Estimulación espinal crónica (EEC) asociada a drogas intratecales en el tratamiento del dolor neuropático refractario. Mecanismos de acción implicados y experiencia clínica en Karolinska Institute (Estocolmo, Suecia)

Gastón Schechtmann; Göran Lind

doi:10.47924/neurotarget2015256

Authors

Gastón Schechtmann Department of Clinical Neuroscience Neurosurgery Section Karolinska Institute and Stockholm University Hospital, Sweden
Göran Lind Department of Clinical Neuroscience Neurosurgery Section Karolinska Institute and Stockholm University Hospital, Sweden

DOI:

https://doi.org/10.47924/neurotarget2015256

Keywords:

neuropathic pain, spinal cord stimulation, baclofen, clonidine

Abstract

Spinal cord stimulation (SCS) is an effective surgical treatment for neuropathic pain refractory to pharmacological therapy. For many patients suffering from this type of chronic pain, SCS is in fact the ultimate treatment option. However, 30 to 40 percent of well selected patients fail to obtain useful pain relief with SCS, and in some patients an initial good analgesic effect diminishes over time. Therefore, the need to improve the efficacy of SCS in these patients, prompted us to perform experimental research in order to advance the comprehension of the underlying mechanisms of SCS and further, to apply this knowledge clinically in order to develop new therapeutic strategies. When SCS is applied to the dorsal columns, multiple neuronal networks may be activated and several neurotransmitters are released in the spinal dorsal horn. This neuronal response to SCS may be regarded as equivalent to in situ drug delivery to the spinal cord in physiological amounts.
The present article describes the analgesic effect of SCS, which partially relies on the activation of the cholinergic and GABAergic systems.
Intrathecal baclofen and clonidine have proven to be effective drugs for neuropathic pain. The concurrent i.t. administration of these drugs and SCS may potentiate the suppressive effect of SCS on mechanical hypersensitivity.
On the basis of experimental studies on SCS performed at Karolinska Institute, a double-blind, placebo-controlled clinical trial was performed, demonstrating that clonidine and baclofen in low intrathecal doses may enhance the analgesic effect of SCS in neuropathic pain, improving also quality of life. A long-term follow-up of a group of patients with combined SCS and clonidine or baclofen treatment revealed that they still enjoyed good pain relief. The present article contributes to the understanding of the mode of action of SCS and it provides a new therapeutic option to enhance the pain relieving effect of SCS by concomitant administration of low doses of intrathecal drugs for patients who obtain insufficient analgesia by SCS alone.

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