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Spinal Cord Stimulator Implant
Introduction
Spinal cord stimulators are designed to treat chronic pain. The implantable device offers a nonpharmacological approach to various pain conditions. Stimulators have been used for the treatment of both neuropathic and ischemic pain. Spinal cord stimulator implantation is usually reserved for patients who have failed various forms of conservative and pharmacological treatment options. After a percutaneous trial, a permanent stimulator is installed. Patients can have long-lasting pain relief following the procedure. There are various indications for implanting a stimulator, but it is most commonly done following failed back surgery. Although severe complications following the installation of a spinal cord stimulator are rare, they can be significant. Various types of stimulators and electrical impulses are used to provide pain relief.
Further research will determine if one type of stimulator is superior compared to another. Many insurance companies require psychological screening before the placement of the stimulator. Mental healthcare disorders are associated with worse outcomes after spinal cord stimulator implantation.[1][2] Chronic monitoring of the patient following implantation, including adjustment to the stimulator settings and battery replacement is often necessary. Revision of the stimulator implantation is very common secondary to lead migration and breakage.
Anatomy and Physiology
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Anatomy and Physiology
Spinal cord stimulator leads are placed within the epidural space. The dura mater lies anteriorly and the vertebral wall posteriorly to the epidural space. Blood vessels, lymph nodes, and fat also make up the posterior wall. The epidural space anatomically lies within the dural sac. Nerve roots are bathed with cerebrospinal fluid lie within the sac. The epidural space is at its fullest at the L2 vertebra; it starts superiorly with the base of the skull at the foramen magnum, then descends inferiorly until the sacrum at the sacral hiatus. Stimulator leads can be implanted within the level of cervical, thoracic, lumbar vertebra, and the sacrum. Electrical signals, either persistent our pulsatile, are applied to the epidural space once the spinal cord stimulator is installed.
Spinal cord stimulators function by neuromodulating the spinothalamic tract within the spinal cord. The spinothalamic tract regulates pain. When this pathway becomes disrupted as in the case of chronic pain, it is said to be dysregulated.[3] A spinal cord stimulator suppresses neurons within the dorsal horn of the spinal cord. These are known as dynamic range neurons.[4][5][6] The implant has been shown to be effective in reducing pain through the descending inhibitory pathways as well. Thus stimulators affect pain by both peripheral and central mechanisms.[7][8]
Indications
Ischemic back pain, such as symptomatic peripheral vascular disease and refractory angina, are possible indications for spinal cord stimulation implantation in inoperable cases. Spinal cord stimulators can improve New York Heart Association (NYHA) classification and enhance the quality of life.
Separately, failed back surgery syndrome is the most common indication for spinal cord stimulator implant. Spinal cord stimulation is an effective analgesic. Implantation is used for persistent radicular pain following surgery.[9][10][11]
Implantation of a stimulator is more effective than medical treatment for greater than fifty percent pain reduction for a multitude of chronic pain disorders, including diabetic neuropathy, chronic back pain, peripheral vascular pain (ischemic pain), failed back surgery syndrome, complex regional pain.[12] Stimulators have also been used for HIV-related polyneuropathy.[13]
Contraindications
Pacemakers and defibrillators are often compatible with spinal cord stimulator implants. However, a history of a prior pacemaker or cardiac defibrillator requires the approval of stimulator implantation by a cardiologist before the procedure. Having either a pacemaker or defibrillator remains a relative contraindication to the implant. Both devices require close follow up following stimulator implants.[14][15][16] Severe thrombocytopenia or uncontrolled coagulopathy are also contraindications to stimulator implant due to increased risk of a spinal epidural hematoma. Active infection is an absolute contraindication to implantation of a spinal cord. There is limited information regarding stimulator implantation in a pregnant patient.[17] Although, given the need for fluoroscopy to guide the procedure, the procedure is almost always postponed until birth.
Equipment
The equipment needed for spinal cord stimulator implantation includes stimulation leads, a cable to connect the leads to a generator, and an implantable pulse generator. The pulse generator’s electrical impulse can be modified to help provide pain relief. There are various types of generators. Paresthesia-based and paresthesia-free (high frequency or burst) stimulators are two types of generators.[18] Anesthetic (bupivacaine), spinal needed for local anesthetic as well. Patients elect to feel paresthesias in the area of pain (paresthesia-based), while others may not (paresthesia-free). Cylindrical leads are often used for percutaneous implantation of a spinal cord stimulator. The patient is also given a programmer for their spinal cord stimulator. Typically there are a few programmed settings following the procedure that can be adjusted on follow up.
