Thoracic Spinal Cord Stimulation Research Articles

A Case Report of Successful Off-Label Neuromodulation for Concurrent Refractory Sacroiliac Pain and Phantom Limb in a Hip Disarticulation Patient

Hip disarticulation is a morbid procedure for those whose bony or soft tissues are unable to be salvaged. It involves extensive resection, and the patient featured in this report expressed mechanical pain from their sacroiliac joint (SIJ) as well as phantom limb pain (PLP). Spinal cord stimulation is known to assist with neuropathic pain syndromes, and SIJ fusion is effective in these cases of multifactorial pain. This report presents a successful off-label use of thoracic spinal cord stimulation in a complex pain condition consisting of coexisting PLP and mechanical SIJ pain in a hip disarticulation patient.

Intrathecal placement of percutaneous spinal cord stimulation leads: illustrative cases.

Spinal cord stimulation (SCS), including the percutaneous placement of epidural stimulation leads, has been increasingly utilized to treat chronic pain. Although lead migration is a well-characterized complication, few studies have reported on malpositioned leads in the intrathecal space. Here, the authors discuss two cases of intrathecal lead placement necessitating surgical revision. This report is a two-case series on the inadvertent placement of percutaneous SCS leads in the intrathecal space. The authors describe the identification of malpositioned leads, describe the clinical presentation, characterize stimulation parameters, and report improvement following neurosurgical revision for each case. Two patients originally presenting with chronic low-back pain underwent percutaneous SCS lead implantation. Both patients presented with atypical pain symptoms in the acute to subacute postprocedural period, raising suspicion for malpositioned leads. Imaging was consistent with intrathecal malpositioning. Both patients underwent revision surgery resulting in symptomatic improvement. Indicators of malpositioned thoracic SCS leads in the intrathecal space include thoracoabdominal or flank pain exacerbated by movement, insufficient pain relief versus that in the SCS trial, very low electrode impedances, direct visualization on imaging, and lack of epidural lead visualization following laminectomy. Revision options include removal of the intrathecal leads and the surgical placement of a paddle electrode in the epidural space. https://thejns.org/doi/10.3171/CASE24275.

Spinal cord stimulation for postural abnormalities in Parkinson’s disease: 1-year prospective pilot study

BackgroundPostural abnormalities (PA) are common in the advanced stages of Parkinson’s disease (PD), but effective therapies are lacking. A few studies suggested that spinal cord stimulation (SCS) could be a potential therapy whereas its effect is still uncertain. We aimed to investigate whether SCS had potential for benefiting PD patients with PA.MethodsT8-12 SCS was operated on six PD patients with PA and all patients were followed for one year. Evaluations were made before and after SCS. Moreover, three patients were tested separately with SCS on-state and off-state to confirm the efficacy of SCS.ResultsImprovements in lateral trunk flexion degree, anterior thoracolumbar flexion degree and motor function were found after SCS. The improvements diminished while SCS was turned off.ConclusionsLower thoracic SCS may be effective for improving PA in PD patients, but further studies are needed to confirm this conclusion.Trial registrationChinese Clinical Trial Registry, ChiCTR1900024326, Registered on 6th July 2019; https://www.chictr.org.cn/showproj.aspx?proj=40835.

Functional mapping of the lower urinary tract by epidural electrical stimulation of the spinal cord in decerebrated cat model

