Background & Aims
Although considered intrinsically safe, spinal cord
stimulation (SCS), surgery related complications
have been reported in literature(1,2,3,4). Local
pain/tenderness/ neuropathic sensations at the
IPG site (0.9-12%, mean 6.15%) is one of the
commonest procedure related complication that
may also result in poor patient satisfaction and
limited compliance of therapy(5).
Gluteal IPG site pain remains a challenge and can
result in failure of therapy despite adequate
dermatomal coverage. Due to the inherent issue
of slow healing, pain can become persistent with
neuropathic characteristics. Persistence of the
pain may mandate revision or even explantation in
unto 7% of patients(7,8). Pre-emptive mitigating measures for this
have never been studied. This is the first
prospective single centre observational study
reporting the effects of pre-emptive use of
lidocaine patches to evaluate their efficacy and
usefulness in the prevention of IPG site pain.
Methods
After local trust committee approval (March
2022), patients implanted with SCS from
March 2022 till November 2022 were reviewed
at their 14 day wound check follow-up. After
ensuring adequate wound closure and
confirmation of no signs of infection, they were
instructed to apply lidocaine patches for 4
weeks over IPG siteIn case of inadequate wound healing, patch
application was delayed by further 2 weeks.
Data were collected at 1, 3 and 6 months
clinical reviews through validated pain
questionnaires. Extended patch application for
further 8 weeks was offered to patients who
presented IPG site pain at the 1 month follow
up.
Results
Total 47 patients were enrolled and followed up
to 6 months . Six patients (13%) reported IPG
site pain ?3/10 on NRS Scale over 6 months
out which four patients (8.5%) reported at one
month follow up. Two of these had complete
resolution of pain by three months. One patient
reported pain at 3 months (5/10) which got
better by 6 months. One patient presented pain
at 6 months (4/10), who was managed
conservatively beyond 6 months. Two required
revision due to other concomitant reasons, who
had persistent IPG site pain. Thus total 3
patients continued with IPG site pain till and
beyond 6 months (6.3%).
Conclusions
In our study, the prevalence of IPG site gluteal
pain at 6 months appears to be with in lower
range of reported limit (6.3%). The pain was
less intense and manageable with the preemptive
application of lignocaine patches.
Delayed wound healing was implicated in the
late start of application of patches for two
patients who had IPG site pain at one month
and responded to lidocaine plasters.
The concomitant factors necessitating revision
included-
1.Allergy to lidocaine plasters , hence inability
to apply
2. Lead migration
These two patients continued to have
persistent IPG site pain after revision surgery
This is the first reported evaluation of preemptive
application of Lidocaine plasters for
the IPG site pain. This may be an effective
therapeutic measure in reducing the IPG site
complication rate. Revision surgery can lead
to increased chance of IPG site pain
irresponsive to lignocaine plasters ,
require meticulous planning to look for alternate IPG site.
References
Shealy CN, Mortimer JT, Hagfors NR. Dorsal column electroanalgesia. J Neurosurg. 1970 May;32(5):560-4. doi: 10.3171/jns.1970.32.5.0560. PMID: 5438096.
Timothy R. Deer, MD, C. Douglas Stewart, PA/C, MBA, Complications of Spinal Cord Stimulation: Identification, Treatment, and Prevention, Pain Medicine, Volume 9, Issue suppl_1, May 2008, Pages S93–S101, https://doi.org/10.1111/j.1526-4637.2008.00444.x
Turner JA, Loeser JD, Deyo RA, Sanders SB. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications. Pain. 2004 Mar;108(1-2):137-47. doi: 10.1016/j.pain.2003.12.016. PMID: 15109517.
Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Thomson S, Raso L, Burton A, DeAndres J, Buchser E, Buvanendran A, Liem L, Kumar K, Rizvi S, Feler C, Abejon D, Anderson J, Eldabe S, Kim P, Leong M, Hayek S, McDowell G 2nd, Poree L, Brooks ES, McJunkin T, Lynch P, Kapural L, Foreman RD, Caraway D, Alo K, Narouze S, Levy RM, North R; Neuromodulation Appropriateness Consensus Committee. The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation. 2014 Aug;17(6):571-97; discussion 597-8. doi: 10.1111/ner.12206. PMID: 25112891.
Sam Eldabe, MB ChB, FCRA, FFPMRCA, Eric Buchser, MD, DEAA, Rui V. Duarte, PhD, Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature, Pain Medicine, Volume 17, Issue 2, February 2016, Pages 325–336, https://doi.org/10.1093/pm/pnv025
Baranidharan G, Bretherton B, Richert G, Kay T, Marsh N, Roberts B, Romanis C. Pocket pain, does location matter: a single-centre retrospective study of patients implanted with a spinal cord stimulator. Reg Anesth Pain Med. 2020 Nov;45(11):891-897. doi: 10.1136/rapm-2020-101752. Epub 2020 Sep 16. PMID: 32938712.
Bao J, Khazen O, Olmsted ZT, Gechtman G, Shao MM, DiMarzio M, Topp G, Sukul VV, Staudt MD, Pilitsis JG. Treatment Strategies for Generator Pocket Pain. Pain Med. 2021 Jun 4;22(6):1305-1311. doi: 10.1093/pm/pnab007. PMID: 33502508; PMCID: PMC8185558.
Presenting Author
Mohd Yunus Khilji
Poster Authors
mohammed yunus khilji
MD, FFPMRCA
Sardar Patel Medical College Bikaner
Lead Author
Topics
- Specific Pain Conditions/Pain in Specific Populations: Neuropathic Pain - Peripheral