Novel use of spinal cord stimulation is life-changing for UK geologist
It is hard to say who was happier to see the other when Patrick Gooding, a geologist and senior research scientist at UK, and UK neurosurgeon Dr. Steve Grupke ran into one another at a Fayette County Schools science fair in early February 2018.
“I gave him a ‘man hug,'” said Gooding. He was thrilled to see the doctor who had implanted a spinal cord stimulator in Gooding’s spine in September 2017. The stimulator gives Gooding relief from peripheral neuropathy, a disease caused by nerve damage, in his hips and legs. That surgery was followed in January by the implant of a dorsal root ganglion (DRG) stimulator to quell neuropathic pain in Gooding’s feet. Dr. Jay Grider, medical director for UK HealthCare Pain Services, performed that procedure.
Grupke, too, was happy to see his patient enjoying a family outing, free of the boiling feeling in his feet and legs that peripheral neuropathy can bring. “I just got a kick out of seeing Patrick walking around,” he said.
Show-and-tell at the science fair
Gooding is not a professor, but throughout his life, he has taught others, whether it is explaining geological formations to graduate students and his grandchildren or expounding the importance of preserving geoscience data to members of Congress.
A jovial, gentle giant of a man with a bushy white beard and a warm, lilting accent that speaks to his days growing up on the Caribbean island of Trinidad, Gooding could not pass up the chance to show Grupke’s children their father’s surgical handiwork. So, he held an impromptu show-and-tell as they all sat on tables in the school’s hallway.
After asking their permission, Gooding pulled up the back of his shirt so Grupke could explain his work to his family. Grupke’s 12-year-old son took in the stimulators’ generators – billfold-size squares beneath the skin on each side of Gooding’s spine, just above his hips – and posed a question to Gooding.
“Are you a cyborg?” he asked.
Grupke answered, “Not quite.”
Pain treated with two stimulators
While Gooding is not exactly a cyborg, he is one of the few patients in the United States – and the first treated at UK HealthCare – with two implanted nerve stimulators.
Spinal cord stimulation is not a new treatment, but recent advances have made it more effective.
Depending on the location of a patient’s pain, doctors select an area over the spinal cord to implant an electrode that is connected to a generator or battery under the skin. The electrode delivers a pulse to the spinal cord that disrupts the pain signal and prevents it from going to the brain. Patients can turn their stimulator up or down, depending on their pain level. Gooding uses an iPod to control his.
The second stimulator, the dorsal root ganglion stimulator or DRG, is a new twist on spinal cord stimulation. It operates like the traditional type, but it delivers electrical impulses to the DRG, a bundle of neurons at the base of the spine, outside the spinal cord. DRG stimulation has proven effective in treating neuropathic pain in the feet in situations where traditional stimulation did not work as well.
DRG stimulation is relatively new; UK performed its first DRG stimulation in 2016, becoming the first academic medical center in the Southeast to do so, according to Grider.
Such advances are impressive, especially considering how they are changing the lives of patients like Gooding.
A love of action and competition
Being hobbled by neuropathic nerve pain is hard on anyone, but especially someone as active as Gooding.
He grew up in a household of sports-minded, highly competitive siblings. At 16, he was six foot, three inches tall, 260 pounds and strong. He played water polo, cricket, tennis and soccer and could hurl a discus, javelin, hammer and shot such distances that he became the national record holder in those events. Gooding made the Trinidad and Tobago Olympic Team in 1968 and won a track and field scholarship to the University of Wisconsin.
Later, he transferred to Eastern Kentucky University, where he earned his degrees before coming to UK. He married his wife, Betty, in 1973, and in 1987, he became a U.S. citizen.
Sports helped fund his education but also wore down his joints, already inclined to arthritis, a trait handed down from his mother’s side of the family.
