Spinal Cord Stimulator Placement Research Articles

Boosting Confidence: Enhancing Spinal Cord Stimulator Needle and Lead Placement Through Simulation Training.

Background This pilot study aims to examine the effectiveness of a spinal cord stimulator (SCS) simulator training system in improving theconfidence of pain fellows in SCS placement. Methodology Five Ukrainian physicians (neurologists, neurosurgeons, and an anesthesiologist) completed a 10-item survey regarding their confidence in various aspects of SCS placement and their opinions on how effective SCS models were for educational purposes. After placing SCS leads using the SCS simulator, the physicians took the same survey again. The Mann-Whitney U test was used to determine if there was a significant difference in total scores pre and post-simulator training.The software PAST (PAleontological STatistics) was used for statistical analysis. Results Overall, five participants had a 38% statistically significant increase in survey scores before and after the intervention (mean: 4.2 vs. 6.2, p = 0.0055). With regards to each item of the survey, participants had a significantly increased confidence in driving leads (2.6 vs. 5.2, p = 0.008) and in overall technical skills for the SCS procedure after the training (2.8 vs. 5.2, p = 0.0188). Although the other eight survey items were not statistically significant (p > 0.05), participants had a 28% increase in confidence when inserting epidural needles, a 20% increase in interpreting simulated X-rays, a 32% increase in navigating challenging anatomical variations, a 12% increase in identifying key anatomical landmarks, a 20% increase in ensuring the correct placement of the lead, or a 53% increase in preparedness for performing an SCS procedure in a real clinical setting. The participant's perspective on how valuable the stimulator training was for enhancing procedural skills increased by 38% and how well the simulator replicated real-life SCS procedure increased by 52%, although both were statistically insignificant (p > 0.05). Conclusions This pilot study shows that the utilization of simulated neuromodulation training is a viable means of augmenting neuromodulation education by increasing physician's confidence in aspects of the SCS placement procedure. The extent to which simulator training improves procedural skills in a real-life SCS placement needs to be investigated further.

Analysis of reasons for medical malpractice litigation due to spinal cord stimulator

Study designRetrospective cohort study. IntroductionMalpractice claims analysis is performed by several specialties to improve quality of patient care and to identify areas where physicians can improve their practice to mitigate the incidence of committing malpractice. The Food and Drug Administration has flagged over 80,000 injuries caused by spinal cord stimulator (SCS), making them the 3rd most flagged medical device. This study analyzed malpractice claims due to SCS by querying two legal databases widely used in medicolegal research. MethodsWestlaw Edge and VerdictSearch were queried for malpractice cases filed between the years 2000 and 2022 using the keywords “spinal cord stimulator.” Case inclusion criteria was defined as a plaintiff's basis of litigation resting on a claim of medical malpractice due to SCS. Additional data collected included date of case hearing, plaintiff sex and age, defendant specialty, verdict ruling, location of the filed claim, payment or settlement amount, and sustained injuries. ResultOf the 1773 reviewed cases, 45 cases were included and categorized as battery or implantable pulse generator malfunction (35.56 %), lead complications (28.89 %), surgical complications (20.00 %), and miscellaneous (15.56 %). Four (8.89 %) cases resulted in settlement, 11 (24.44 %) in a plaintiff verdict, and 30 (68.00 %) resulted in a defendant verdict. Claims filed due to infection related to SCS were more likely to result in a defendant verdict (p = .047), whereas claims filed due to neurological deficit were more likely to result in a plaintiff verdict (p = .020). The average settlement amount for the 4 cases is $1,975,309.61. ConclusionOur findings suggest obtaining adequate neuroimaging preoperatively with MRIs, disclosing neurological risks specifically paralysis on informed consent, and evaluating radiography intraoperative and postoperatively with anterior-posterior (AP) and lateral x-ray films to ensure proper SCS placement are practices that may mitigate malpractice due to SCS. Battery defects and lead complications were the most common grounds for SCS-related malpractice claims.

Analysis of spinal canal diameter in the placement of thoracic spinal cord stimulator paddle leads.