Personnel
- Primary care provider
- Pain medicine specialist
- First assistant for the spinal cord implantation.
- Nursing team
- Anesthesiologist
Preparation
The management of antiplatelet and anticoagulant medications should be discussed with the primary medical team prior to implantation. Patients taking anticoagulants may be at increased risk of developing spinal epidural hematomas.[19] A successful trial of the spinal cord stimulator is required before permanent implantation. The trial determines the efficacy and patient tolerance before permanent placement. Trials are done as an outpatient procedure under fluoroscopy to determine proper lead placement. Furthermore, percutaneous trials are done with a local anesthetic. Permanent implantation typically requires operative anesthesia care. The goal is often to limit the patient's pain without completing masking it for correct lead placement during implantation. The consensus on appropriate trial length, on average, lasts three to seven days.
Technique or Treatment
Stimulators that are paraesthesia based or paraesthesia free are the two main types of stimulators. There are persistently activated stimulators, high frequency, and burst stimulators. Electrical impulse control determines either persistent or tonic delivery.[20][21] Closed-loop evoked action potential stimulation is a type of stimulator that uses an algorithm to determine the frequency and pulse amplitude. This type of stimulator is persistently adjusting settings based on neural input. Spinal cord stimulators can be either chargeable or non-rechargeable. There are also stimulators being developed that are wireless. However, more studies need to be determined by their efficacy.[22] Chargeable stimulators charge through the patient's skin. Non-rechargeable batteries have a shorter battery life compared to rechargeable, four to seven years, and ten years respectively. Most of the current spinal cord stimulator generators are MRI compatible. Alternatively, older model safety should be reviewed before getting an MRI.
The technique of installation is relatively comparable from one type of stimulator to another. When surgical leads are placed, it is typically done with spinal anesthesia using bupivacaine. Paresthesia testing can still be complete despite the anesthesia.[23] If necessary, general anesthesia can be used. Yet, general anesthesia increases the risk of catastrophic injury during stimulator implantation. Paresthesia free stimulators do not require patient feedback during the procedure. The frequencies of stimulation can be changed on the generator during the procedure. Both low frequency and high-frequency stimulation has been studied.[24][25][26][27] High-frequency stimulators are less energy-efficient and may require battery replacement more frequently compared to other settings.
Stimulator implantation requires fluoroscopy to determine proper lead placement. Lead placement depends on the location of the patient's back pain. A small cut is made to insert an epidural needle and to insert the leads. For example, in the case of chronic low back pain, the leads would be placed at the levels of T8 to L1. For neck pain, the leads are positioned above C3 in the epidural space.[28][14][29] In a trial, the temporary percutaneous leads are connected to an external generator for three to seven days. If successful, a permanent stimulator is installed. Permanent implantation is typically complete one to two weeks following the trial run.[14][30][31][32][33] The leads are anchored after their insertion and confirmed correct placement via fluoroscopy. The topography of the patient's pain correlates with lead placement. Thus the goal of successful implantation is at least 80 percent overlap with the area of the patient's pain and lead coverage. A tunnel track, created during the permanent procedure, connects the generator to the leads. The stimulator leads are tunneled to the generator via an extension cable. A second cut is made for the generator to reside.
