Effects of Spinal Cord Stimulation in Patients with Chronic Nausea, Vomiting, and Refractory Abdominal Pain

Abstract

Background: Patients with chronic nausea and vomiting often also have chronic abdominal pain. Spinal cord stimulation (SCS) may provide pain control, but scarce data are available regarding the effect of SCS on chronic nausea and vomiting.

Aims: We aimed to determine the effect of SCS in patients with chronic nausea, vomiting, and refractory abdominal pain.

Methods: Retrospective chart review of 26 consecutive patients who underwent SCS trial for a primary diagnosis of nausea, vomiting and refractory abdominal pain.

Results: 26 patients underwent SCS trial, with an average age of 48 years. Twenty-three patients (88.5%) reported > 50% pain relief during the temporary SCS trial and then underwent permanent implantation. Patients were then followed for 41 (22-62) months. At baseline, 20 of the 23 patients (87.0%) reported daily nausea, but at 6 months and the most recent follow-up, only 8 (34.8%) and 7 (30.4%) patients, respectively, had daily nausea (p < 0.001). Days of nausea decreased from 26.3 days/month at baseline to 12.8 and 11.7 days/month at 6 months and at the most recent visit, respectively. Vomiting episodes decreased by 50%. Abdominal pain scores improved from 8.7 to 3.0 and 3.2 at 6 months and the most recent visit, respectively (both p < 0.001). Opioid use decreased from 57.7 mg MSO4 equivalents to 24.3 mg at 6 months and to 28.0 mg at the latest patient visit (both p < 0.05).

Conclusions: SCS may be an effective therapy for long-term treatment of symptoms for those patients afflicted with chronic nausea, vomiting, and refractory abdominal pain.

Keywords: Chronic abdominal pain; Chronic nausea and vomiting; Gastric dysmotility; Spinal cord stimulation.

Fig. 1

Fluoroscopic anterior–posterior view of two different epidural lead placement configurations used in patients with chronic nausea, vomiting, and refractory abdominal pain. a Paresthesia-based placement of two parallel octrode leads at the T4 level. Traditional low-frequency SCS elicited paresthesia responses covered abdominal area with concordant pain. b Two stacked electrode leads placed in fluoroscopically midline position with distal tip at top of T4 vertebral body (right lead) and T5 (left lead) used for high frequency 10 kHz stimulation

Fig. 2

a The average abdominal pain scores (± SEM) from visual analog scale (VAS) with 0 indicting no pain and 10 indicating severe pain are shown at baseline, 6 months, and at the last patient visit after SCS implantation (last visit). Abdominal pain scores decreased significantly at 6 months and at the last patient visit compared with baseline (p < 0.001) (n = 23). b Bar graph showing average abdominal pain scores in the high frequency spinal cord stimulators (10 kHz-SCS) group (n = 12) and the traditional low frequency spinal cord stimulators (Trad-SCS) group (n = 11). Abdominal pain decreased more in the 10 kHz-SCS group, but not statistically significant when compared with Trad-SCS group at 6 months and most recent visit (last visit) (p > 0.2)

Fig. 3

Percent change in reported pain compared with baseline for each patient in the case series is shown at approximately 6 months after implant (a) and during the most recent visit (b). Responders were defined by achievement of greater than 50% pain relief. Overall, 17 of 23 patients were responders. Of the six non-responders, four were low frequency spinal cord stimulators (Trad-SCS) and two were high frequency spinal cord stimulators (10 kHz SCS)

Fig. 4

a Long-term decrease in opioid use as measured in morphine milligram (MSO4 mg) equivalents with all spinal cord stimulator implantations (SCS). Overall reduction of opioid use was more than 50% at last follow-up (p = 0.006 vs. baseline) for all SCS. b Treatment with a high frequency spinal cord stimulator (10 kHz-SCS) resulted in significant reduction in opioid use (p < 0.05) at follow-up visits, both 6 month and last follow-up (last FU), that was not recorded after treatment with low frequency spinal cord stimulators (Trad-SCS). There was no significant difference between 10 kHz-SCS and Trad-SCS in opioid use at baseline, or follow-ups

Fig. 5

Days per month of nausea (a) and vomiting frequency per month (b) at baseline, at 6 months, and the last visit after spinal cord stimulator implantation. The number of days per month of nausea and vomiting frequency per month decreased by 50% or more at 6 months post-implant and this effect persisted without significant difference to the last visit. c Days per month of nausea are shown in patients treated with high frequency spinal cord stimulators (10 kHz) and low frequency spinal cord stimulators (Trad). Treatment with high frequency spinal cord stimulators resulted in significant reduction in days per month of nausea compared with low frequency spinal cord stimulators at 6 months (p = 0.022) and the last visit (p = 0.035)