Several neurologic diseases including spinal cord injury, Parkinson’s disease or multiple sclerosis are accompanied by disturbances of the lower urinary tract functions. Clinical data indicates that chronic spinal cord stimulation can improve not only motor function but also ability to store urine and control micturition. Decoding the spinal mechanisms that regulate the functioning of detrusor (Detr) and external urethral sphincter (EUS) muscles is essential for effective neuromodulation therapy in patients with disturbances of micturition. In the present work we performed a mapping of Detr and EUS activity by applying epidural electrical stimulation (EES) at different levels of the spinal cord in decerebrated cat model. The study was performed in 5 adult male cats, evoked potentials were generated by EES aiming to recruit various spinal pathways responsible for LUT and hindlimbs control. Recruitment of Detr occurred mainly with stimulation of the lower thoracic and upper lumbar spinal cord (T13-L1 spinal segments). Responses in the EUS, in general, occurred with stimulation of all the studied sites of the spinal cord, however, a pronounced specificity was noted for the lower lumbar/upper sacral sections (L7-S1 spinal segments). These features were confirmed by comparing the normalized values of the slope angles used to approximate the recruitment curve data by the linear regression method. Thus, these findings are in accordance with our previous data obtained in rats and could be used for development of novel site-specific neuromodulation therapeutic approaches.

348 Comparison of Brain Functional Imaging of Pain States Using Resting-State fMRI and Multi-Delay pCASL to Clinical Scores of Pain in Chronic Low Back Pain Patients Implanted With Thoracic Spinal Cord Stimulation

INTRODUCTION: Thoracic spinal cord stimulation (tSCS) is an interventional option for patients with refractory chronic low back pain (cLBP). The use of functional imaging of brain regions involved in pain as a quantitative method to evaluate treatment effectiveness has not yet been studied. METHODS: pCASL data using 5 post-label delays (0.5-2.5s) alongside rs-fMRI data was gathered from five patients (4 M, 1F) post-tSCS with cLBP post-implantation with the SCS device turned off at a 3.0T scanner. Arterial transit time (ATT), cerebral blood flow (CBF), and cerebral blood volume (CBV) were derived from pCASL data. Amplitude of low-frequency fluctuation (ALFF), fractional ALFF (fALFF), degree of centrality (DC) and regional homogeneity (ReHo) were derived from rs-fMRI data. These data were registered against a pain-ROI atlas. The following clinical pain scores were assessed in the same five patients: Numerical Pain Rating Scale (NPRS), Visual Analogue Scale (VAS), Central Sensitization Inventory (CSI), Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCS), Pittsburgh Sleep Quality Index (PSQI) and Hospital Anxiety and Depression Scale (HADS). Predictive linear associations between pain ROIs and clinical scores were investigated using linear regression. RESULTS: Significant linear associations (p-value < 0.001) were found between pCASL-derived ATT to the dorsolateral prefrontal cortex (DLPC) and the NPRS; CBF to the ventral posterolateral thalamus (VPL) and the VAS, and of the posterior cingulate cortex (PCC) and the VAS; CBV of the posterior short gyrus (PS) and the VAS; and rs-fMRI-derived fALFF of the amygdala and the CSI. CONCLUSIONS: A comparison of functional imaging results and clinical pain scores suggest predictive relationships between resting-state function/brain perfusion in regions involved in pain perception and processing and various clinical pain assessments.

354 Feasibility and Clinical Imaging of Pain States Based on Multi-Delay Arterial Spin Labeling in Chronic Low Back Pain Patients Implanted With Thoracic Spinal Cord Stimulation

INTRODUCTION: Multi-delay, pseudo-continuous arterial spin labelling (PCASL) is a novel technique capable of perfusion imaging without contrast. It overcomes the limitation of a low signal-to-noise ratio of pulsed-ASL, and multiple post-label delays allow it to account for and measure arterial transit time (ATT). This makes it a suitable tool for the perfusion assessment. To date, there have been no studies to assess changes in ASL-measured perfusion in chronic low-back pain (cLBP) patients treated with thoracic spinal cord stimulation (tSCS). METHODS: PCASL data was acquired in five patients post-tSCS and five healthy subjects. ATT was estimated using weighted delays from multiple delay times, and it was used to calculate cerebral blood flow (CBF) and cerebral blood volume (CBV). Maps were normalized into MNI space and smoothed. Averaged values of ATT, CBF and CBV from pain ROI atlas were extracted and compared between cLBP and healthy control groups. Statistics comparing perfusion changes between patients and healthy subjects were conducted after Box-Cox transformation of data using Wilcoxon rank sum. RESULTS: Our results demonstrated the feasibility of MRI scanning with ASL sequence in patients with SCS. Specific absorption rates ranged from 0.031–0.042W/kg. Wilcoxon test indicated that ATT was significantly greater in cLBP patients within the supplementary motor area, posterior short gyrus, and the orbitofrontal cortex. There were no significant differences in patients and controls in CBF or CBV. CONCLUSIONS: Rate of perfusion as indexed by PCASL-derived ATT is reduced in cLBP treated with SCS patients in regions associated with pain processing, cognition, and motor planning. Insignificant results in CBF and CBV measures are likely due to low sample size of patients.