Complications
The complication rate following spinal cord stimulator implantation is relatively high, between 5.3 to 40 percent of cases. The majority are due to the hardware malfunction, such as lead migration, requiring revisions.[34][14] Lead migration is the sudden loss of pain coverage, due to the change of location of one or both of the leads. When this occurs, the leads are often anchored.[30][35] Anchoring devices have been developed to minimize lead migration.[36][37] Lead migration occurs more often in the cervical vertebra rather than more inferior secondary to the increased range of motion of the neck.[29][38] Lead fractures can occur in above nine percent of cases.[14][39][40] Strenuous physical activity can cause a lead fracture.[41] Seromas can occur postoperatively, many resolves spontaneously but can require incision and drainage.[30][42] Infections range between two to twelve percent of cases one year following implantation.[43][44][45] Dural puncture causing as a cerebrospinal fluid leak can occur, but it is rare. The puncture of the dura can occur during lead placement, with headaches occurring in up to 70 percent of cases. Refractory cases require a blood patch for treatment.[46][47] Spinal epidural hematoma is a medical emergency requiring urgent neurosurgical intervention. The hematoma must be decompressed. Luckily, spinal epidural hematomas and spinal cord trauma are extremely rare following stimulator implantation. In 20 to 40 percent of patients with a spinal cord stimulator, tolerance develops. The effectiveness of the stimulator to provide adequate pain relief decreases over time.[48] An estimated eight percent of stimulators are explanted, the majority due to inadequate pain relief.[49][46][30]
Clinical Significance
Pain relief can continue for even weeks after a stimulator has been turned off.[50][51] Pain thresholds reduction has both been seen in EEG finds, as well as somatosensory evoked potentials following stimulator implantation.[52][3] Interestingly, not every type of stimulator works on both the peripheral nervous system and supraspinal mechanisms. For example, high-frequency spinal cord stimulation does not work via a central mechanism.[4] For patients who received a stimulator secondary to ischemic pain, stimulators have been shown to improve oxygen supply and demand, by improving blood flow to help improve pain.[50][51] Stimulators also work as vasodilators to improve ischemic pain via sympathetic nervous system activation.[53] High frequency, as well as burst spinal cord stimulation, have been efficacy in pain reduction compared to traditional stimulation [12]. Although not traditionally used for axial skeleton pain, stimulators are being studied in their use.[54][25][26][55] Small studies have assessed the use of a stimulator for painful diabetic neuropathy and persistent perineal pain.[56][57] Spinal cord stimulators are up to 85 percent effective if placed within two years after the onset of the patient’s pain. Patients with at least a 15-year history of chronic pain were found to find stimulators helpful to provide pain relief in only nine percent of cases.[36] Paresthesia free stimulators have also been shown to improve back pain.[20] High-frequency spinal cord stimulators have been used for various types of back pain. They are more than than 70 percent effective for greater than 50 percent pain relief on six months followup.[26] A burst stimulator (paresthesia free) is more effective in the treatment of neuropathic pain than standard paresthesia inducing stimulators. Paresthesia free stimulators were shown to be preferred to conventional stimulators by over 70 percent of patients at one year follow up.[18] Over 80 percent of patients will likely need an MRI within five years of implantation of their spinal cord stimulator, often due to lead migration.[58] Migration is widespread in the early post-procedure period.
Enhancing Healthcare Team Outcomes
Spinal cord stimulator implantation is an outpatient procedure and can provide pain relief to patients with various chronic pain syndrome. The procedure has minimal serious complications, but lead migration and breakage are common. It is imperative to identify the risk factors to the procedure and perform a thorough mental health assessment of the patient before any surgery. A team approach is an ideal way to limit the complications of this procedure. Before and following surgery, the patient should have the following done:
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Evaluation of the patient's back pain and symptoms of peripheral neuropathy by the primary care provider. Conservative management options should be exhausted before stimulator implantation.
- Workup and treatment of the primary pain complaint often include the need for further evaluation by a neurologist, orthopedic surgeon, or neurosurgeon.
- Following unsuccessful back surgery, the surgeon should address the possible need for a spinal cord stimulator for pain further pain relief.
-
A pain medicine specialist should be consulted for spinal cord stimulator implantation.
- An interprofessional team should address comorbid mental health disorders before implantation of the stimulator.
-
Before implantation, anticoagulation is typically held. The duration of holding anticoagulation should be coordinated with the primary care team, and for high-risk patients, the patient's cardiologist.
-
Patients with pacemakers and cardiac defibrillators require approval by cardiology before stimulator implantation.
- Postoperative complications should be monitored closely, including postoperative infection and spinal epidural hematoma formation.
- Following implantation, stimulator settings should be adjusted to provide optimal pain relief.
Nursing, Allied Health, and Interprofessional Team Interventions
Mental health disorders must be optimized before spinal cord stimulator implantation. Comorbid major depressive disorder and generalized anxiety disorder are prevalent comorbidities associated with chronic pain. The treatment of underlying anxiety and depression can have a lasting impact on the efficacy of a spinal cord stimulator and the treatment of the primary pain disorder. A primary care provider, cognitive-behavioral therapist, and psychiatrist are often needed to address the patient's mental healthcare. Both pharmacological and nonpharmacological treatment options are often necessary.
