Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Chronic Neuropathic Pain

Summary Patient Selection & Prognosis

Information to determine a patient's suitability for a screening trial is gathered from the history, including pain location and intensity; physical examination; imaging studies; and a psychological evaluation (required before system implantation).

Relative contraindications to the screening trial:

• An unresolved major psychiatric comorbidity
• The unresolved possibility of secondary gain
• An active and untreated substance abuse disorder
• Inconsistency among the history, pain description, physical examination, and diagnostic studies
• Abnormal or inconsistent pain ratings
• A predominance of non-organic signs (note that Waddell’s signs are non-specific)
• Alternative therapies with a risk/benefit ratio comparable to that of SCS remain to be tried
• Pregnancy
• Occupational risk
• Local or systemic infection
• Presence of a demand pacemaker
• Presence of a cardioverter defibrillator
• Foreseeable need for an MRI
• Presence of a major comorbid chronic pain syndrome
• Anticoagulant or anti-platelet therapy

Contraindications to SCS therapy:

• Inability to control the device
• Nerve compression amenable to surgery causing a serious neurologic deficit
• Gross instability at risk for progression
• Coagulopathy, immunosuppression, or other condition associated with an unacceptable surgical risk
• Need for therapeutic diathermy

Prognostic factors:

• Age: The safety and effectiveness of SCS in children is not established.  Age-related infirmity might reduce the chances of a good outcome with SCS, but each patient must be assessed on an individual basis.
• Sex: No reason exists to exclude patients based on their sex.
• Pregnancy:  The safety status of SCS during pregnancy remains to be established.  The use of SCS must be balanced against known or potential adverse effects of alternative pain treatments.
• Life expectancy:  An SCS system with an external stimulator might be more cost effective than an implanted generator in a patient (for example, one with terminal cancer) who has a very short life expectancy.
• Worker's compensation or litigation status:  We have inadequate information to determine if worker’s compensation or litigation status influences SCS outcome. 
• Pain characteristics:  Radicular or radiating neuropathic pain that 1) has an objective basis, 2) has a distribution consistent with the results of the physical examination and diagnostic studies, and 3) is linked to a specific diagnosis is most straightforward to treat.  Treatable pain will be adequately relieved during a screening trial.