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

Infection

What is the incidence, time to appearance of symptoms, usual resolution and impact on therapy, and worst case adverse sequelae of infection following SCS treatment, and how can this risk be reduced?

  • Incidence: approximately 5%
  • Time to appearance of symptoms: typically weeks to months, but can be overnight post-procedure or, at the other extreme, several years if the infection arises from hematogenous seeding or slow-growing bacteria
  • Treatment: Culture a specimen to guide antibiotic therapy, remove any involved portion of the SCS system (infections limited to the skin over the implant may be treated without removing the underlying, non-involved implant), and administer an appropriate course of antibiotics.  Note that the system will not function with any part removed, and eradicating the infection is easier if the foreign body implant is removed in its entirety.
  • Usual resolution and impact on therapy: Infection usually resolves with appropriate treatment.  During the time the SCS system is removed, the patient must be treated for pain by other means.  The SCS system can be reimplanted when the infection clears.
  • Worst case adverse sequelae: paralysis, death.
  • Risk reduction: Use normal sterile techniques, maintain sterile dressing during the screening trial phase, administer prophylactic intravenous antibiotics before permanent implantation.
Strength of recommendation Evidence source(s)/rationale
B = Recommended
Uncertain validity, apparently useful
  • Consensus
  • Cohort studies
  • Retrospective case series
  • Case reports

Villavicencio AT, Leveque JC, Rubin L, Bulsara K, Gorecki JP. Laminectomy versus percutaneous electrode placement for spinal cord stimulation. Neurosurgery 46(2):399-405, 2000.
Abstract | Wikistim Entry

van Buyten J-P, van Zundert J, Vueghs P, Vanduffel L. Efficacy of spinal cord stimulation: 10 years of experience in a pain centre in Belgium. Eur J Pain 5(3):299-307, 2001.
Abstract | Wikistim Entry

Sundaraj SR, Johnstone C, Noore F, Wynn P, Castro M. Spinal cord stimulation: a seven-year audit. J Clin Neurosci 12(3):264-270, 2005.
Abstract | Wikistim Entry

Slavin KV, Burchiel KJ, Anderson VC, Cooke B. Efficacy of transverse tripolar stimulation for relief of chronic low back pain: results of a single center. Stereotact Funct Neurosurg 73(1-4):126-130, 1999.
Abstract | Wikistim Entry

Simpson BA. Spinal cord stimulation in 60 cases of intractable pain. J Neurol Neurosurg Psychiatry 54(3):196-199, 1991.
Abstract | Wikistim Entry

Simpson BA, Bassett G, Davies K, Herbert C, Pierri M. Cervical spinal cord stimulation for pain: A report on 41 patients. Neuromodulation 6(1):20-26, 2003.
Abstract

Siegfried J, Lazorthes Y. Long-term follow-up of dorsal cord stimulation for chronic pain syndrome after multiple lumbar operations. Appl Neurophysiol 45:201-204, 1982.
Abstract | Wikistim Entry

Shealy CN. Dorsal column stimulation: optimization of application. Surg Neurol 4(1):142-145, 1975.
Abstract | Wikistim Entry

Segal R, Stacey BR, Rudy TE, Baser S, Markham J. Spinal cord stimulation revisited. Neurol Res 20(5);391-396, 1998.
Abstract | Wikistim Entry

Rosenow JM, Stanton-Hicks M, Rezai AR, Henderson JM. Failure modes of spinal cord stimulator hardware. Neurosurg Spine 5(3):183-190, 2006.
Abstract | Wikistim Entry

Renard VM, North RB. Prevention of percutaneous electrode migration in spinal cord stimulation by a modification of the standard implantation technique. J Neurosurg Spine 4(4):300-303 2006.
Abstract | Wikistim Entry

Ohnmeiss DD, Rashbaum RF, Bogdanffy GM. Prospective outcome evaluation of spinal cord stimulation in patients with intractable leg pain. Spine 21(11):1344-1350, 1996.
Abstract | Wikistim Entry

Meglio M, Cioni B, Visocchi M, Tancredi A, Pentimalli L. Spinal cord stimulation in low back and leg pain. Stereotact Funct Neurosurg 62(1-4):263-266, 1994.
Abstract | Wikistim Entry

Meglio M, Cioni B, Rossi GF. Spinal cord stimulation in management of chronic pain. A 9-year experience. J Neurosurg 70(4):519-524, 1989.
Abstract | Wikistim Entry

May MS, Banks C, Thomson SJ. A retrospective, long-term, third-party follow-up of patients considered for spinal cord stimulation. Neuromodulation 5(3):137-144, 2002.
Abstract | Wikistim Entry

Levy R, Henderson J, Slavin K, Simpson BA, Barolat G, Shipley J, North R Incidence and avoidance of neurologic complications with paddle type spinal cord stimulation leads. Neuromodulation 14:412-422, 2011.
Abstract | Wikistim Entry

Leveque J-C, Villavicencio AT, Bulsara KR, Ruvin L, Gorecki JP. Spinal cord stimulation for failed back surgery syndrome. Neuromodulation 4(1);1-9, 2001.
Abstract | Wikistim Entry

