Oh, the relief of finding an answer to my back pain after forty years!
After four decades of excruciating back pain, retired nurse Beverley Palmer had given up hope of ever finding relief. then last year, she finally found a treatment that worked.
Called spinal cord neuromodulation, the treatment could alleviate the agony of chronic back pain for potentially thousands of people — it is thought 7 per cent of older adults are disabled by back problems.
Neuromodulation involves an implant in the spine controlled by a battery pack that is able to block pain signals to the brain. experts are now calling for it to be much more widely available on the NHS.
for although the technology has been around for 25 years and the treatment has been found to be cost- effective by the National Institute for Health and Care excellence (NICE), which approved it in 2008, only a fraction of those who could benefit are getting it.
Beverley’s back pain, which related to injuries sustained in her job as a special needs nurse, ruled her life.
‘I lifted children without a hoist and strained my back,’ says Beverley, 58, who lives with her husband near Sevenoaks in Kent. ‘At first, I was prescribed a course of the anti-inflammatory painkiller naproxen and the opioid co- codamol and sent for physiotherapy, but the pain would ease temporarily and then return.
‘It started when I woke — after little sleep — and built up the more I did anything through the day. I also had pain in both my hips, coccyx, left leg and foot.’
Over the years, she tried physio and Pilates to strengthen her abdominal core muscles supporting the spine, which both helped with managing the pain to some degree.
‘At one stage, I was spending £45 a week on physio and £15 a time for weekly Pilates classes,’ she says. ‘Still, my life felt like it was on hold. When socialising with friends, I often had to leave restaurants after an hour, because sitting down was so painful.
‘I would cancel holidays, as I couldn’t face sitting on a plane for hours and sleeping in a bed that might make my back feel worse.’ BY 2010, Beverley’s physiotherapist said they could do no more and referred her to a private consultant neurosurgeon, who prescribed injections of an anaesthetic and steroids into her spine.
‘these gave me some relief, but not for long,’ says Beverley, who has two grown-up children. ‘two years later, I was advised to have surgery, where four of my vertebrae would be fused together with pins. I eventually decided to have only two fused, as I didn’t want to restrict my movement.’
She wasn’t offered it earlier, as doctors are reluctant to carry out this type of surgery except as a last resort, because it limits movement — and the added pressure on the remaining non-fused parts of the spine means these, too, can deteriorate, causing further problems.
Although this surgery provided some relief for years, by 2015 she was in agony again.
She was prescribed tramadol, an opiate similar to morphine, but soon developed a tolerance. ‘I also felt knocked out, so tried not to take more than one 50mg tablet a day at first, although I also took multiple other pills: paracetamol, pregabalin for nerve pain and anti-inflammatories — around 18 tablets a day.’
By early last year, Beverley was taking four tramadol tablets a day. ‘I couldn’t get out of bed without a cocktail of drugs,’ she says.
After being referred to an NHS Pain Clinic at Barts Health trust in London, she saw Dr Serge Nikolic, a consultant in pain medicine, who gave her more painkilling injections in her spine.
they worked initially, but did not work the second time. this was followed by nerve lasering, where radiofrequency energy is used to burn the nerves responsible for ongoing pain, which didn’t help, either.
Her breakthrough came last year when Dr Nikolic suggested the spinal cord stimulator implant.
Here, wires with electrodes are implanted beside the vertebrae in the spine in the epidural space, an area between the dura (a membrane) and the vertebral wall. these are connected to a battery pack that produces a small electrical field, which blocks pain signals to the brain.
Initially, two wires, each with eight electrodes attached, are implanted, guided by X-ray and aligned with a nerve ending. they are then connected to an external battery to stimulate the wires to check it works for the patient. the programmes are personalised for specific pain areas.
the patient uses the device for one to two weeks and is reviewed twice in that time to see if the machine works for them.
‘If they report at least a 50 per cent improvement in pain, we insert a small battery pack the size of a pacemaker through an incision in their buttock and connect it to the wires,’ explains Dr Nikolic. Around 80 per cent of patients who have the device inserted on a trial basis go ahead with the full implant, he adds.
Patients are given an external zapper to control the device and the stimulation’s intensity. the machine operates continuously. Batteries can last ten years or longer and can be replaced in a simple procedure.
Dr Nikolic, who performed Beverley’s operation privately at the London Independent Hospital, says it is for people who have severe chronic pain that limits their daily activity, and have already tried all conservative therapies, such as painkillers or physiotherapy.
He has performed more than 100 implant operations in the past six years and says that 70 per cent of patients experience significant long- term reductions in pain, while 50 per cent are discharged from pain clinics back to their GP’s care.
A review of randomised controlled trials, published by the University of Saskatchewan, Canada, in 2014, concluded the safety, efficacy and cost-effectiveness of spinal cord stimulation was well established in treating chronic pain associated with failed back surgery.
Neurostimulators can also be used to treat nerve damage from diabetes, intractable sciatica ( nerve pain in the legs and buttocks that is not due to disc compression), vascular limb pain caused by blocked arteries which cannot be treated by surgery, chronic angina pain from heart disease with no treatable cause, and arthritis where there is nerve pain.
However, not all patients with back pain are suitable for it, including those with uncorrected bulging discs or deformities.
Side- effects of surgery include infections, while other risks include the leads from the implant moving out of place, or the device can stop working — although these are relatively uncommon.
the implant costs around £20,000 and the total cost for device and surgery is around £35,000 privately, but the NHS has a cheaper tariff.
‘I would argue that it’s costeffective, as it can get people back to work and save on multiple hospital attendances, physiotherapy appointments and prescriptions,’ says Dr Nikolic.
experts from the British Pain Society (BPS) also believe more people could benefit from the implants. Dr Simon thomson, a consultant in pain medicine and neuromodulation at Basildon and thurrock University Hospitals NHS trust and member of the BPS, says patients can face long waits for neuromodulation operations because local Clinical Commissioning Groups (CCGs) won’t fund them at local hospitals.
Instead, CCGs insist patients are referred to large specialised hospitals, where the operations are paid for by NHS england.
‘this isn’t being done because these centres do the operations any better than local hospitals — it is purely a funding issue,’ says Dr thomson. THE result is the waiting list for these operations can be two years or more, when the operations could be done locally much quicker. It’s frustrating that nine years after NICE recommended spinal cord stimulation as an effective treatment and 25 years after I first started implanting these devices that more people are not benefiting.
‘Across the UK, my colleagues and I are currently treating about 1,300 new patients with spinal cord neurostimulation per year when we should be treating ten times that figure — this is a treatment that is proven to be clinically and cost-effective.’
After Beverley’s operation in August 2017, her pain levels dropped dramatically.
‘By day three, I was pain-free,’ she says. ‘I don’t feel any sensation at all from the neurostimulation — it just feels normal.’
She has since flown to visit her son, who lives in Bali — a journey that would previously have left her in agony. She adds: ‘I only wish I’d been referred for this ten years ago.’