To the Editor: We have read with great interest the article about back pain and the role of spinal cord stimulation by Rigoard et al.1 We agree that failed back surgery syndrome represents one of the most frequent etiologies of chronic back pain and is a major public health issue. Spinal cord stimulation (SCS) has been used both for failed back surgery syndrome and complex regional pain syndrome with variable results. Management of post lumbar surgery syndrome with numerous modalities of treatments, including interventional techniques, results in moderate improvement, because it leaves a proportion of patients with intractable pain. The international literature concerning to the effectiveness of SCS in relieving chronic intractable pain of post lumbar surgery syndrome indicates a level of evidence of II-1 or II-2 with 1B or 1C/strong recommendation for clinical use on a long-term basis.2,3 As well discussed in the article by Rigoard et al,1 chronic pain is a complex condition that requires a multidisciplinary team made up neurosurgeons, anesthetists, and psychologists to manage these patients safely and accurately. Psychological assessment seems to be of crucial importance in such an issue, because psychiatric pathologies can negatively modify the effectiveness of the technique. In particular, panic attack syndrome is an unpredictable psychiatric disorder that may be not suspected on the initial clinical interview and may limit the effectiveness of the SCS in the long run. In brief, we can provide a case of a young woman experiencing chronic low back pain syndrome caused by a degenerative spondylolisthesis at L4-L5 segment. She underwent regular fixation. After 2 years of mild health, she reported severe low back pain, numbness of the legs, and painful walk. She underwent L5-S1 laminectomy and radicular decompression. For 1 year after surgery, she underwent pain medical therapies and physiotherapy without beneficial effects. Therefore, the patient was enrolled for SCS device implantation. Patient underwent regular clinical pain psychological interview, and she did not reveal any psychiatric disorders such as signs of depression, suicidal ideation, or anxiety. Therefore, a rechargeable neurostimulator (Restore-Ultra, Medtronic, Minneapolis, MN) was implanted. The patient experienced a relatively long period free of pain, thus improving her quality of life. However, 2 months later, she presented with severe anxiety, chest tightness, and insomnia, she was irritable, and the pulse generator was making difficult the decubitus on the side where it was implanted. The frequency of the generator was changed several times, but the symptoms did not change. Subsequently, the generator was turned off, but the patient was continuously complaining her symptoms. The patient underwent a new psychological interview, which documented a panic attack syndrome. During such an examination the patient affirmed her assumption that she could not tolerate the device because it was, in her opinion, the cause of her mental disorder. After thorough discussion with the patient by the specialist, the patient accepted her condition and preferred to keep the device in place because it was providing her with some beneficial effects. The mental disturbance of the patient, unpredictable and rare, interfered with the possibility of fully recovering from her painful condition, limiting and confusing the effectiveness of the SCS. Our experience points out that, even though psychological tests may be able to predict outcomes in SCS treatment, panic attack syndrome could not be predictable and could be considered as a secondary condition following the device implantation.4 Despite its rarity, panic attack syndrome is to be taken into account in the preoperative evaluation of all the patients selected as candidates for neurostimulation, because it may affect the final result. Disclosure The study, in part, has been supported by academic funds (ex 60% of the first author).
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Oct 1, 2024
Catherine Léonard 
Open Access