“I tell him his scholarships didn’t come cheap,” said Kevin Curtsinger, an outpatient clinic coordinator for the UK Outpatient Physical and Occupational Therapy Clinic. Curtsinger has worked with Gooding through multiple rehabilitations after joint problems and surgeries.
Gooding’s professional life has also brought physical wear and tear. Now 66, he celebrated 40 years at the Kentucky Geological Survey in 2017. He manages the survey’s Well Sample and Core Library, where 22 million vertical feet of core samples and well drillings are stored and used for research. His work has required heavy lifting from time to time, as well as long walks across uneven farm fields and mountain hillsides to oversee the collection of core samples across the state.
With age, joints degenerate
In his 40s, Gooding began to realize that the joint problems that plagued his mother and aunts would be an issue for him too. “I always felt I would not let the arthritis get to me,” he said. But it did.
After every surgery, he devoted himself to regaining his strength. In addition to therapy with Curtsinger after knee replacements, he devised his own rehab, a water exercise class at the YMCA’s warm-water pool. “I was 55, in class with 80 and 90-year-olds.”
But eight years ago, in his late 50s, he began to experience a pain he could not power through. It hit him hard at a national geologists conference, after many hours of walking around a convention center and attending receptions. His hips and thighs began to burn intensely, a signal of the nerve damage that’s indicative of peripheral neuropathy.
Back home, Gooding was referred to Grider, who gave him steroid injections in his spine, a conservative measure that’s often the first course of treatment for such cases.
“He really did well with epidurals for years,” said Grider. “But about two years ago, they just started to last shorter and shorter intervals until he just wasn’t getting the benefit out of it.”
It is not unusual for injections to become less effective. “For one, people respond to steroids variably,” said Grider. “But also, in Patrick’s case, he has a slowly progressive disease so what got you through in your late 50s might not work in your mid-60s.”
Presented with two options – possible back surgery or spinal cord stimulation – Gooding chose stimulation. Grider explained its advantages to Gooding, as he does with all patients who might benefit from it.
“The great thing about stimulation is that unlike hip, back or knee surgery, you get to try this on during a trial period,” said Grider. “You have it implanted temporarily – it takes about 15 to 20 minutes to do in the office – and you get to see how it does so you have some idea of what you are buying before you have it.”
He added: “Another beauty of these systems is that even if you have it implanted and four to five years out, things continue to evolve and it stops working for you, taking it out is easy and your spine is left exactly as you found it.”
Trials are done with patients mildly sedated so they can respond to the physician’s questions about where the electrical impulses are most effective along the spine. Sometimes, patients are a little uncomfortable during the procedure, although few remember it later. Gooding, for example, felt extremely hot. He appreciated a kind nurse, who got wet towels to cool him off.
“I told them, ‘Now I know what a hot flash feels like,’” he said. Despite his temporary discomfort, like most patients Gooding got immediate relief from his pain.
“Man, with the implant, I felt so good. I begged them to let me keep it over the weekend.” His appeal worked and he got to keep the trial stimulator a couple of extra days.
Several weeks later, Gooding received a permanent implant, which worked well until he took a fall about a year later. His pain returned with a vengeance, so intense that he showed up at Grider’s office first thing on a Monday morning to see if he could get in to see the doctor. Staff squeezed him in that afternoon.
It was determined that the stimulator was no longer working, but at the same time, Gooding had developed new issues. He weaved when he walked and his legs were weak. After tests showed no problems with the structure of his spine, he was referred to Grupke, who does permanent spinal cord stimulator implants. Grider refers about 30 percent of his patients who have done well in trial to Grupke.
Two stimulators tackle neuropathic pain
Grupke determined that Gooding needed a new spinal cord stimulator to ease the pain in his hips and thighs. Gooding was sedated while Grupke performed surgery, implanting a generator and drilling off a sliver of bone to reach the back of the spine, where he implanted a paddle lead containing 16 electrodes. Those electrodes short-circuited the pain pathway.
