treatment can be effective for patients, the process to implant the device and test whether patients can tolerate a feeling of constant tingling is inefficient:

  • Patients undergo a surgical procedure done by a neurosurgeon to partially implant the device – the leads for the electrodes aren't embedded under the skin.
  • The patient then stays in hospital, usually up to five days, to see how they respond to the electrical pulses. If the patient responds well, the stimulator is then fully implanted; but if not, it is removed.
  • Staying in the hospital, however, isn't the best setting to test the stimulator since it isn't the patient's home setting and they aren't engaging in their regular routine, activities or even sleeping as well as they might at home.
  • Keeping the patient in the hospital also occupies a bed and uses other hospital resources.

But procedures are often improved upon through either method or technological advancements and the SCPNC's Dr. Bhatia, with encouragement and support of the neurosurgical team, travelled to the United Kingdom in early 2016 to acquire the latest skills in neuromodulation implantation – which can now be done under local anesthetic by a pain physician through the skin:

  • The electrodes are implanted via an epidural to the pain affected area – a less invasive procedure that results in less pain for the patient and avoids the need to cut through bone as with surgery.
  • Since only local anesthetic is needed, the patient is awake during this procedure which allows specialists to better test the effectiveness of the stimulation while the patient provides real-time feedback.
  • Rather than stay in hospital, the patient goes home the same day of the procedure. A dressing is placed over the electrodes which are left on the outside of the skin, and there is only a small stitch in the spine from the incision for the epidural.
  • After five to seven days, the patient will return to the hospital for follow up and, if the stimulation results in significant pain relief, they will have the device fully implanted after a month of surveillance to guard against infection.

For patients who cannot have the electrode implanted through the less-invasive procedure (for example because of previous extensive spine surgery), TW neurosurgeons Dr. Mojgan Hodaie and Dr. Suneil Kalia will perform a surgical implantation.

The nature of the collaborative program ensures that the right care is available to the right patient at the right time.

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