Neurologic deficit is known as a rare complication of thoracic spinal cord stimulator (SCS) paddle lead implantation, but many believe its incidence after SCS paddle lead placement is under-reported. It is possible that imaging characteristics may be used to help predict safe paddle lead placement. This imaging study was undertaken to determine the minimum canal diameter required for safe paddle lead placement. Patients who underwent thoracic laminotomy for new SCS paddle lead placement from January 2018 to March 2023 were identified retrospectively. Preoperative thoracic canal diameter was measured in the sagittal plane perpendicular to the disc space from T5/6 to T11/12. These thoracic levels were chosen because they span the most common levels targeted for SCS placement. Patients with and without new neurologic deficits were compared using a Mann-Whitney U-test. Of 185 patients initially identified, 180 had thoracic imaging available for review. One (0.5%) and 2 (1.1%) of 185 patients complained of permanent and transient neurologic deficit after thoracic SCS placement, respectively. Patients with neurologic deficits had average canal diameters of <11 mm. The average canal diameter of patients with and without neurologic deficits was 10.2 mm (range 6.1-12.9 mm) and 13.0 mm (range 5.9-20.2), respectively (p < 0.0001). Postoperative neurologic deficit is an uncommon complication after thoracic laminotomy for SCS paddle lead placement. The authors recommend ensuring a starting thoracic canal diameter of at least 12 mm to accommodate a SCS paddle lead measuring 2 mm thick to ensure a final diameter of >10 mm. If canal diameter is <12 mm, aggressive undercutting of the lamina, a second laminotomy, or placement of smaller SCS wire leads should be considered.

Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation

ObjectivesPlacement of a standard paddle lead for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a “skip” laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified. Materials and MethodsParticipants who underwent SCS paddle placement at Albany Medical Center between 2016 and 2017 were identified. Operative reports were reviewed to identify the paddle type, level of initial laminotomy, target level, and skip laminotomy level. Preoperative thoracic magnetic resonance images (MRIs) were reviewed, and spinal canal diameter, interpedicular distance, and dorsal cerebral spinal fluid thickness were measured for each participant when available. ResultsA total of 106 participants underwent thoracic SCS placement. Of these, 97 had thoracic MRIs available for review. Thirty-eight participants required a skip laminotomy for placement of the paddle compared with 68 participants who did not. There was no significant difference in demographic features including age, sex, body mass index, and surgical history. Univariate analyses that suggested trends were selected for further analysis using binary logistic regression. Level of initial laminotomy (odds ratio [OR] = 1.51, p = 0.028), spinal canal diameter (OR = 0.71, p = 0.015), and dorsal cerebrospinal fluid thickness (OR = 0.61, p = 0.011) were correlated with skip laminotomy. Target level (OR = 1.27, p = 0.138) and time from trial (1.01, p = 0.117) suggested potential association. The multivariate regression was statistically significant, X2(10) = 28.02, p = 0.002. The model explained 38.3% of the variance (Nagelkerke R2) and predicted skip laminectomy correctly in 73.3% of cases. However, for the multivariate regression, only a decrease in spinal canal diameter (OR = 0.59, p = 0.041) was associated with a greater odds of skip laminotomy. ConclusionsThis study aims to characterize the patient and radiographic factors that may predict the need to perform a skip laminotomy during the initial placement of SCS paddles. Here, we show that radiographic and anatomic variables, primarily spinal canal diameter, play an important role in predicting the need for a skip laminotomy. Furthermore, we suggest that target level for placement and level of initial laminotomy also may contribute. Further investigation of the predictive factors for performing a skip laminotomy would help optimize surgical planning and preoperative patient selection and counseling.

