The successful treatment of refractory neuropathic pain using electrical stimulation of the dorsal columns was first demonstrated in the 1960s (1). However, high-powered randomized controlled trials supporting the efficacy of spinal cord stimulation (SCS) for this indication did not exist until only the past decade (2, 3). As such, many barriers to the implementation of this rapidly evolving treatment modality remain, perhaps due to a lack of knowledge by referring providers as well as a lack of initiative by practitioners of pain management to educate their colleagues. For this study, we sought to identify what barriers to referral for SCS implementation were most common for referring providers across multiple specialties at the University of Florida.
Materials and Methods
After receiving IRB approval, we distributed an online survey to the attendings and trainees (i.e. residents and fellows) of multiple specialties at the University of Florida. Informed consent was given to all survey participants. The survey consisted of five questions:
1. Are you a trainee or an attending?
2. What is your primary specialty?
3. Do you believe that spinal cord stimulation (SCS) is a potential therapeutic modality for your patients experiencing chronic pain?
4. Is referring for SCS evaluation part of your practice algorithm for any subset of patients you see?
5. What are the barriers (if any) for considering SCS for the treatment of your patients?
Overall, 189 people participated in our survey (34% trainee, 44% attending), though not all participants completed the entire survey and certain subspecialties were more heavily represented than others (Table 1). While most participants (64%) identified SCS as a potential treatment modality for chronic pain patients in their practice, most participants (61%) also acknowledged that referral to pain management for SCS implementation was not currently part of their treatment algorithm for chronic pain. The following barriers to referral were chosen by survey participants, in order of most to least common: unsure of patient selection (39%), unsure of who to consult (38%), lack of relationship with SCS provider (35%), unsure of SCS efficacy (34%), unsure of cost:benefit (33%), unsure of risk:benefit (30%), lack of patients with chronic pain conditions at my practice (19%), no barrier (13%).
While the survey we created is imperfect and participation amongst various specialties was not uniform, our study nonetheless highlights an obvious disconnect between potential referring providers for SCS implementation and practitioners of pain management. As the United States suffers an epidemic of prescription opioid misuse and overdose (4), practitioners of pain management must take the lead and actively disseminate information about bourgeoning interventions such as SCS rather than passively accepting patient referrals after misguided medication management has already failed. Newer forms of SCS are gaining FDA- approval for an expanding list of chronic pain conditions (5), and so it is incumbent on the practitioners of pain management to educate their colleagues on SCS, and thus allow patients with appropriate chronic pain conditions access to this revolutionary treatment modality.
1. Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. AnesthAnalg. 1967 Jul-Aug;46(4):489- 491.
2. Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, Thompson S, O’Callaghan J, Eisenberg E, MilbouwG, Buscher E, Fortini G, Richardson J, North RB. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentrerandomised control led trial in patients with failed back surgery syndrome. Pain. 2007 Nov;132(1-2):179- 88.
3. Kapural L, Yu C, Doust MW, Gliner BE, Vallejo R, Sitzman BT, Amirdelfan K, Morgan DM, Brown LL, Yearwood TL, Bundschu R, Burton Aw, Yang T, Benyamin R, Burgher AH. Novel 10-kHz high-frequency therapy (HF10 Therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: The SENZA-RCT randomized controlled trial. Anesthesiology. 2015 Oct:123(4);851-60.
4. Dowell D, Haegerich TM, Chou R. CDC Guidelines for Prescribing Opioids for Chronic Pain – United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45.
5. Liem L, Russo M, Huygen FJ, Van Buyten JP, Smet I, Verrills P, Cousins M, Brooker C, Levy R, Deer T, Kramer J. One-year outcomes of spinal cord stimulation of the dorsal root ganglion in the treatment of chronic neuropathic pain. Neuromodulation. 2015 Jan;18(1):41-8.