Many patients who are candidates for a spinal cord stimulator suffer from failed back surgery syndrome. Coordination of care between the primary care provider, orthopedic or neurosurgeon, and the pain medicine physician is needed.
Nursing, Allied Health, and Interprofessional Team Monitoring
- Following implantation of the spinal cord stimulator, the healthcare team must be cognitive of lead migration over time, as well as the possible need for further adjustments of the settings of the stimulator to maximize pain relief.
- Complications following the procedure should be monitored closely, especially in the first few weeks postoperatively.
- For patients with a cardiac defibrillator or pacemaker, they should be monitored by cardiology following spinal cord stimulator implantation, in case of malfunction of the devices.
- If there is a concern for lead migration, such as a sudden reduction in pain relief following stimulator implantation. X-rays should be obtained to determine the stimulator lead location (AP and lateral views).
- Postoperative follow up after implantation usually occurs one week after the procedure. Close monitoring and adjustments of the stimulator settings following the procedure are routine.
References
Celestin J, Edwards RR, Jamison RN. Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis. Pain medicine (Malden, Mass.). 2009 May-Jun:10(4):639-53. doi: 10.1111/j.1526-4637.2009.00632.x. Epub [PubMed PMID: 19638142]
Level 1 (high-level) evidenceParoli M, Bernini O, De Carolis G, Tollapi L, Bondi F, Martini A, Dario A, Paolicchi A. Are Multidimensional Pain Inventory Coping Strategy Profiles Associated with Long-Term Spinal Cord Stimulation Effectiveness? Pain medicine (Malden, Mass.). 2018 May 1:19(5):1023-1032. doi: 10.1093/pm/pnx106. Epub [PubMed PMID: 28549170]
Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Ramesh R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectronic medicine. 2019 Jun 28:5():. doi: 10.1186/s42234-019-0023-1. Epub [PubMed PMID: 31435499]
Chakravarthy K, Kent AR, Raza A, Xing F, Kinfe TM. Burst Spinal Cord Stimulation: Review of Preclinical Studies and Comments on Clinical Outcomes. Neuromodulation : journal of the International Neuromodulation Society. 2018 Jul:21(5):431-439. doi: 10.1111/ner.12756. Epub 2018 Feb 12 [PubMed PMID: 29431275]
Level 2 (mid-level) evidenceSchechtmann G, Song Z, Ultenius C, Meyerson BA, Linderoth B. Cholinergic mechanisms involved in the pain relieving effect of spinal cord stimulation in a model of neuropathy. Pain. 2008 Sep 30:139(1):136-145. doi: 10.1016/j.pain.2008.03.023. Epub 2008 May 9 [PubMed PMID: 18472215]
Level 3 (low-level) evidenceSdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain practice : the official journal of World Institute of Pain. 2018 Nov:18(8):1048-1067. doi: 10.1111/papr.12692. Epub 2018 Apr 23 [PubMed PMID: 29526043]
Linderoth B, Foreman RD. Conventional and Novel Spinal Stimulation Algorithms: Hypothetical Mechanisms of Action and Comments on Outcomes. Neuromodulation : journal of the International Neuromodulation Society. 2017 Aug:20(6):525-533. doi: 10.1111/ner.12624. Epub 2017 May 31 [PubMed PMID: 28568898]
Level 3 (low-level) evidenceSong Z, Ultenius C, Meyerson BA, Linderoth B. Pain relief by spinal cord stimulation involves serotonergic mechanisms: an experimental study in a rat model of mononeuropathy. Pain. 2009 Dec 15:147(1-3):241-8. doi: 10.1016/j.pain.2009.09.020. Epub [PubMed PMID: 19836134]
Level 3 (low-level) evidenceNorth RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005:56(1):98-106; discussion 106-7 [PubMed PMID: 15617591]