Paper 22: High Tibial Osteotomy: Return to Duty in an Active Duty Military Population

Objectives: Evidence on both return to sport and work following high tibial osteotomy (HTO) has been limited, especially in a young, military population with high occupational demands. The purpose of this study was two-fold: 1) to identify if objective measures of preoperative knee condition severity or intraoperative correction were associated with successful return to duty and 2) to assess if postoperative complications and return to the operating room were associated with successful return to duty. Methods: A retrospective cohort study was performed of patients in the Military Health System who underwent HTO between 2003 and 2018. All patients were between 18 and 55 years and presented with osteoarthritis isolated to the medial compartment with or without other knee injuries. Concomitant meniscal and cartilage procedures were included while ligamentous procedures were excluded as they were viewed as a separate pathology. The inclusion criteria were as follows: active duty status at the time of the index procedure and two-year minimum follow-up with both preoperative knee radiographs and pre- and postoperative long-leg alignment radiographs. Preoperative Kellgren-Lawrence grade, pre- and postoperative hip-knee-ankle angle, and postoperative weightbearing axis were collected. The primary outcome was return to duty, stratified by failure defined as medical separation from the military or conversion to total knee arthroplasty. Success was defined as remaining on active duty without restriction while modified success was defined as remaining on active duty with permanent activity restrictions. The secondary outcome was reoperation for any reason. Results: Fifty-five HTOs were performed in 50 patients with a mean age of 39.0 years (range 22.8-55.0). Mean follow up was 5.0 years (range 2.1-10.7). 18.2% (10/55 knees) failed HTO (one conversion to TKA, nine medical separations), 27.3% (15/55 additional knees) had permanent activity restrictions, and 54.5% (30/55 knees) returned to active duty without restriction. 34.5% of HTOs had reoperation at any time point and return to the operating room was associated with medical separation (p=0.027). Reoperation occurred for unplanned removal of hardware (7), irrigation and debridement (4), revision HTO (3), meniscal transplant (2), meniscal repair (1), spinal cord stimulator placement (1), and decompressive fasciotomies (1). Younger age was associated with both medical separation (p=0.003) and permanent restrictions (p=0.006) following HTO and was the only significant variable identified on multiple logistic regression analysis. Patients with residual postoperative varus deformity &gt;5 degrees were more likely to undergo medical separation (p=0.023). Conclusions: When performed in a military population, HTO succeeded in returning 54.5% of knees to full duty without restriction despite 34.5% of knees requiring reoperation for complications. However, HTOs with residual varus deformity or complications requiring additional procedures were associated with lower return to duty rates. No correlation was identified between return to duty and osteoarthritis grading or amount of deformity. [Table: see text][Table: see text]

ID: 218045 Fast Acting Sub-Perception Therapy Spinal Cord Stimulation for Chronic CRPS Type II After Lipoma Resection

Spinal cord stimulators (SCS) are indicated for chronic intractable pain of the back or limbs including unilateral or bilateral pain associated with failed back surgery syndrome, Complex Regional Pain Syndrome (CRPS) Types I and II, and neuropathic pain1. The mechanism of action is unclear though current theory involves stimulation of Aβ-fibers2 via the Gate Control theory, and modulation of neurotransmitters such as GABA2,3. Recent research suggests activation of Aβ-fibers at adjacent segments also play a significant role via surround inhibition4,5. Here we present a patient with intractable right leg pain following a lipoma resection with significant improvement after fast-acting sub-perception therapy (FAST) spinal cord stimulator placement.

ID: 218213 Successful Spinal Cord Stimulator Trial in the Visually Impaired

A 72-year-old gentleman was referred to the chronic pain clinic after being deemed a non-surgical candidate for a multilevel lumbar fusion per orthopedic spine surgery. His past medical history is notable for coronary artery disease, diabetes mellitus, obstructive sleep apnea, and blindness in bilateral eyes. The patient has been suffering for years from lower back pain, without red flag symptoms, and had failed multiple treatment modalities, including bilateral sacroiliac joint injections, L3-4, L4-5, and L5-S1 facet blocks. Although he is capable of performing most of his activities of daily living, his blindness unfortunately has been a barrier to both surgical interventions and pain management therapy. After consultation with a chronic pain physician, he was offered a spinal cord stimulator trial. With direct communication between the patient and the spinal cord stimulator company representative, a remote-less algorithm was able to be programmed that allowed for successful mapping of target nerves generating 80% efficacy in pain therapy. A thorough literature review demonstrated a lack of research focus in neuromodulation for patients with disabilities. With tailored guidance this patient achieved adequate pain relief which significantly improved his quality of life during the trial phase. The patient is determined to undergo a permanent spinal cord stimulator placement soon. This case report outlines a successful neuromodulation trial in a visually impaired patient. Ultimately, there is still work to be done to ensure advancements in pain medicine are accessible to all patients regardless of disabilities.

