Integrating Spinal Cord Stimulation into Surgical Practice

31st Annual Meeting of the North American Spine Society Highlight

Spinal cord stimulation (SCS) is relatively easy to integrate into a surgical practice with the right technical support and in collaboration with other pain specialists as part of a multidisciplinary team, explained F. Todd Wetzel, MD, at the 31st Annual Meeting of the North American Spine Society (NASS) in Boston, MA.1 Dr. Wetzel discussed use of SCS in the context of failed back surgery syndrome (FBSS).

“Rates of reconstruction surgery are declining because the outcome data simply are not as promising as many people initially thought, particularly surgeons who were part of the original feeding frenzy associated with pedicle screws in the early 1990s,” said Dr. Wetzel, who is President of the NASS and Professor of Orthopaedic and Neurological Surgery at Temple University School of Medicine in Philadelphia, PA.
The word "Outcome" on the key of a computer keyboardFrom a surgical point of view, patients with FBSS can be divided into two groups: revision candidates and long-term pain management candidates. Conventional wisdom has always been to address all surgically reversible pathology before you consider something like deafferentation or implantable therapies, including neurostimulation or intrathecal pain therapy, Dr. Wetzel said. However, Dr. Wetzel believes that some implant technologies will be used sooner in the treatment continuum in the near future.

“It is amazing how easily spinal cord stimulation can be integrated in a surgical practice,” Dr. Wetzel said. A key aspect of this integration is learning how to provide an optimal SCS trial, which includes the decision to use a percutaneous (temporary or permanent) versus surgical lead placement.

SCS Trial: Temporary vs Permanent Percutaneous Leads
The benefits of using temporary percutaneous leads during SCS trials include reversibility and low morbidity. These leads can be placed and anchored to the skin in an outpatient setting by the surgeon or the pain management/specialist, Dr. Wetzel explained. After initial placement of the temporary percutaneous lead, the lead can be retracted and mapped with different real-time paresthesia responses to guide placement of the permanent lead, Dr. Wetzel said.

Dr. Wetzel places permanent percutaneous leads during SCS trials for patients he is convinced will respond to SCS. During this procedure, he places a temporary lead extender out to the side, so that if the trial is positive, he does not have to move the lead during permanent implantation. After the patient takes a 10-day course of antibiotics and returns to the operating room, “I just remove the temporary extender, tunnel, and put in the pulse generator,” Dr. Wetzel explained.

Dr. Wetzel said he does not prefer to use a temporary percutaneous SCS trial followed by permanent percutaneous placement, given the difficulties inherent in trying to place the permanent lead in the exact same place as the temporary lead. He added that approximately 50% of his SCS trials involve permanent percutaneous placement.

Surgical Lead Placement
The SCS trial also can be performed surgically using a laminotomy, an approach that requires a general anesthetic with motor and sensory monitoring and somatosensory evoked potentials or electromyography mapping.

Dr. Wetzel emphasized the importance of anchoring the SCS lead to the fascia using multiple nonabsorbable sutures, and noted it may be difficult to find the fascia in patients who are overweight or obese (ie, body mass index >30 kg/m2).

In these patients, “Don’t be afraid to make a big incision, or bigger incision, if you have to get to the fascia because it will pay dividends,” Dr. Wetzel said.

Immediate postoperative care for permanent lead placement should involve preoperative antibiotics with no further antibiotics required except in higher-risk  patients.

Rehabilitation, Medications, and Psychological Support
Dr. Wetzel emphasized that SCS should not be used in isolation, and that patients require long-term physical rehabilitation and conditioning, adjuvant medications, and psychological support (preintervention evaluation, directed treatment, and long-term support), Dr. Wetzel said.

In particular, he noted that adjuvant use of pain medications after implantation should not be misconstrued as SCS failure. “Adjuvant therapy with a nonsteroidal or occasionally low-dose narcotic maintenance, I think is perfectly reasonable, as long as you are doing that as a partnership,” Dr. Wetzel said.

Dr. Wetzel concluded his lecture by saying that SCS is comparatively easy to integrate this into a surgical practice, and suggested to audience members that they should refer complicated cases to physicians with more expertise while they are learning to perform SCS. “Remember that patients will find the more enabled physician with or without your help,” he noted.

To view additional meeting highlights from the 31st Annual Meeting of NASS, click here.

Updated on: 10/26/17
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Spinal Cord Stimulation’s Place in the Pain Treatment Continuum and Advancements in Technology
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