Level 1 (high-level) evidenceEldabe S, Kumar K, Buchser E, Taylor RS. An analysis of the components of pain, function, and health-related quality of life in patients with failed back surgery syndrome treated with spinal cord stimulation or conventional medical management. Neuromodulation : journal of the International Neuromodulation Society. 2010 Jul:13(3):201-9. doi: 10.1111/j.1525-1403.2009.00271.x. Epub 2010 Feb 22 [PubMed PMID: 21992833]
Level 2 (mid-level) evidenceNorth RB, Kidd DH, Zahurak M, James CS, Long DM. Spinal cord stimulation for chronic, intractable pain: experience over two decades. Neurosurgery. 1993 Mar:32(3):384-94; discussion 394-5 [PubMed PMID: 8455763]
Lamer TJ, Moeschler SM, Gazelka HM, Hooten WM, Bendel MA, Murad MH. Spinal Stimulation for the Treatment of Intractable Spine and Limb Pain: A Systematic Review of RCTs and Meta-Analysis. Mayo Clinic proceedings. 2019 Aug:94(8):1475-1487. doi: 10.1016/j.mayocp.2018.12.037. Epub 2019 Jul 3 [PubMed PMID: 31279543]
Level 1 (high-level) evidenceKnezevic NN, Candido KD, Rana S, Knezevic I. The Use of Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy. Pain physician. 2015 Jul-Aug:18(4):E643-50 [PubMed PMID: 26218955]
Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Thomson S, Raso L, Burton A, DeAndres J, Buchser E, Buvanendran A, Liem L, Kumar K, Rizvi S, Feler C, Abejon D, Anderson J, Eldabe S, Kim P, Leong M, Hayek S, McDowell G 2nd, Poree L, Brooks ES, McJunkin T, Lynch P, Kapural L, Foreman RD, Caraway D, Alo K, Narouze S, Levy RM, North R, Neuromodulation Appropriateness Consensus Committee. The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation : journal of the International Neuromodulation Society. 2014 Aug:17(6):571-97; discussion 597-8. doi: 10.1111/ner.12206. Epub [PubMed PMID: 25112891]
Level 3 (low-level) evidenceBuchser E, Durrer A, Albrecht E. Spinal cord stimulation for the management of refractory angina pectoris. Journal of pain and symptom management. 2006 Apr:31(4 Suppl):S36-42 [PubMed PMID: 16647595]
Andréll P, Yu W, Gersbach P, Gillberg L, Pehrsson K, Hardy I, Ståhle A, Andersen C, Mannheimer C. Long-term effects of spinal cord stimulation on angina symptoms and quality of life in patients with refractory angina pectoris--results from the European Angina Registry Link Study (EARL). Heart (British Cardiac Society). 2010 Jul:96(14):1132-6. doi: 10.1136/hrt.2009.177188. Epub 2010 May 18 [PubMed PMID: 20483898]
Level 2 (mid-level) evidenceFedoroff IC, Blackwell E, Malysh L, McDonald WN, Boyd M. Spinal cord stimulation in pregnancy: a literature review. Neuromodulation : journal of the International Neuromodulation Society. 2012 Nov-Dec:15(6):537-41; discussion 541. doi: 10.1111/j.1525-1403.2012.00448.x. Epub 2012 Apr 11 [PubMed PMID: 22494315]
Level 3 (low-level) evidenceDeer T, Slavin KV, Amirdelfan K, North RB, Burton AW, Yearwood TL, Tavel E, Staats P, Falowski S, Pope J, Justiz R, Fabi AY, Taghva A, Paicius R, Houden T, Wilson D. Success Using Neuromodulation With BURST (SUNBURST) Study: Results From a Prospective, Randomized Controlled Trial Using a Novel Burst Waveform. Neuromodulation : journal of the International Neuromodulation Society. 2018 Jan:21(1):56-66. doi: 10.1111/ner.12698. Epub 2017 Sep 29 [PubMed PMID: 28961366]
Level 1 (high-level) evidenceGhaly RF, Lissounov A, Candido KD, Knezevic NN. Are there a guidelines for implantable spinal cord stimulator therapy in patients using chronic anticoagulation therapy? - A review of decision-making in the high-risk patient. Surgical neurology international. 2016:7():33. doi: 10.4103/2152-7806.179855. Epub 2016 Apr 7 [PubMed PMID: 27127698]
