In European countries, outside the UK, many patients with refractory angina pain are referred to the implantation of spinal cord stimulator. We do this in our center as well. The studies have shown this method is effective in decrease of pain intensity and improvement if the quality of life (Lanza et al., Neuromodulation 2012; Borjesson, Future Cardiol 2011). But from our experience, these patients may get complicated - electrode displacement, infection, etc. We have had quite good experience within last few years with a following algorithm - 1. US guided stellate ganglion block - if the patients respond - 2. VATS thoracic sympathectomy- Any comments, ideas, experiences?
In my experience these patients are the easy ones with relative little complications with electrode displacement/migrations, infections (extremely rare) etc. The success rate (correct stimulation) in this group is approximately around 95 % compared to the neurogenic pain (65-70 %) and they have also a lot less electrode displacement problems. An option in the group with localized pain is instead DRG-stimulation.
In my opinion there is only little evidence for SCS implantations when compared to other treatment options. The risk of side effects can not be negated. However, the mentioned review states the advantages. Up to date, there are only few trials comparing SCS to other treatments and I agree with the proposed method of neuraltherapy which, from a clinical point of view, could be considered a safe technique and way less invasive. Try a series (at least 6) of ganglion blocks using procaine (1%): 1-2 ml might be enough. This would, at the end, be a nice trial comparing both methods.
I concur with Johannes - the other problem with SCS is that the person is, from that time onwards, a patient of your service. Developing effective coping strategies, understanding that this pain is not an indication of harm, and judicious use of blocks/sympathectomy is far less prone to complications.
Thank for your response. He have slightly changed our algorithm within last 9 months, offering for those patients responsive to the stellate ganglion block, left sided RF percutaneous thoracic sympathectomy instead of the surgical VATS sympathectomy - no need for GA in these risky patients, out-patient procedure, and first six pilot patients showing benefit. We are still offering TENS and subsequent SCS for those patients not responding to the sympathetic blocks.
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