349 Brain Functional Imaging of Pain States Using Resting-State fMRI and Multi-Delay PCASL in Chronic Low-Back Pain Patients Implanted With Thoracic Spinal Cord Stimulation

INTRODUCTION: A treatment of chronic low-back pain is implantation of a thoracic spinal cord stimulator (tSCS), which has been shown to reduce pain. The functional changes in pain processing regions of the brain as assessed by resting-state fMRI and multi-delay pseudocontinuous arterial spin labeling (PCASL) have never been studied. METHODS: PCASL data based on 5 post-label delays (0.5–2.5s) as well as rsfMRI were acquired in five patients (1F) post-tSCS with cLBP and five healthy subjects (2F). Patient MRI scans were taken post-implantation with the SCS device turned off. Three PCASL measures and four rsfMRI measures were derived and normalized into MNI space and smoothed. Averaged values for each measure from the pain ROI atlas were extracted and compared between patients and controls. Statistics were conducted following Box-Cox transformation of data. RESULTS: Arterial transit time derived from PCASL showed a significant difference in the OFC, SMA, and PSG of patients, but other ASL measures showed no effect. Several regions across the rs-fMRI measures showed significant differences, including those involved in cognition (DLPFC, PCC), and pain processing (PSG) and sensation (S2). CONCLUSIONS: Functional imaging showed that cLBP patients treated with SCS display differences in resting-state function and brain perfusion across several pain regions of the brain. These areas are mainly part of the cognitive and behavioral components of the pain circuitry.

360 Diffusion Imaging-Derived Structural Changes in Cerebral Pain Regions of Chronic Low-Back Pain Patients Implanted With Thoracic Spinal Cord Stimulation

INTRODUCTION: Thoracic spinal cord stimulation (tSCS) is an effective treatment of chronic low-back pain (cLBP). Although diffusion imaging has been conducted in this group of patients, the study of diffusion-derived structural imaging of regions involved in pain processing has not been conducted. METHODS: Diffusion-weighted imaging scans were acquired in five patients (1 female) post-tSCS with cLBP and five healthy subjects (2 female). Patient MRI scans were taken post-implantation with the SCS device turned off during the MRI session. Four DTI maps and four MAP maps were derived and normalized into MNI space and smoothed. DTI and MAP values for each measure from the pain ROI atlas were extracted and compared between patients and controls. RESULTS: Statistically significant differences were found in regions involved with sensory processing of pain (ASG, PSG) as well as affective pain experience (ACC) across the DTI measures. MAP measures showed significance across five ROIs involved with sensory processing of pain, affective pain experience, and fear response (AMYG). CONCLUSIONS: Diffusion-derived structural imaging of pain regions suggests that cLBP patients receiving SCS have differences in diffusion imaging-derived structural parameters involved with pain processing, cognition, and fear response.

