What is Neuromodulation?
Neuromodulation is the use of medication or technology to alter pain signaling in the body with the goal of reducing pain, improving function and positively impacting your overall quality of life. This term often refers to technological devices that are surgically implanted in the body to help with chronic pain problems.
There are various technology options offered at Mayo Clinic which include:
- Spinal Cord Stimulation
- Dorsal Root Ganglion (DRG) Stimulation
- Peripheral Nerve Stimulation
- Pain Pumps (Intrathecal Drug Delivery)
Having access to these different technologies and a variety of vendors allows us to select a therapy that suites your individual needs and gives you the best chance for pain relief and restoration of function.
Patients are generally referred to Pain Medicine to discuss neuromodulation after initial measures of pain control have failed. Your current care team can help to facilitate this referral. The process begins with an appointment in the pain medicine clinic with a neuromodulation expert to evaluate if neuromodulation could be an option for your pain condition and to consider which therapy is most appropriate for your individual needs.
External referring providers may use the online referral process.
Neuromodulation procedures are often covered by insurance policies. You are encouraged to check with your insurance company to verify that Mayo Clinic is within your network and for any prior authorization needs. Billing and Insurance at Mayo Clinic
Coverage is specific to your individual plan and carrier.
Testing Before Neuromodulation Procedures
- Patients have usually had a complete work-up for the underlying cause of their pain by an appropriate specialist and less invasive pain relieving have been trialed.
- Often times, advanced imaging of the spine (MRI or CT scan) is needed to be sure that this it is safe to place the neuromodulation equipment.
- Psychological evaluation will often be ordered by the pain provider and is required by most insurance companies. Do not attempt to complete this ahead of your appointment.
- Each patient's individual health history is also evaluated. Patients with histories of bleeding problems, blood thinning medicines (anti-coagulants), problems with infections, or other serious health problems may warrant further testing and advice from sub-specialty experts.
Spinal Cord Stimulation
A common form of neuromodulation is Spinal Cord Stimulation.
Spinal cord stimulation is a procedure in which small wires are inserted into the spinal canal and connected to a battery. This system delivers small amounts of electricity directly to the pain neurons within the spine (similar to how a pace maker works on the heart). The use of this therapy has been scientifically shown to reduce certain types of pain in many patients. Stimulator implantation is done through a minimally invasive procedure and is reversible. The therapy has been in existence for over 50 years, although the equipment and technology continues to be refined and improved.
If, during your consultation, a spinal cord stimulator is determine to be the best option for you, a procedure will be scheduled for a trial implantation. The trial begins with an outpatient, minimally invasive procedure in which temporary leads will be inserted into your spinal canal. The leads will be attached to an external battery source. The procedure takes approx. 60 minutes to complete and you will be discharged to home following the procedure. The trial leads will remain in place for 1 week; during this time there is an opportunity for program adjustments to obtain optimal pain relief. You will have the opportunity to gauge how stimulation improves your pain levels, functionality, sleep, and other personalized goals.
At the end of the trial period, the temporary leads are removed during an office visit and a shared decision making discussion will occur between you and your provider to determine if permanent implantation is appropriate. If you decide to move forward with the permanent device, you will be scheduled for the outpatient procedure for a future date.
Permanent implantation is very similar to the temporary device insertion; however the leads and battery are fully implanted under the skin. You will see your care team the day following your procedure for programming adjustments and at 10 days post-op for wound check. Additional needs can be addressed by sending a secure message to your care team or via phone call. Patients are given a remote control to make adjustments to their system as needed.
Who is a candidate for this type of stimulator (may include others)
- Ongoing spinal pain after back surgery
- Nerve related pain of the extremities (peripheral neuropathy, diabetic neuropathy, radiculopathy, nerve injury)
- CRPS (complex regional pain syndrome)
- Chronic chest pain (angina)
Connect with others that are asking about Spinal Cord Simulators via the Mayo Connect Discussion Group
- Has anybody had an implantable neurostimulator for chronic pain?
- Has anyone had the STim Wave spine stimulator installed?
- HF 10 Spinal Cord Stimulation Device (relieves back and leg pain)
Dorsal Root Ganglion (DRG) Stimulation
DRG is a version of spinal cord stimulation where the leads are placed to stimulate to dorsal root ganglion rather than the spinal cord itself. The Dorsal Root Ganglion is a small bundle of nerves located near the spinal cord. An advantage of this therapy is targeted stimulation to specific areas of the body. Implantation is similar to spinal cord stimulation including a trial period.
Who is a candidate for this type of stimulator (may include others)
- Foot pain
- CRPS (complex regional pain syndrome)
- Post-inguinal hernia repair pain
- post-knee surgery pain
Connect with others that are asking about DRG via the Mayo Connect Discussion Group
Peripheral Nerve Stimulation
In contrast to spinal cord stimulation which targets an area of pain by stimulating the spinal cord, peripheral nerve stimulation targets an area of pain by stimulating a nerve outside of the spine.
