Spinal embolization and neurostimulation: indications, stages

Q: What conservative treatment methods exist for failed back surgery syndrome (FBSS)?

Conservative treatment of failed back surgery syndrome includes pharmacotherapy and physical rehabilitation methods. - Nonsteroidal anti-inflammatory drugs (NSAIDs) — used as part of conservative therapy. - Early mobilization — part of the complex of conservative treatment. - Physiotherapy — used as part of conservative therapy. With persistent radicular pain and ineffectiveness of conservative therapy for 6–12 weeks, epidural injections of local anesthetic and corticosteroids may be indicated. Spinal cord stimulation (SCS) may be used when adequate pain relief is not achieved by other appropriate conservative methods.

Stages of spinal embolization

Let us examine the algorithm using the treatment of an aggressive osteoblastoma as an example — a tumor characterized by marked hypervascularization (especially when localized in the posterior structures of the lumbar spine).

Diagnostic stage (angiography). Selective cannulation of the segmental lumbar arteries is performed to precisely visualize the vascular network supplying the neoplasm.
Embolization stage. Bilateral occlusion of the lumbar arteries is performed at both the target lesion level and the superior segment. The following are used for this:
Polyvinyl alcohol (PVA) microparticles, 500 µm in size.
Microcoils (microcoil embolisation), which block blood flow in the main feeding vessels and remain in the body (in situ).
Surgical stage. Due to preliminary embolization, surgery (laminectomy with fixation of the affected segment) can be performed as early as the next day with minimal blood loss.

Neurostimulation and spinal cord stimulation (SCS)

For the treatment of severe radiculopathies, isolated dorsal root ganglion (DRG) stimulation, as well as peripheral nerve stimulation, has proven to be highly effective and safe.

Spinal cord stimulation (SCS) is a minimally invasive and completely reversible procedure. Treatment success directly depends on the correct choice of the electrode placement level (leads), which is determined by the source of pain:

Upper thoracic spine: used for chronic visceral (splanchnic) pain, angina pectoris, and intercostal neuralgia.
Mid-thoracic spine (epidural): optimal for lower back pain and proximal leg pain.
Lower thoracic spine: indicated for patients with refractory sciatica and lower extremity pain.
L1 vertebra level: targets the conus medullaris (conus medullaris) and cauda equina nerve roots (cauda equina). Relieves pain in the pelvic and sacrococcygeal structures.

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Indications for neuromodulation (according to NACC data)

The NACC Committee recommends using neuromodulation techniques in patients with chronic pain syndrome if other adequate conservative treatment methods have failed to provide proper pain relief or have caused intractable side effects.

Specific indications:

Failed Back Surgery Syndrome (FBSS) — SCS should ideally be implanted before attempting revision surgery.
Opioid alternative — stimulation is indicated before converting the patient to long-term systemic sustained-release opioid analgesics.

Complications of SCS systems

Despite being minimally invasive, the overall complication rate during neurostimulation system implantation is 30%–40%.

Hardware issues. The most frequent group of complications. Includes breakage or malfunction of the device itself, as well as electrode migration in the tissues.
Infectious processes. Encountered significantly less frequently (in less than 10% of cases).
Management tactics. The development of the vast majority of these complications requires surgical intervention for explantation (complete removal) of the installed hardware.

Briefly: answers to topical questions

What materials are used for endovascular occlusion during spinal embolization?

Special microparticles and microcoils are used for endovascular occlusion during spinal embolization.

Polyvinyl alcohol microparticles (PVA) — administered via the feeding arteries (e.g., lumbar) at the target and superior levels, measuring approximately 500 µm.
Microcoils (microcoils) — used for reliable occlusion of the main feeding vessels and remain in the body in situ.

Which arteries form the blood supply system of the spinal cord?

The arterial blood supply system of the spinal cord is formed by three main longitudinal arteries and segmental branches.

Anterior spinal artery — supplies the anterior and lateral regions, located in the anterior median fissure.
Posterior spinal arteries — two arteries running posterolaterally and supplying the posterior half of the spinal cord.
Sulcocommissural artery — supplies strictly one half of the segment parenchyma.
Artery of Adamkiewicz (artery of Adamkiewicz) — the largest feeding vessel branching from the aorta.

The feeding vessels also include terminal branches of the subclavian, vertebral, intercostal, lumbar, and iliac arteries.

What conservative treatment methods exist for failed back surgery syndrome (FBSS)?

Conservative treatment for failed back surgery syndrome includes pharmacotherapy and physical rehabilitation methods.

Nonsteroidal anti-inflammatory drugs (NSAIDs) — used as part of conservative therapy.
Early mobilization — included in the complex of conservative treatment.
Physiotherapy — used as part of conservative therapy.

With persistent radicular pain and the ineffectiveness of conservative therapy for 6–12 weeks, epidural injections of a local anesthetic and corticosteroids may be indicated. Spinal cord stimulation (Spinal Cord Stimulation, SCS) can be used if acceptable pain relief is not achieved by other adequate conservative methods.

How to memorize

Electrode levels: Upper — viscera (visceral pain), Middle — back (lower back), Lower thoracic — legs (sciatica), L1 — pelvis and coccyx.

Class and exam questions

How soon after embolization can the main surgery be performed?

Embolization allows surgery (such as laminectomy) to be performed as early as the next day, ensuring minimal blood loss.

What to do if SCS electrode migration or infection occurs?

In most cases, the development of hardware or infectious complications requires surgical explantation (removal) of the system elements.

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What else to study on this topic

Technique of selective cannulation of segmental arteries.
Features of the blood supply to the posterior structures of the lumbar spine.
Mechanism of action of the dorsal root ganglion (DRG) in pain impulse transmission.
Diagnostic criteria for failed back surgery syndrome (FBSS).

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Spinal embolization