353 Comparison of Brain Diffusion-Weighted Imaging of Cerebral Pain Regions Using DTI and MAP to Clinical Scores of Pain in Chronic Low Back Pain Patients Implanted With Thoracic Spinal Cord Stimulation

INTRODUCTION: Thoracic spinal cord stimulation (SCS) may be an effective treatment option for patients with chronic low back pain (cLBP), and pain levels can be assessed using subjective clinical scores. The use of diffusion-derived imaging of brain regions involved in pain has yet to be studied. METHODS: DTI and MAP data was gathered from five cLBP patients (4 M, 1F) post-tSCS scanned at a 3.0T scanner. Four DTI measures and four MAP measures were extracted and registered against a pain-ROI atlas. The following clinical pain scores were assessed in the same five patients: Numerical Pain Rating Scale (NPRS), Visual Analogue Scale (VAS), Central Sensitization Inventory (CSI), Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCS), Pittsburgh Sleep Quality Index (PSQI) and Hospital Anxiety and Depression Scale (HADS). The associations between clinical scores and pain ROIs were investigated using linear regression. RESULTS: Within these eight measures, 16 significant linear associations were found between pain ROIs and clinical pain scores. The regions involved are areas of the cerebrum and thalamus involved in pain perception and processing: the secondary somatosensory cortex, the ventral posterolateral and mediodorsal nuclei of the thalamus, and the anterior long, anterior inferior, and middle short gyri of the insula. CONCLUSIONS: Diffusion-derived imaging, using DTI and AMURA/MAP techniques, shows microstructural changes in brain regions involved in pain with significant linear associations with clinical pain scores. As a result, diffusion-derived indices show potential to be used as a complementary quantitative measure to assess pain in cLBP patients receiving tSCS.

Perceptions of pain in aging females undergoing spinal cord stimulation.

Aim: Effects of age and sex on chronic pain outcomes following spinal cord stimulation (SCS) have not yet been assessed. Methods: We retrospectively reviewed 1year outcomes from a database of patients receiving thoracic SCS. Subjects were divided into four cohorts: pre-menopausal and post-menopausal females, and aged-matched males. Improvement using the numerical rating scale, Oswestry Disability Index (ODI), Beck's Depression Inventory (BDI), McGill Pain Questionnaire and Pain Catastrophizing Scale (PCS) was assessed. Results: Older females were notably different from males and females under 60 as they had greater improvements in ODI, BDI and PCS. Further, females ≥60 had greater improvement in PCS compared with males ≥60. Conclusion: Our findings suggest greater improvement with 1year SCS treatment in post-menopausal females, compared with age-matched males.

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.

Combined cervical and thoracic spinal cord stimulation for chronic pain: A systematic literature review.

Spinal cord stimulation (SCS) is conventionally placed at either cervical or thoracic spinal regions to treat chronic pain. However, for patients with multiarea pain, concomitant cervical and thoracic SCS (ctSCS) may be necessary to provide sufficient coverage. It remains unknown whether ctSCS is effective and safe. Thus, we aimed to survey the existing literature and assess the efficacy and safety of ctSCS. A systematic review of the literature was performed according to the 2020 PRISMA guidelines to investigate pain, functional, and safety outcomes related to ctSCS. Articles between 1990 and 2022 available through PubMed, Web of Science, Scopus, and Cochrane Library databases were included if they assessed these outcomes in the context of ctSCS. Data extracted from articles included study type, number of ctSCS implantations, stimulation parameters, indications for implantation, complications, and frequency. The Newcastle-Ottawa scale was used to assess risk of bias. Three primary studies met our inclusion criteria. Overall, ctSCS was effective in providing analgesia. Pain severity was captured with patient-reported pain scales and changes in analgesic requirements. Various metrics were used to quantify quality of life and functional outcomes. Failed back surgery syndrome was the most common indication for ctSCS implantation. Implanted pulse generator pocket pain was the most common postoperative adverse event. Despite the limited evidence available, ctSCS seems to be effective and generally well tolerated. The dearth of relevant primary literature illustrates a knowledge gap, and future studies are needed to better clarify the efficacy and safety profile of this SCS variant.