Similar to spinal cord stimulation, the system includes a small wearable stimulator, and a very fine threadlike wire or "lead". The system sends mild electrical pulses directly to the nerves that can reduce pain signals.
In clinical trials, more than 70% of patients reported significant pain relief or improved ability to participate in daily activities.
Trial Period for peripheral nerve stimulation is usually completed via a single nerve block injection. During an outpatient procedural visit, the provider injects a numbing agent into the desired location with the goal to produce a pain relieving response. If the block is successful, a subsequent outpatient procedural visit will be scheduled at which time leads will be placed under your skin via an ultrasound guided, minimally invasive procedure. Following your procedure, initial programming of your device will be performed by your care team. Subsequently, stimulation will be self-adjusted using a remote control.
Removal of the Peripheral Nerve Simulator
At the end of the prescribed therapy period (typically 60 days) your provider will withdraw the lead during an office visit. Some versions of peripheral nerve stimulators are left in place permanently.
Pain pumps are implantable devices that include a small catheter (tube) connected to a pump filled with medication. The pump very accurately delivers small amounts of medication through the tube and into the spinal fluid surrounding the spinal cord. Many different medications can be placed into the pump, although the most common are local anesthetics (numbing medicine), opioids (pain medicine) or baclofen (medication to help with chronic spasms).
Pain pumps are placed using a minimally invasive procedure in which the catheter is placed in the spinal canal using a needle, and the pump is implanted under the skin in the abdomen or flank area. The catheter is then routed under the skin and connected to the pump. Usually patients are kept in the hospital for at least one night to adjust the powerful pain medications while being monitored for any side effects.
Who is a candidate for this procedure?
- Most commonly, intractable cancer related pain
- Others on a case by case basis
The dose of the medication can be adjusted by communicating with the pump through the skin. Close follow-up is needed after pain pump implantation for dose adjustments, observation of any side effects or complications, and refilling of the medication within the pump. The pump refill procedure is completed in the clinic setting by using a needle that can access the pump medication reservoir.
Connect with others via Mayo Clinic Connect Discussion groups
- Pain pump, I have one, how about you
Risks of Neuromodulation Procedures
Overall, the process of implantation is very safe procedure and is completed under an appropriate level of sedation. A discussion about the full risks and benefits will occur during the shared decision making consultation with your provider. The most common risks are rare events and include (but are not limited to):
- lead movement
- infection of the implanted device
- bleeding complications
- nerve injury
Preparing for your procedure
Stimulator procedures are outpatient procedures. This means you will not have an overnight hospital stay. The day of your procedure you will report to your designated location and the nursing team will get you ready for your procedure. The proceduralist will answer any final questions heading to the procedure suite or operating room. You will receive sedation for the procedure. Following the procedure, you will have a brief recovery period and discharged to self-care/home. Most patients typically spend 4-6 hours on the unit from start to finish.
*Pain pump procedures do usually require an overnight hospital stay. You will be transferred from the surgical area to the hospital after you have recovered.
NPO prior to procedures: Please do not eat after midnight before your assigned surgical day. Clear fluids are allowed up to 2 hours before your assigned arrival time.
Driving: A driver will be required following your procedure so please plan accordingly.
Diet: you may resume your normal diet upon discharge from the outpatient unit
Bathing: Specific instructions will be given to your physician team. Expect to have a short period of time with no or limited bathing to allow the wound to heal properly.
Activity: Specific instructions will be given to you by your physician team. Expect to have mild activity limitations for several weeks after a stimulator has been placed.
When should I call the Doctor?
- If you experience a fever of 101.5 degrees Fahrenheit
- If you are having bleeding, increased redness or pus-like drainage on or around your incisions
- Markus (Mark) A. Bendel, M.D.
- Jason Dauffenbach, D.O.
- Jennifer Goins, M.D.
- Jonathan (Jon) Hagedorn, M.D.
- Christine (Christy) Hunt, D.O.
- Narayan R. Kissoon, M.D.
- Tim J. Lamer, M.D.
- William D. Mauck, M.D.
- Susan M. Moeschler, M.D.
- Oludare (Dare) Olatoye, M.D.
- Matthew J. Pingree, M.D.
- Thomas P. Pittelkow, D.O.
Putting Pain in the Past (Sharing Mayo Clinic)
Spine Stimulator for Pain (Mayo Clinic YouTube)
Saying goodbye to chronic pain (Sharing Mayo Clinic)
Defeating Foot Pain with Neurostimulation(Sharing Mayo Clinic)
Spinal cord stimulator sparks pain-free journey to better health (Sharing Mayo Clinic)
Freed from unrelenting pain (Sharing Mayo Clinic)
Spinal cord stimulator ends 17-year battle with chronic pain (Sharing Mayo Clinic)
Back on her feet and free from debilitating back pain thanks to spinal cord stimulator (Sharing Mayo Clinic)