ID: 209037 Retrograde Paddle Implant for Spinal Cord Stimulation in Complex Failed Back Surgery Syndrome Cases

Complex spine arthrodesis can challenge the approach for spinal cord stimulation (SCS). Percutaneous SCS placement is limited by epidural fibrosis and bone grafts over the puncture sites (1) making traditional techniques prone to higher complication rates and suboptimal lead placement (2). Placing retrograde SCS paddle can overcome these technical issues and promote effective SCS therapy in select patients.

Trends in spinal cord stimulation utilization: change, growth and implications for the future

Chronic pain impacts more than 100 million Americans and has a significant impact on the economy and quality of life. Spinal cord stimulation (SCS) has demonstrated efficacy in managing a...

Letter: Integration of Veterans Affairs Medical Centers Into Neurosurgical Residency Programs.

To the Editor: We read with great interest the recent article published by Yearly et al1 highlighting the integration of Veterans Affairs (VA) Medical Center rotation into neurosurgery residency programs across the United States. The authors summarize succinctly the current state of affairs. At the University of Miami training program, our postgraduate year 3 (PGY3) residents rotate at the Bruce W. Carter VA Medical Center for 4 months. The VA rotation at our program has become known for its breadth through the wide skillset of contracted attendings, its innovation through the robust VA infrastructure, and its flexibility to continue training opportunities at the primary teaching site through its manageable clinical obligations. All these elements add to the findings of Yearly et al,1 affirming the formative nature of a VA rotation within neurosurgery training programs when possible. BREADTH There are 3 contracted attendings at our VA center, who specialize in complex spine, functional, tumor, and general cranial. Through this range of interests, the VA resident is exposed to these areas on a one-to-one basis with the attending because they are the sole resident on service. Our VA service make-up mirrors much of what Yearly et al1 report, in that spine surgeries are the most common, but within that, the complexities range from single-level laminectomy to multilevel cervical laminoplasties and lumbar fusions. Outside spine, a variety of procedures are also performed—a recent week's example includes spinal cord stimulator placement for pain, radiofrequency ablation for spinal metastasis, and endoscopic transsphenoidal resection for pituitary tumor. By having attendings who specialize in different areas, the VA rotation can provide the rotating resident exposure to a large breadth of surgical techniques. INNOVATION The infrastructure at the VA allows our department to incorporate new concepts and materials for the better of our patients. So much so that the invested interest from our anesthesia colleagues, operating room staff, and hospital managers has allowed the VA rotation to become known for better exposure to particular techniques than some of the other teaching sites within our program. This includes navigated single-position corpectomies and fusions and percutaneous spinal cord stimulator placements (Supplemental Figure 1,https://links.lww.com/NEU/D758). Furthermore, on the horizon for approval includes robotic spine surgery and stereotactic deep brain stimulation. Our experience therefore demonstrates the potential for the VA rotation within training programs to not only expose residents to standard operative techniques but also new and emerging ones too. FLEXIBILITY A normal week at the VA for our resident includes 2 operative days and 2 clinic days. Outside these clinical obligations, the vicinity of the primary teaching hospital allows the VA resident to participate in other clinical activities at the primary site. This can include further operative time and pursuing research interests which are both encouraged pending the resident's preference. A unique aspect of our VA center is its close proximity to the primary teaching hospital of our program—across the road. This location allows the VA resident to participate in all primary site learning activities (both in the morning and in the evening), as well as talk in-house overnight call at the primary site. Although not all VA centers are located so close to the primary teaching sites, our experience demonstrates that within a flexible set of obligations, a VA rotation is not a compromise in operative and academic opportunities if appropriate arrangements and schedules can be made ahead of time. At the University of Miami training program, the VA rotation has become a key and much looked forward to rotation among the residents. This is because of both the reasons Yearly et al1 highlight, as well as the elements we detail above. The VA rotation can be a pivotal experience for neurosurgery residents in their training, and maximizing where possible its breadth, innovation, and flexibility is highly encouraged.

