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Spinal Cord Stimulator May be Option for Severe Back Pain

DEAR DR. ROACH: I am an 83-year-old African American female who is contemplating having a neurostimulator implanted in my back. I am a noninsulin diabetic, and my last A1C was 6.7. I had a laminectomy with fusion 15 years ago. I have researched the procedure and found many cons as opposed to pros. What are the risks and prognosis? — S.

ANSWER: Spinal cord stimulators have moderate effectiveness for people with persistent pain after surgery. In studies, stimulators were more likely to give significant pain relief than repeat surgery, and were more effective than standard medical therapy, but the studies may not be applicable for your particular reasons for pain.

Approximately 30% of people will have a complication, such as infection, movement or breakage of the electrical leads, and wound breakdown. They can rarely (less than 1% of the time) cause bleeding, which is an emergency since the spinal cord is a very dangerous place for bleeding.

All my patients who have gone through this have had two procedures: a trial placement (ranging from a few days to a week or so) to determine whether it is helpful, followed by permanent placement if it is.

Spinal cord stimulators should be used only in people with severe pain who are not getting good relief with other treatments, and with full understanding of the relatively high complication rate. People should also know that pain relief can wane over time.

DEAR DR. ROACH: As I understand it, the influenza virus nomenclature is H#N#, where the numbers can be 1 through 9. I may have the letters backward but H defines how the virus enters and N defines how the virus exits the cells.

Here is the stupid question: If we get immunized for all the H1 through H9, why is it necessary to get a flu shot every year? Also, if we have had an H1 flu, aren’t we immune to further H1 strains regardless how they exit? I am tired of being a pin cushion. — R.F.

ANSWER: It’s a bit more complicated. There are 18 subtypes of hemagglutinin, a viral protein that lets the influenza virus attach to target cells, and nine subtypes of neuraminidase, which in addition to opening up the infected target cells to let more flu virus out, allows the virus to move through the mucus in your respiratory tract, making it more effective at causing disease. Certain strains of neuraminidase (N1 and N2) are more virulent than others, even though N3 and N7 may also cause death.

Unfortunately, immunity, whether from natural infection (if you survive) or from the influenza vaccine, is not always long-lasting. Half of people who were infected with the 2009 H1N1 flu lost their antibodies within six months. On the other hand, survivors of the 1918 (Spanish) flu (also H1N1) continued to have protective antibodies 90 years later, and also had immunity to the 2009 strain. It’s not clear why the immunity lasts so long in some strains and not others.

Even within one particular strain of hemagglutinin, the antibodies produced may or may not provide immunity to other strains. The influenza virus is highly adaptable and variable. There has, however, been promising work on a “universal” flu vaccine that may solve the problem we all have, which is that being a pin cushion year after year is the only way to ensure up-to-date immunity, and even that immunity is not perfect, as the particular strain circulating doesn’t always match the strain the vaccine was made for.

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