Maheshwari A, Pope JE, Deer TR, Falowski S. Advanced methods of spinal stimulation in the treatment of chronic pain: pulse trains, waveforms, frequencies, targets, and feedback loops. Expert review of medical devices. 2019 Feb:16(2):95-106. doi: 10.1080/17434440.2019.1567325. Epub 2019 Jan 21 [PubMed PMID: 30625000]
De Ridder D, Vanneste S, Plazier M, van der Loo E, Menovsky T. Burst spinal cord stimulation: toward paresthesia-free pain suppression. Neurosurgery. 2010 May:66(5):986-90. doi: 10.1227/01.NEU.0000368153.44883.B3. Epub [PubMed PMID: 20404705]
Weiner RL, Yeung A, Montes Garcia C, Tyler Perryman L, Speck B. Treatment of FBSS Low Back Pain with a Novel Percutaneous DRG Wireless Stimulator: Pilot and Feasibility Study. Pain medicine (Malden, Mass.). 2016 Oct:17(10):1911-1916 [PubMed PMID: 27125284]
Level 2 (mid-level) evidenceLind G, Meyerson BA, Winter J, Linderoth B. Implantation of laminotomy electrodes for spinal cord stimulation in spinal anesthesia with intraoperative dorsal column activation. Neurosurgery. 2003 Nov:53(5):1150-3; discussion 1153-4 [PubMed PMID: 14580282]
Shechter R, Yang F, Xu Q, Cheong YK, He SQ, Sdrulla A, Carteret AF, Wacnik PW, Dong X, Meyer RA, Raja SN, Guan Y. Conventional and kilohertz-frequency spinal cord stimulation produces intensity- and frequency-dependent inhibition of mechanical hypersensitivity in a rat model of neuropathic pain. Anesthesiology. 2013 Aug:119(2):422-32. doi: 10.1097/ALN.0b013e31829bd9e2. Epub [PubMed PMID: 23880991]
Level 3 (low-level) evidenceKapural L, Yu C, Doust MW, Gliner BE, Vallejo R, Sitzman BT, Amirdelfan K, Morgan DM, Brown LL, Yearwood TL, Bundschu R, Burton AW, Yang T, Benyamin R, Burgher AH. Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: The SENZA-RCT Randomized Controlled Trial. Anesthesiology. 2015 Oct:123(4):851-60. doi: 10.1097/ALN.0000000000000774. Epub [PubMed PMID: 26218762]
Level 1 (high-level) evidenceVan Buyten JP, Al-Kaisy A, Smet I, Palmisani S, Smith T. High-frequency spinal cord stimulation for the treatment of chronic back pain patients: results of a prospective multicenter European clinical study. Neuromodulation : journal of the International Neuromodulation Society. 2013 Jan-Feb:16(1):59-65; discussion 65-6. doi: 10.1111/ner.12006. Epub 2012 Nov 30 [PubMed PMID: 23199157]
Russo M, Van Buyten JP. 10-kHz High-Frequency SCS Therapy: A Clinical Summary. Pain medicine (Malden, Mass.). 2015 May:16(5):934-42. doi: 10.1111/pme.12617. Epub 2014 Nov 7 [PubMed PMID: 25377278]
Level 3 (low-level) evidenceBarolat G, Massaro F, He J, Zeme S, Ketcik B. Mapping of sensory responses to epidural stimulation of the intraspinal neural structures in man. Journal of neurosurgery. 1993 Feb:78(2):233-9 [PubMed PMID: 8421206]
Vallejo R, Kramer J, Benyamin R. Neuromodulation of the cervical spinal cord in the treatment of chronic intractable neck and upper extremity pain: a case series and review of the literature. Pain physician. 2007 Mar:10(2):305-11 [PubMed PMID: 17387353]
Level 3 (low-level) evidenceKumar K, Buchser E, Linderoth B, Meglio M, Van Buyten JP. Avoiding complications from spinal cord stimulation: practical recommendations from an international panel of experts. Neuromodulation : journal of the International Neuromodulation Society. 2007 Jan:10(1):24-33. doi: 10.1111/j.1525-1403.2007.00084.x. Epub [PubMed PMID: 22151809]
Stojanovic MP, Abdi S. Spinal cord stimulation. Pain physician. 2002 Apr:5(2):156-66 [PubMed PMID: 16902666]
Van Buyten JP, Van Zundert J, Milbouw G. Treatment of failed back surgery syndrome patients with low back and leg pain: a pilot study of a new dual lead spinal cord stimulation system. Neuromodulation : journal of the International Neuromodulation Society. 1999 Nov:2(4):258-65. doi: 10.1046/j.1525-1403.1999.00258.x. Epub [PubMed PMID: 22151259]