Paddle-Lead Spinal-Cord Stimulation Surgeries for Chronic Neuropathic Pain: A Single Surgeon Case-Series Outcome Analysis in Indian Population.

Background Spinal-cord stimulation (SCS) for relief of chronic neuropathic pain is well established. Objective The inherent limitations with conventional percutaneous lead SCS are lead migration, positional variations in stimulation, as well as possible nonreplication of benefits after permanent SCS implantation, which were experienced during a positive trial period. To circumvent these limitations, we analyzed five consecutive cases of chronic intractable neuropathic pain who underwent direct SCS paddle lead placement during the trial period for pain relief. In addition, during the process of placing a permanent paddle lead, the impediment created by prior epidural scarring in such chronic patients can be obviated mechanically thereby increasing the efficacy of the procedure. Material and Methods The demographic details, diagnosis, preoperative visual analogue scale score (VAS), and follow-up VAS were recorded. Surgical procedure consisted of a standard dorsal laminotomy followed by placement of permanent paddle leads. Results All patients reported significant improvement in their VAS scores. Mean duration of follow-up was 23.6 months (9-35 months). Mean preoperative VAS was 9.4 and 1.4 at the last follow-up. No major complications were found. Conclusion With careful patient selection and appropriate surgical strategy, it was possible to implant permanent paddle leads during SCS trial itself in our five patients thereby replicating and sustaining the trial period pain relief. We argue that this can be a new cost-effective and reliable technique for the placement of SCS leads achieving excellent and sustained pain relief.

The Association of Psychiatric Comorbidities With Short-Term and Long-Term Outcomes Following Spinal Cord Stimulator Placement

BackgroundOutcomes after spinal cord stimulator (SCS) placement are affected by psychologic comorbidities. It is part of routine practice to do psychologic assessments prior to SCS trials to assess for the presence of maladaptive behavioral patterns. However, few studies have sought to quantify the effect of psychiatric comorbidities on complications, reoperation, and readmission rates. The purpose of this study was to assess the association of psychiatric comorbidities with postprocedural outcomes after SCS implantation. Materials and MethodsInclusion criteria included SCS placement between 2015 and 2020 (percutaneous approach or an open laminectomy-based approach) using Healthcare Corporation of America National Database. Data on psychiatric comorbidities present at the time of SCS implantation surgery were collected. Outcomes of interest included complication rates (defined as lead migration, fracture, malfunction, battery failure, postoperative pain, infection, dural puncture, or neurological injury), reoperation rates (defined as either revision or explant [ie, removal]), and readmission rates within 30-day and 1-year time after SCS implantation. We measured the association between psychiatric comorbidities and outcomes using multivariable regression and reported odds ratio (OR) and respective 95% confidence intervals. ResultsA total of 12,751 cases were included. The most common psychiatric comorbidities were major depressive disorder (16.1%) and anxiety disorder (13.4%). In unadjusted univariate analysis, patients with any psychiatric comorbidity had heightened rates of any complication (27.1% vs 19.4%), infection (5.9% vs 1.9%), lead displacement (2.2% vs 1.3%), surgical pain (2.1% vs 1.2%), explant (14.7% vs 8.8%), and readmission rates at one year (54.2% vs 33.8%) (all p < 0.001). In multivariable logistic regression, with each additional psychiatric comorbidity, a patient had increased odds of experiencing any complication (OR = 1.5, 95% CI = 1.36–1.57, p < 0.001), requiring a reoperation (OR = 1.5, 95% CI = 1.37–1.6, p < 0.001), and requiring readmission (OR = 1.7, 99% CI = 1.6–1.8, p < 0.001). ConclusionsThe presence of psychiatric comorbidities was found to be associated with postoperative complication rates, reoperation, and readmission rates after SCS placement. Furthermore, each consecutive increase in psychiatric comorbidity burden was associated with increased odds of complications, reoperation, and readmission. Future studies might consider examining the role of presurgical mental health screening (ie, patient selection, psychologic testing) and treatment in optimizing outcomes for patients with psychiatric comorbidities.