Safety and Feasibility of Cervical and Thoracic Transcutaneous Spinal Cord Stimulation to Improve Hand Motor Function in Children With Chronic Spinal Cord Injury

ObjectiveIn adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI. Materials and MethodsIn this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3–C4 and C6–C7) and thoracic (T10–T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks. ResultsAll seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20–70 mA and thoracic site = 25–190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS. ConclusionsWe indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS. Clinical Trial RegistrationThe Clinicaltrials.gov registration number for the study is NCT04032990.

ID: 209150 Cervical and High Thoracic Spinal Cord Stimulation to Treat Refractory Failed Back Surgery Syndrome

Failed back surgery syndrome (FBSS) is defined as spinal pain of unknown origin, which persists following surgical intervention or newly presents after spine surgery. This pain may originate from surgery, or the surgery may worsen or insufficiently reduce prior pain (1). From 2004 to 2015, the volume of lumbar fusion surgery increased by 62.3% (2). With the frequency of lumbar fusion surgery comes an increased propensity to develop FBSS. The risk of developing FBSS in patients who have undergone lumbar spine surgery is as high as 50% (3). Spinal cord stimulation (SCS) is a well-established, safe, and effective treatment modality for refractory neuropathic pain conditions such as FBSS (4).

ID: 217176 Conus Medullaris Stimulation Versus Thoracic Spinal Cord Stimulation for the Management of Chronic Pelvic Pain

While spinal cord stimulation has been well studied for the treatment of chronic neuropathic pain for the upper and lower extremities, few reports exist for the utility of spinal cord stimulation for the management of chronic pelvic pain. Furthermore, of the studies that describe spinal cord stimulation for pelvic pain, few are able to effectively compare the efficacy of thoracic spinal cord stimulation versus other stimulation modalities in the same patient. Pelvic sympathetic viscera are innervated by fibers at T12-L2 roots, while parasympathetic roots are at S1-S4. Evidence suggests that pelvic pain is well covered with conus stimulation as it captures the S2-S5 segment.

ID: 210537 Perceptions of Pain in Menopausal Women Undergoing Spinal Cord Stimulation

Older women transitioning to menopause undergo a myriad of physical symptoms such as low back pain, joint pain, mood disturbances, and chronic pain due to hormonal alterations1. Furthermore, aging results in altered perceptions of pain2. A current need exists to ascertain the benefits of spinal cord stimulation (SCS) in older women. We therefore retrospectively reviewed a prospectively collected database of thoracic SCS patients.

Neuromodulation Through Spinal Cord Stimulation Restores Ability to Voluntarily Cycle After Motor Complete Paraplegia.

Abstract Epidural spinal cord stimulation (eSCS) of the lower thoracic spinal cord has been shown to partially restore volitional movement in patients with complete chronic spinal cord injury (cSCI). Combining eSCS with intensive locomotor training improves motor function, including standing and stepping, but many patients with cSCI suffer from long-standing muscle atrophy and loss of bone mineral density, which may prohibit safe implementation. Safe, accessible, and effective avenues for pairing neuromodulation with activity-based therapy remain unexplored. Cycling is one such option that can be utilized as an eSCS therapy given its low-risk and low-weight-bearing requirement. We investigated the feasibility and kinematics of motor-assisted and passive cycle-based therapy for cSCI patients with epidural spinal cord stimulation. Seven participants who underwent spinal cord stimulation surgery in the Epidural Stimulation After Neurologic Damage (E-STAND) trial (NCT03026816) participated in a cycling task using the motor assist MOTOmed Muvi 300. A factorial design was used such that participants were asked to cycle with and without conscious effort with and without stimulation. We used mixed effects models assessing maximum power output and time pedaling unassisted to evaluate the interaction between stimulation and conscious effort. Cycling was well-tolerated and we observed no adverse events, including in participants up to 17 years post-initial injury and up to 58 years old. All participants were found to be able to pedal without motor assist, which primarily occurred when stimulation and effort were applied together (p = 0.001). Additionally, the combination of stimulation and intention was significantly associated with higher maximum power production (p < 0.0001) and distance pedaled (p = 0.0001). No association was found between volitional movement and participant factors: age, time since injury, and spinal cord atrophy. With stimulation and conscious effort, all participants were able to achieve active cycling without motor assistance. Thus, our stationary cycling factorial study design demonstrated volitional movement restoration with eSCS in a diverse study population of cSCI participants. Further, motor-assist cycling was well-tolerated without any adverse events. Cycling has the potential to be a safe research assessment and physical therapy modality for cSCI patients utilizing eSCS who have a high risk of injury with weight bearing exercise. The cycling modality in this study was demonstrated to be a straightforward assessment of motor function and safe for all participants regardless of age or time since initial injury.