Lang P. The treatment of chronic pain by epidural spinal cord stimulation - a 15 year follow up: present status. Axon 71-73, 1997.
Abstract | Wikistim Entry

Kumar K, Toth C, Nath RK, Laing P. Epidural spinal cord stimulation for treatment of chronic pain--some predictors of success. A 15-year experience. Surg Neurol 50(2):110-120, 1998.
Abstract | Wikistim Entry

Kumar K, Nath R, Wyant GM. Treatment of chronic pain by epidural spinal cord stimulation: a 10-year experience. J Neurosurg 75(3):402-407, 1991.
Abstract | Wikistim Entry

Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, Thomson S, O’Callaghan J, Eisenberg E, Milbouw G, Buchser E, Fortini G, Richardson, J, North RB The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery 63(4):762-768, 2008.
Abstract | Wikistim Entry

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 58(3):481-494, 2006.
Abstract | Wikistim Entry

Kumar K, Wilson JR, Taylor RS, Gupta S. Complications of spinal cord stimulation, suggestions to improve outcome, and financial impact. J Neurosurg Spine 5(3):191-203, 2006.
Abstract | Wikistim Entry

Kumar A, Felderhof C, Eljamel MS. Spinal cord stimulation for the treatment of refractory unilateral limb pain syndromes. Stereotact Funct Neurosurg 81(1-4):70-74, 2003.
Abstract | Wikistim Entry

Kemler MA, Barendse GA, van Kleef M, Van cen Wildenberg FA, Weber WE. Electrical spinal cord stimulation in reflex sympathetic dystrophy: retrospective analysis of 23 patients. J Neurosurg 90(1 Suppl):79-83, 1999.
Abstract | Wikistim Entry

Kay AD, McIntyre MD, Macrae WA, Varma TR. Spinal cord stimulation--a long-term evaluation in patients with chronic pain. Br J Neurosurg 15(4):335-341, 2001.
Abstract | Wikistim Entry

Gutiérrez Vall de Cabres V, Solans Laque R, Pigrau Sarrallach C, Pahissa Berga A. Psoas abscess due to an epidural spinal cord stimulation catheter. Scand J Infect Dis 24(1):119, 1992.
Abstract | Wikistim Entry

Forouzanfar T, Kemler MA, Weber WE, Kessels AG, van Kleef M. Spinal cord stimulation in complex regional pain syndrome: cervical and lumbar devices are comparably effective. Br J Anaesth 92(3):348-353, 2004.
Abstract | Wikistim Entry

Follett 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 100(6):1582-1594, 2004.
Abstract | Wikistim Entry

De Mulder PA, te Rijdt B, Veeckmans G, Belmans L. Evaluation of a dual quadripolar surgically implanted spinal cord stimulation lead for failed back surgery patients with chronic low back and leg pain. Neuromodulation 8(4):219-224, 2005.
Abstract | Wikistim Entry

de la Porte C, Siegfried J. Lumbosacral spinal fibrosis (spinal arachnoiditis). Its diagnosis and treatment by spinal cord stimulation. Spine 8(6):593-603, 1983.
Abstract | Wikistim Entry

Burchiel KJ, Anderson VC, Brown FD, Fessler RG, Friedman WA, Pelofsky S, Weiner RL, Oakley J, Shatin D. Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine 21(23):2786-2794, 1996.
Abstract | Wikistim Entry

Blond S, Armignies P, Parker F, Dupard T, Guieu JD, Duquesnoy B, Christiaens JL. Chronic sciatalgia caused by sensitive deafferentiation following surgery for lumbar disk hernia: Clinical and therapeutic aspects. Apropos of 110 patients [French]. Neurochirurgie 37(2):86-95, 1991.
Abstract | Wikistim Entry

Bennett DS, Aló KM, Oakley J, Feler CA. Spinal cord stimulation for complex regional pain syndrome I (RSD). A retrospective multicenter experience from 1995-1998 of 101 patients. Neuromodulation 2(3):202-210, 1999.
Abstract | Wikistim Entry

Barolat G. Experience with 509 plate electrodes implanted epidurally from C1 to L1. Stereotact Funct Neurosurg 61(2):60-79, 1993.
Abstract | Wikistim Entry

Barolat G, Schwartzman R, Woo R. Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy. Stereotact Funct Neurosurg 53(1):29-39, 1989.
Abstract | Wikistim Entry

Arxer A, Busquets C, Vilaplana J, Villalonga A. Subacute epidural abscess after spinal cord stimulation implantation [letter]. Eur J Anesthesiol 20:753-759, 2003.
Abstract | Wikistim Entry

Aló KM, Redko V, Charnov J. Multiple program spinal cord stimulation in the treatment of chronic pain: follow-up of multiple program SCS. Neuromodulation 2(4):266-272, 1999.
Abstract | Wikistim Entry

Aló KM, Redko V, Charnov J. Four year follow-up of dual electrode spinal cord stimulation for chronic pain. Neuromodulation 5(2):79-99, 2002.
Abstract | Wikistim Entry

Abejón D, Reig E, del Pozo C, Contreras R, Insausti J. Dual spinal cord stimulation for complex pain: preliminary study. Neuromodulation 8(2):105-111, 2005.
Abstract | Wikistim Entry