Spinal Cord Injury After Revisional Placement of Percutaneous Cervical Spinal Cord Stimulator in the Patient With Cervical Central Canal Stenosis: A Case Study

Spinal Cord Injury After Revisional Placement of Percutaneous Cervical Spinal Cord Stimulator in the Patient With Cervical Central Canal Stenosis: A Case Study

Establishing Minimal Clinically Important Difference in Sleep Outcomes after Spinal Cord Stimulation in Patients with Chronic Pain Disorders

Introduction: As one of the most common medical conditions for which patients seek medical care, chronic pain can be debilitating. The relationship between chronic pain and sleep is thought to be bidirectional, suggesting that treatment of one can be beneficial to the other. There is mounting evidence that spinal cord stimulation (SCS) improves aspects of sleep. How meaningful that is to patients’ lives has not been ascertained. Objective: The aim of the current study was to further elucidate the effect of SCS on sleep by examining the relationship between pain outcome measures with the insomnia severity index (ISI) and to establish the minimally clinical important difference (MCID), which is defined as the smallest noticeable change that an individual perceives as clinically significant. Materials and Methods: We prospectively collected ISI, Epworth sleepiness scale (ESS), Numerical Rating Scale, McGill Pain Questionnaire-Short Form, Oswestry Disability Index, Beck Depression Inventory, and Pain Catastrophizing Scale data both pre- and postoperatively for chronic pain patients who underwent SCS placement and had long-term outcomes. The ISI is a well-studied questionnaire used to assess an individual’s level of insomnia. Results: We correlated the ESS and ISI with pain outcome measures in sixty-four patients at a mean follow-up of 9.8 ± 2.9 months. The ISI showed correlations with disability as measured through the Oswestry Disability Index (p = 0.014) and depression as measured through the Beck Depression Inventory (p = 0.024). MCID values for the ISI were calculated using both anchor- and distribution-based methods. The minimal detectable change method resulted in an MCID of 2.4 points, standard error of measurement resulted in an MCID of 2.6 points, and the change difference resulted in an MCID of 2.45. The receiver operating characteristic method yielded an MCID of 0.5-point change with an area under the curve of 0.61. Conclusion: This study successfully established MCID ranges for the ISI outcome measure to help gauge improvement in insomnia after SCS. The ISI has ample evidence of its validity in assessment of insomnia, and MCID values of 2.4–2.6 correlate with improvement in disability and depression in our patients.

Spinal Cord Stimulator (SCS) Placement: Examining Outcomes Between the Open and Percutaneous Approach

BackgroundSpinal cord stimulator (SCS) placement has been gaining traction as an approach to modulate pain levels for several different chronic pain conditions. This procedure can be performed via a percutaneous or open approach. Data regarding SCS complications are relatively limited. ObjectiveThe purpose of this study was to leverage a large national database to examine outcomes between the percutaneous and open SCS placement approaches. Outcomes in this study include length of stay (LOS), complication rates, reoperation rates, and 1-year readmission rates. Materials and MethodsInclusion criteria for the current study is SCS placement between 2015 and 2020, with receipt of an SCS using either a percutaneous approach or an open laminectomy based approach. Encounters included were limited to true SCS placement, such that trial placements were not included in the study. Univariate statistics and multivariable logistic regression was performed to compare outcomes between cohorts. ResultsTotal SCS case volumes were 9935 between the percutaneous (n = 4477, 45.1%) and open (n = 5458, 54.9%) approach. Patients receiving the percutaneous approach were found to have a mean decrease in LOS of 9.91 hours when compared to those receiving the open approach. The percutaneous approach was significantly associated with the need for reoperation within one year compared to the open approach (odds ratio [OR]: 0.663, p < 0.001), as well as with the need for readmission within 30 days (51.2% vs 40.2%, OR: 0.759, p < 0.001). ConclusionThe open approach, when compared to the percutaneous approach, had a longer mean LOS, lower outpatient discharge rates, and higher odds of experiencing an operative complication in comparison to the percutaneous approach. The percutaneous approach had relatively increased odds of thirty-day readmission, although no significant difference in one-year readmission or removal was demonstrated.

