Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Chronic Neuropathic Pain
Choosing Implanted Electrodes
What advantages do percutaneous catheter electrodes and surgical plate/paddle electrodes offer?
- Patient preference: Patients who are satisfied with the result of the screening trial with the percutaneous catheter electrode might choose it for the permanent implant.
- Patient body size: During implantation in children who have yet to reach their full stature, provisions for growth should be considered. In obese patients, percutaneous catheter electrode placement using specially-designed Tuohy needles might be advantageous.
- Clinician factors: Sometimes the choice of electrode follows the choice of technique. A surgeon, for example, might place a surgical plate/paddle electrode if this is perceived to be the best option. An anesthesiologist or physiatrist, on the other hand, would be expected to employ the percutaneous technique.
- Pain/paresthesia mapping: A percutaneous electrode offers relatively easy access to multiple spinal levels and, thus, facilitates paresthesia mapping. A surgical plate/paddle electrode, however, might be required for screening if a percutaneous catheter electrode cannot access the epidural space satisfactorily, for example, in a patient who has undergone a previous laminectomy or posterior fusion at the level of insertion.
- Fracture: There is no inherent difference in the fracture rate for these electrodes.
- Migration: Longitudinal or lateral migration of an electrode (either a single electrode or one of a pair) can reduce or eliminate pain/paresthesia overlap. Due to its shape, a surgical plate/paddle electrode resists migration once it is encapsulated in fibrous tissue, and, if it has multiple columns of contacts, these are fixed in position with respect to one another. A percutaneous catheter electrode, on the other hand, retains a greater potential to migrate, even after encapsulation. To the extent that migration of percutaneous catheter electrodes can be avoided with the new anchoring techniques referenced herein, this issue is mitigated.
- Extraneous stimulation: According to one case series with blinded, internal controls, the dorsal insulation on a surgical plate/paddle electrode prevents uncomfortable extraneous stimulation, viz. of nerve fibers in ligamentum flavum, seen in small fraction of patients
- Insertion/removal: Placement of a surgical plate/paddle electrode requires a laminectomy or laminotomy; its removal requires laminotomy. Insertion/removal of the percutaneous catheter electrode does not require laminectomy or laminotomy. Thus, the pain associated with insertion of a plate/paddle electrode might be greater than that experienced after insertion of a percutaneous catheter electrode.
- Electrode revision: The scarring that occurs after electrode implantation is greater for surgical plate/paddle electrodes than for percutaneous catheter electrodes; this can present a greater problem if the electrode requires revision.
- Power requirement: A surgical plate/paddle electrode requires less power than a percutaneous electrode with the same contact areas and spacing; therefore, use of a surgical plate/paddle electrode increases the time before surgical battery replacement or recharging is required.
- Targeting specific sites:
- One RCT and one case series found that, in the treatment of low back and leg pain, compared with use of percutaneous catheter electrodes at the same spinal level, the use of an insulated surgical plate/paddle electrode improves pain/paresthesia coverage, pain relief, and clinical outcome. Many case series have reported successful treatment of low back and leg pain with both electrode designs.
- Nonrandomized controlled trials concluded that in patients with axial low back pain, an electrode with a single column of contacts placed on the midline affords coverage superior to that provided by a dual column of contacts [created with (1) percutaneous catheter electrodes implanted in parallel or (2) a single surgical plate/paddle electrode]. Clinical outcomes, however, were assessed only for the dual column configurations, and they were comparable to those reported in the SCS literature in general. Many large case series report good outcomes with dual column electrodes.
- Modeling studies indicate that use of a transverse tripole electrode with three columns that allow lateral anodes to bracket a central cathode and, thus, reduce segmental side effects might be advantageous. Limited clinical outcome studies have been reported for this configuration.
| Strength of recommendation | Evidence source(s)/rationale |
| A = Recommended or required Valid, useful, or non-negotiable |
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Abstract | Wikistim Entry Tanabe Y, Kimura N, Kida N, Nakao A, Miyazawa K, Iseki M, Miyazaki T. A case of intractable lower limb pain treated successfully by spinal cord stimulation with an electrode inserted retrogradely [Japanese]. Masui 55(6):732-734, 2006.
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Abstract | Wikistim Entry
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