Level 3 (low-level) evidenceLinderoth B, Foreman RD. Physiology of spinal cord stimulation: review and update. Neuromodulation : journal of the International Neuromodulation Society. 1999 Jul:2(3):150-64. doi: 10.1046/j.1525-1403.1999.00150.x. Epub [PubMed PMID: 22151202]
Hayek SM, Veizi E, Hanes M. Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database. Neuromodulation : journal of the International Neuromodulation Society. 2015 Oct:18(7):603-8; discussion 608-9. doi: 10.1111/ner.12312. Epub 2015 Jun 5 [PubMed PMID: 26053499]
Osborne MD, Ghazi SM, Palmer SC, Boone KM, Sletten CD, Nottmeier EW. Spinal cord stimulator--trial lead migration study. Pain medicine (Malden, Mass.). 2011 Feb:12(2):204-8. doi: 10.1111/j.1526-4637.2010.01019.x. Epub 2010 Dec 10 [PubMed PMID: 21143759]
Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience. Neurosurgery. 2006 Mar:58(3):481-96; discussion 481-96 [PubMed PMID: 16528188]
Level 2 (mid-level) evidenceJustiz R 3rd, Bentley I. A case series review of spinal cord stimulation migration rates with a novel fixation device. Neuromodulation : journal of the International Neuromodulation Society. 2014 Jan:17(1):37-40; discussion 40-1. doi: 10.1111/ner.12014. Epub 2013 Jan 7 [PubMed PMID: 23294189]
Level 2 (mid-level) evidenceWolter T, Kieselbach K. Cervical spinal cord stimulation: an analysis of 23 patients with long-term follow-up. Pain physician. 2012 May-Jun:15(3):203-12 [PubMed PMID: 22622904]
Level 2 (mid-level) evidenceNorth RB, Kidd DH, Olin JC, Sieracki JM. Spinal cord stimulation electrode design: prospective, randomized, controlled trial comparing percutaneous and laminectomy electrodes-part I: technical outcomes. Neurosurgery. 2002 Aug:51(2):381-9; discussion 389-90 [PubMed PMID: 12182776]
Level 1 (high-level) evidenceHenderson JM, Schade CM, Sasaki J, Caraway DL, Oakley JC. Prevention of mechanical failures in implanted spinal cord stimulation systems. Neuromodulation : journal of the International Neuromodulation Society. 2006 Jul:9(3):183-91. doi: 10.1111/j.1525-1403.2006.00059.x. Epub [PubMed PMID: 22151706]
Dragovich A, Weber T, Wenzell D, Verdolin MH, Cohen SP. Neuromodulation in patients deployed to war zones. Anesthesia and analgesia. 2009 Jul:109(1):245-8. doi: 10.1213/ane.0b013e3181a3368e. Epub [PubMed PMID: 19535717]
Level 3 (low-level) evidenceBedder MD, Bedder HF. Spinal cord stimulation surgical technique for the nonsurgically trained. Neuromodulation : journal of the International Neuromodulation Society. 2009 Apr:12 Suppl 1():1-19. doi: 10.1111/j.1525-1403.2009.00194.x. Epub [PubMed PMID: 22151467]
Rudiger J, Thomson S. Infection rate of spinal cord stimulators after a screening trial period. A 53-month third party follow-up. Neuromodulation : journal of the International Neuromodulation Society. 2011 Mar-Apr:14(2):136-41; discussion 141. doi: 10.1111/j.1525-1403.2010.00317.x. Epub 2010 Nov 4 [PubMed PMID: 21992200]
Level 2 (mid-level) evidenceFollett KA, Boortz-Marx RL, Drake JM, DuPen S, Schneider SJ, Turner MS, Coffey RJ. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology. 2004 Jun:100(6):1582-94 [PubMed PMID: 15166581]
Falowski SM, Provenzano DA, Xia Y, Doth AH. Spinal Cord Stimulation Infection Rate and Risk Factors: Results From a United States Payer Database. Neuromodulation : journal of the International Neuromodulation Society. 2019 Feb:22(2):179-189. doi: 10.1111/ner.12843. Epub 2018 Aug 17 [PubMed PMID: 30117635]