Long-term Outcomes in Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators Compared With Conventional Medical Therapy for Chronic Pain.

Spinal cord stimulators (SCSs) are increasingly used for the treatment of chronic pain. There is a need for studies with long-term follow-up. To determine the comparative effectiveness and costs of SCSs compared with conventional medical management (CMM) in a large cohort of patients with chronic pain. This was a 1:5 propensity-matched retrospective comparative effectiveness research analysis of insured individuals from April 1, 2016, to August 31, 2018. This study used administrative claims data, including longitudinal medical and pharmacy claims, from US commercial and Medicare Advantage enrollees 18 years or older in Optum Labs Data Warehouse. Patients with incident diagnosis codes for failed back surgery syndrome, complex regional pain syndrome, chronic pain syndrome, and other chronic postsurgical back and extremity pain were included in this study. Data were analyzed from February 1, 2021, to August 31, 2022. SCSs or CMM. Surrogate measures for primary chronic pain treatment modalities, including pharmacologic and nonpharmacologic pain interventions (epidural and facet corticosteroid injections, radiofrequency ablation, and spine surgery), as well as total costs. In the propensity-matched population of 7560 patients, mean (SD) age was 63.5 (12.5) years, 3080 (40.7%) were male, and 4480 (59.3%) were female. Among matched patients, during the first 12 months, patients treated with SCSs had higher odds of chronic opioid use (adjusted odds ratio [aOR], 1.14; 95% CI, 1.01-1.29) compared with patients treated with CMM but lower odds of epidural and facet corticosteroid injections (aOR, 0.44; 95% CI, 0.39-0.51), radiofrequency ablation (aOR, 0.57; 95% CI, 0.44-0.72), and spine surgery (aOR, 0.72; 95% CI, 0.61-0.85). During months 13 to 24, there was no significant difference in chronic opioid use (aOR, 1.06; 95% CI, 0.94-1.20), epidural and facet corticosteroid injections (aOR, 1.00; 95% CI, 0.87-1.14), radiofrequency ablation (aOR, 0.84; 95% CI, 0.66-1.09), or spine surgery (aOR, 0.91; 95% CI, 0.75-1.09) with SCS use compared with CMM. Overall, 226 of 1260 patients (17.9%) treated with SCS experienced SCS-related complications within 2 years, and 279 of 1260 patients (22.1%) had device revisions and/or removals, which were not always for complications. Total costs of care in the first year were $39 000 higher with SCS than CMM and similar between SCS and CMM in the second year. In this large, real-world, comparative effectiveness research study comparing SCS and CMM for chronic pain, SCS placement was not associated with a reduction in opioid use or nonpharmacologic pain interventions at 2 years. SCS was associated with higher costs, and SCS-related complications were common.

Comparison of Characteristics, Inpatient Outcomes, and Trends in Percutaneous Versus Open Placement of Spinal Cord Stimulators

