Limitations of spinal cord stimulation for pain management

the spinal cord stimulation is very useful treatment modality for intractable pain. The spinal cord stimulator (SCS) has been applied for the treatment of pain associated with many different disease entities, including intractable pain, headache, and angina pain. It has also been applied for non-pain-related conditions such as congestive heart failure, ischemic peripheral vascular disease, interstitial cystitis, intractable spasticity, and cerebral vasospasm after subarachnoid hemorrhage [2-6]. In a previous issue of the Korean journal of anesthesiology, Lee et al. [7] described the pain management during a procedure for permanent spinal cord stimulation with a cylindrical type lead insertion. They mentioned that implantation of a permanent SCS system is painful and intolerable in some patients. Therefore they attempted to perform the procedure under epidural anesthesia. SCS systems are composed of three components: leads/electrodes, a generator/power source, and a programmer/ controller [8]. The leads can be divided into percutaneous leads and paddle leads. When pain physicians use percutaneous cylindrical type leads, procedure is usually performed under local anesthetic infiltration. However, actually many patients complain of pain or discomfort during SCS device implantation because they have existing severe pain that make worse. This case report suggests that epidural anesthesia is a good choice for reducing pain and ensuring safety during establishment of permanent spinal cord stimulation with percutaneous cylindrical type lead insertion. Many pain physicians, myself included, believe that the spinal cord stimulation is a lamp of hope for patients with intractable pain. However, some limitations confound our endeavors. Me-khail et al. [9] reported indications and complications of SCS in 707 cases with discussion. The reported complication rate ranges from 30 to 40%. The lead migration rate is 22.6%, the lead connection failure rate is 9.5%, and lead breakage rate is 6.0%. Lead migration complication is more frequent with percutaneous than paddle-type electrodes [3,5]. Infection was reported in 4.5% of patients and pain at the generator site in 12.0% of patients. Other complications include bleeding, paresthesia, and dural puncture [2,4,6]. Hardware related problems, such as lead failure, migration, and device malfunction, are more common than infection [10]. Complications may be avoided or at least diminished by performing a proper and strict aseptic surgical technique as well as regular checks and continuous follow-up [5]. Hayek et al. [11] reported the long-term implant survival rate and complications of SCS. The complication rate was 34.6%, and hardware related complications were the most common type of complications …