High-Frequency Cervical and High Thoracic Spinal Cord Stimulation to Treat Refractory Failed Back Surgery Syndrome in a Patient with Chronic Neck and Low Back Pain: Case Report

BACKGROUND: Failed back surgery syndrome (FBSS) is defined as lumbar spinal pain of unknown origin that persists following surgical intervention or newly presents after spine surgery (1). This pain may originate from surgery, or the surgery may worsen or insufficiently reduce prior pain (1). From 2004 to 2015, the volume of lumbar fusion surgery increased by 62.3% (2). With the frequency of lumbar fusion surgery comes an increased propensity to develop FBSS. The risk of developing FBSS in patients who have undergone lumbar spine surgery is as high as 50% (3). Spinal cord stimulation (SCS) is a well-established, safe, and effective treatment modality for refractory neuropathic pain conditions such as FBSS (4). CASE REPORT: A 47-year-old patient presented to the clinic with a history of cervical radiculopathy status post C4-C7 posterior spinal fusion, lumbar radiculopathy, lumbar spinal stenosis, congenital spondylolisthesis status post L5-S1 anterior lumbar interbody fusion complicated by a malpositioned screw at the L4-L5 level, L4-L5 retrolisthesis, L5-S1 pseudoarthrosis with subsequent T10 to pelvis fusion, which was later extended to T8 after a fall. The patient developed FBSS resulting in debilitating neck and low back pain. Permanent SCS with leads at C7-T3 were placed without complication. The SCS implant resulted in successful treatment of FBSS with an 80% reduction in pain scores, 86% reduction in MME consumption, and an improvement in performance of activities of daily living. CONCLUSION: This case highlights the use of SCS leads placed over the low cervical and high thoracic levels for the treatment of cervical and lumbar back pain. Due to the complex surgical history of the patient, a unique lead implantation location spanning C7-T3 was required. This lead location is significantly cephalad to the typical lead implantation location of T8-L1 for the treatment of chronic lumbar back pain, as the T8-L1 levels are where neurons responsible for back pain are most heavily concentrated (5). This case highlights the effectiveness of SCS therapy implanted at an atypical location for the treatment of FBSS. KEY WORDS: Atypical cervical and thoracic spinal cord stimulation, case report, chronic refractory neck and low back pain, failed back surgery syndrome, neuromodulation

A Case of Spinal Cord Injury Caused By Electrical Stimulation of Thoracic Spinal Cord for Treatment of Diabetic Foot

The thoracic Spinal Cord Stimulator (SCS) has been widely accepted as a treatment option for diabetic foot and is gaining acceptance. This case highlights a previously unreported potential complication of the SCS. A 66-year-old man had long-standing diabetes (30 years) and hypertension (10 years), accompanied by diabetic foot and generalized psoriasis. The patient reported pain in the bilateral lower extremities, especially in both feet, which was significant at night and when walking. His Visual Analog Scale (VAS) pain score was 10/10. The pain was accompanied by slight numbness without sensory disturbance. These symptoms gradually exacerbated over 2 months. His Quality of Life Scale (QOLS) score was 186, and the skin temperature of both his feet decreased at rest. Following conservative treatment elsewhere, the abovementioned symptoms remained refractory; the patient presented to our hospital for further treatment. SCS was implanted on June 6, 2021 for pain relief.