ObjectivesSpinal cord stimulation (SCS) is an effective treatment modality for chronic pain conditions for which other treatment modalities have failed to provide relief. Ample prospective studies exist supporting its indications for use and overall efficacy. However, less is known about how SCS is used at the population level. Our objective is to understand the demographics, clinical characteristics, and utilization patterns of open and percutaneous SCS procedures. Materials and MethodsThe Nationwide Inpatient Sample data base of 2016–2019 was queried for cases of percutaneous or open placement (through laminotomy/laminectomy) of SCS (excluding SCS trials) using International Classification of Disease (ICD), 10th revision, procedure coding system. Baseline demographic characteristics, complications, ICD-Clinical Modification, Diagnosis Related Group, length of stay (LOS), and yearly implementation data were collected. Complications and outcomes were evaluated in total and between the open and percutaneous SCS groups. ResultsA total of 2455 inpatients had an SCS placed, of whom 1970 (80.2%) received SCS through open placement. Placement of open SCS was associated with Caucasian race (odds ratio [OR] = 1.671, p < 0.001), private insurance (OR = 1.332, p = 0.02), and age more than 65 years (OR = 1.25, p = 0.034). The most common diagnosis was failed back surgery syndrome (23.8%). Patients with percutaneous SCS were more likely to have a hospital stay of < 1 day (OR = 2.318; 95% CI, 1.586–3.387; p < 0.001). Implant complications during the inpatient stay were positively associated with open SCS placement and reported in 9.4% of these cases (OR = 3.247, p < 0.001). ConclusionsPatients who underwent open SCS placement were more likely to be older, Caucasian, and privately insured. Open SCS placement showed greater LOS and implant-related complications during their hospital stay. These findings highlight both potential socioeconomic disparities in health care access for chronic pain relief and the importance of increasing age and medical comorbidities as important factors that can influence SCS implants in the inpatient setting.

P111. Spinal cord stimulators adversely affect outcomes in deformity surgery

P111. Spinal cord stimulators adversely affect outcomes in deformity surgery

Spinal cord stimulator for the treatment of central neuropathic pain secondary to cervical syringomyelia: illustrative case.

Central neuropathic pain (CNP) of the cervical and/or thoracic spinal cord has many etiologies, both natural and iatrogenic. Frequently, CNP is medically refractory and requires surgical treatment to modulate the perception of pain. Spinal cord stimulation is a modality commonly used in adults to treat this type of refractory pain; however, it is rarely used in the pediatric population. The authors reported a case involving a common pediatric condition, Chiari malformation type I with syrinx, that led to a debilitating complex regional pain syndrome. The associated life-altering pain was successfully alleviated following placement of a spinal cord stimulator. CNP, or the syndromic manifestations of the pain (complex regional pain syndrome), can alter an individual's life in dramatic ways. Spinal cord stimulator placement in carefully selected pediatric patients should be considered in these difficult pain treatment paradigms.

Incidence and Predictors of Inadvertent Dural Puncture After Percutaneous Spinal Cord Stimulation: A Retrospective Database Analysis

ObjectivesInadvertent dural puncture (IDP) is a known complication associated with traditional neuraxial procedures; however, its characterization after percutaneous spinal cord stimulation (SCS) lead placement has yet to be clearly established in large population studies. This retrospective analysis aims to understand the incidence and associated characteristics of patients with IDP after percutaneous SCS lead placement. Materials and MethodsThe PearlDiver Mariner database of national all-payer claims was used to identify patients who received percutaneous SCS leads and had a claim for IDP (intraoperative IDP or postdural puncture headache [PDPH] claim) within 45 days. The primary outcome was to determine the overall incidence of IDP. Secondary outcomes included an evaluation of associated risk factors for IDP and treatments used in symptomatic management. ResultsA total of 90,952 patients who underwent percutaneous lead SCS placement were included. The incidence of IDP was 0.48% (436/90,952 patients). Older age (odds ratio [OR]: 0.96; 95% CI: 0.95–0.97; p < 0.0001) and male sex (OR: 0.66; 95% CI: 0.53–0.81; p < 0.001) had a lower odds of having a claim for IDP, whereas a history of IDP was associated with a higher OR (95% CI) by 13.72 times (10.72–17.58) (p < 0.0001). Of the IDP patients, 64% (277/436 patients) had a claim for a therapeutic blood patch. Discrepancy in type of claim for IDP was observed, with most being for PDPH. ConclusionsOur findings suggest that IDP after percutaneous SCS lead placement is an uncommon event; however, certain factors are associated with its development. Overall, early recognition of IDP after percutaneous SCS lead placement is imperative to facilitate the delivery of targeted treatments and prevent further harmful consequences to the patient.