Costigan SN, Sprigge JS. Dural puncture: the patients' perspective. A patient survey of cases at a DGH maternity unit 1983-1993. Acta anaesthesiologica Scandinavica. 1996 Jul:40(6):710-4 [PubMed PMID: 8836266]
Level 3 (low-level) evidenceTurnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. British journal of anaesthesia. 2003 Nov:91(5):718-29 [PubMed PMID: 14570796]
Kemler MA, de Vet HC, Barendse GA, van den Wildenberg FA, van Kleef M. Effect of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final follow-up of patients in a randomized controlled trial. Journal of neurosurgery. 2008 Feb:108(2):292-8. doi: 10.3171/JNS/2008/108/2/0292. Epub [PubMed PMID: 18240925]
Level 1 (high-level) evidenceVan Buyten JP, Wille F, Smet I, Wensing C, Breel J, Karst E, Devos M, Pöggel-Krämer K, Vesper J. Therapy-Related Explants After Spinal Cord Stimulation: Results of an International Retrospective Chart Review Study. Neuromodulation : journal of the International Neuromodulation Society. 2017 Oct:20(7):642-649. doi: 10.1111/ner.12642. Epub 2017 Aug 18 [PubMed PMID: 28834092]
Level 2 (mid-level) evidenceNorth RB, Kidd DH, Petrucci L, Dorsi MJ. Spinal cord stimulation electrode design: a prospective, randomized, controlled trial comparing percutaneous with laminectomy electrodes: part II-clinical outcomes. Neurosurgery. 2005 Nov:57(5):990-6; discussion 990-6 [PubMed PMID: 16284568]
Level 1 (high-level) evidenceForeman RD, Linderoth B. Neural mechanisms of spinal cord stimulation. International review of neurobiology. 2012:107():87-119. doi: 10.1016/B978-0-12-404706-8.00006-1. Epub [PubMed PMID: 23206679]
Level 3 (low-level) evidenceWeigel R, Capelle HH, Flor H, Krauss JK. Event-related cortical processing in neuropathic pain under long-term spinal cord stimulation. Pain physician. 2015 Mar-Apr:18(2):185-94 [PubMed PMID: 25794205]
Level 2 (mid-level) evidencePrager JP. What does the mechanism of spinal cord stimulation tell us about complex regional pain syndrome? Pain medicine (Malden, Mass.). 2010 Aug:11(8):1278-83. doi: 10.1111/j.1526-4637.2010.00915.x. Epub [PubMed PMID: 20704677]
Level 3 (low-level) evidenceNorth RB, Kidd DH, Olin J, Sieracki JM, Farrokhi F, Petrucci L, Cutchis PN. Spinal cord stimulation for axial low back pain: a prospective, controlled trial comparing dual with single percutaneous electrodes. Spine. 2005 Jun 15:30(12):1412-8 [PubMed PMID: 15959371]
Level 1 (high-level) evidenceRusso M, Cousins MJ, Brooker C, Taylor N, Boesel T, Sullivan R, Poree L, Shariati NH, Hanson E, Parker J. Effective Relief of Pain and Associated Symptoms With Closed-Loop Spinal Cord Stimulation System: Preliminary Results of the Avalon Study. Neuromodulation : journal of the International Neuromodulation Society. 2018 Jan:21(1):38-47. doi: 10.1111/ner.12684. Epub 2017 Sep 18 [PubMed PMID: 28922517]
Baranidharan G, Simpson KH, Dhandapani K. Spinal cord stimulation for visceral pain--a novel approach. Neuromodulation : journal of the International Neuromodulation Society. 2014 Dec:17(8):753-8; discussion 758. doi: 10.1111/ner.12166. Epub 2014 Mar 10 [PubMed PMID: 24612387]
de Vos CC, Meier K, Zaalberg PB, Nijhuis HJ, Duyvendak W, Vesper J, Enggaard TP, Lenders MW. Spinal cord stimulation in patients with painful diabetic neuropathy: a multicentre randomized clinical trial. Pain. 2014 Nov:155(11):2426-31. doi: 10.1016/j.pain.2014.08.031. Epub 2014 Aug 29 [PubMed PMID: 25180016]
Level 1 (high-level) evidenceDesai MJ, Hargens LM, Breitenfeldt MD, Doth AH, Ryan MP, Gunnarsson C, Safriel Y. The rate of magnetic resonance imaging in patients with spinal cord stimulation. Spine. 2015 May 1:40(9):E531-7. doi: 10.1097/BRS.0000000000000805. Epub [PubMed PMID: 25646745]
Level 2 (mid-level) evidence