When stimulators are implanted and when patients return for follow-ups, representatives from the companies that make the devices are on hand to help patients learn how to use the controls and adjust them. Gooding has gotten to know his rep well and has his phone number handy when questions or problems arise.
The new device worked well for Gooding’s hip and leg pain but did not help his feet, where the neuropathic pain had become nearly unbearable. “He would say, ‘My feet. They are burning!’” said Grider.
Grider performed a trial for a DRG stimulator, and Gooding responded well. It worked so well that Gooding asked Jennifer Fahrson, who schedules procedures for Grider, if she could get him in as soon as possible for a permanent DRG implant. It is a request Fahrson hears a lot.
“The biggest thing is to try to get them in as soon as possible,” she said. “I understand they are in pain, and then they have that brief little timeframe of being pain-free when we have the trial. Then, we take the leads away and tell them it is going to be another month or six weeks before we can give that back to them, and I hate to do that to them.”
Fahrson was able to schedule Gooding’s surgery several weeks earlier than expected. This is not always easy or possible given the many issues that must be resolved before a procedure: finding a slot in a tight surgery schedule; getting approval from insurers; reviewing results from presurgical tests; and getting OKs from a patient’s other physicians to temporarily take them off medications such as blood thinners.
Thanks to the dual spinal cord stimulators, Gooding is now free of leg and foot pain. His family physician, Dr. Tina Fawns, expects his overall health to also improve. Fawns treats not only Gooding, but also his wife, Betty, and sister, Patricia, who lives with the Goodings and has Down syndrome. The three come to each other’s appointments to listen and to chime in with thoughts and information.
One of Fawns’ goals for Patrick Gooding is to improve his A1c test results through diet and exercise. The test measures the level of hemoglobin A1c in the blood to determine average blood sugar levels for the preceding two to three months. Gooding has lost 85 pounds over the past year.
Type 2 diabetes, which runs in his family, often contributes to the nerve damage that results in the peripheral neuropathy. Fawns is pleased he will no longer need some of the medications used to treat neuropathic pain. She has closely monitored Gooding’s surgical incisions and other injuries, including a serious wound he suffered when he impaled himself with a stick while doing yard work. Fawns removed stitches when that serious wound healed and referred him to Wound Care for treatment.
She describes Gooding as a model patient, hampered in his efforts to stay healthy by extreme pain. “By far, he is his best advocate,” she said. “He has a very positive attitude and is compliant with treatment and going to physical therapy. But he was really discouraged because until he got the stimulator he wasn’t able to exercise like he wanted to.”
She added: “After he got his stimulators, he could start doing more physical therapy and walking, and he got more motivated with his diet. So I think it all played a role – when he was not able to participate in his care, it affected everything.”
Strengthened through physical therapy
His successful treatment is also allowing Gooding to rebuild his strength through physical therapy, and by early 2018, he was again having regular sessions with Curtsinger. Curtsinger’s role has always been important – his physical evaluations have helped doctors determine when Gooding needed different and sometimes more aggressive treatment for his pain.
Like Fawns, Curtsinger has come to know not only Gooding but his family. “We are good friends – him, his wife and his sister. It is more than just patient-provider relationship with us,” Curtsinger said. “I have a relationship with my patients as they go through different stages in life. They are in and out of here for different conditions over the years. I sometimes say they are never gone from therapy, they are just taking a small vacation.”
Speaking of vacations, Gooding now looks forward even more to family trips to the beach, his favorite destination. “Our whole life revolved around the beach,” he said of growing up on an island. Able to walk and stand for long periods without pain, he will also be more of force at conferences of the American Association of Petroleum Geologists; he’s a leader of the organization now, president of its Eastern Section.
Freed of neuropathic pain, the simplest of things bring sustenance. A couple of months after his last surgery, he told Betty, “I am going to do some major cooking on Saturday.” He spent the day, standing on feet and legs that no longer cause him pain, happily churning out pots of chili and chicken curry for his family.