Successful relief of central poststroke pain with BurstDR spinal cord stimulation: A case series.

Background: Central poststroke pain (CPSP) is a commonly undertreated condition that can negatively impact a patient's quality of life. The efficacy of spinal cord stimulation (SCS) for the treatment of CPSP is not established due to limited studies. Case Description: Here, two patients, ages 42 and 75, sustained strokes resulting in CPSP. After failed medical management, both underwent placement of paddle-lead SCS systems utilizing BurstDR stimulation that successfully resulted in pain resolution. Conclusion: Two patients with CPSP were successfully treated with paddle lead SCS with BurstDR programming.

Movement disorder Deep brain stimulation Hybridization: Patient and caregiver outcomes.

Background and Objectives: Deep brain stimulation (DBS) is a well-established surgical treatment for certain movement disorders and involves the implantation of brain electrodes connected to implantable pulse generators (IPGs). As more device manufacturers have entered the market, some IPG technology has been designed to be compatible with brain electrodes from other manufacturers, which has facilitated the hybridization of implant technology. The aim of this study was to assess the benefits of hybridization of non-rechargeable, constant voltage IPGs to rechargeable, constant current IPGs. Methods: A list of DBS movement disorder patients who had their non-rechargeable, constant voltage IPGs replaced with rechargeable, constant current IPGs from a different manufacturer was compiled. Structured surveys of these patients, and their caregivers when applicable, were undertaken to determine both patient and caregiver satisfaction in this DBS hybridization strategy. Results: Eighteen patients met inclusion criteria and twelve patients or their caregivers completed the structured survey (67% response rate). Nine patients had Parkinson's disease (75%), three had essential tremor (25%). Nine (75%) were converted from bilateral single-channel IPGs, and three (25%) were converted from a unilateral dual-channel IPGs. Overall, 92% of patients and caregivers surveyed reported improvement or no change in their symptoms, 92% reported a decrease or no change in their medication requirements, and 92% report they are satisfied or very satisfied with their IPG hybridization and would recommend the surgery to similar patients. There were no immediate surgical complications. Conclusion: In this series of movement disorder DBS patients, surgery was safe and patient and caregiver satisfaction were high with a hybridization of non-rechargeable, constant voltage IPGs to rechargeable, constant current IPGs.

Inactivation of spinal cord stimulator implanted pulse generators after elective surgery: an under-recognized problem.

STUDY DESIGN: We retrospectively analyzed a database of implanted pulse generators (IPGs) for spinal cord stimulation (SCS) implanted by a single surgeon (NDT). We additionally report a series of five illustrative patient cases. OBJECTIVES: The electronics of SCS IPGs are susceptible to damage when implanted patients undergo surgery. Some SCSs have a dedicated surgery mode, while others recommend turning the SCS off to protect it from damage. IPG inactivation may require resetting or replacement surgery. We aimed to explore the prevalence of this real-world problem which has not been studied. SETTING: Pittsburgh, Pennsylvania. METHODS: Using a single surgeon SCS database, we identified cases of IPG inactivation after a non-SCS surgery and analyzed the management. We then reviewed the charts of five illustrative cases. RESULTS: Among 490 SCS IPG implantations between 2016-2022, 15 (3%) of the 490 patients' IPGs became inactivated after another non-SCS surgery. 12 (80%) required surgical IPG replacement, while 3 (20%) were able to have their IPG function restored non-operatively. In cases analyzed thus far, surgery mode was often not activated prior to surgery. CONCLUSION: SCS IPG inactivation by surgery is not a rare problem and is presumably engendered by monopolar electrocautery. Premature IPG replacement surgery carries risks and reduces the cost-effectiveness of SCS. Awareness of this problem may prompt more preventative measures to be taken by surgeons, patients, and caretakers, and encourage technological advances to render IPGs less vulnerable to surgical tools. Further research is needed to determine what quality improvement measures could prevent electrical damage to IPGs.

Paddle Lead Spinal Cord Stimulation in the Morbidly Obese Patient Population: Outcomes and Complications in a Single-Surgeon Cohort.

BACKGROUND: Paddle lead spinal cord stimulation (SCS) is used to treat refractory chronic pain. Morbidly obese patients seek SCS to reduce chronic pain. However, these patients face worse surgical outcomes, and the SCS literature has not evaluated safety and efficacy in this patient population. This study is the largest single-surgeon case series to date on morbidly obese patients with paddle lead SCS implantations. The primary objective is to report postoperative complication rates in morbidly obese patients receiving SCS implants. The secondary objective is to report patient-reported pain scores and Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and physical function scores in these patients. METHODS: A retrospective chart review was conducted. The patient charts were reviewed from the day of procedure consent to 6 months postop. Demographic information, pain scores, PROMIS scores, neurological complications, infections, and wound complications were documented. RESULTS: Sixty-seven patients were included. The mean preoperative BMI was 44.47 ± 4.02 kg/m2. The mean age was 58.9 ± 11.4 years old. There were no neurological complications. 3/67 (4%) developed culture-positive infections. Nine out of sixty-seven (13%) patients developed superficial wound dehiscence without underlying infection. The mean postop PROMIS physical function score was 31.6 ± 6.2 (n = 16) and the mean post-op PROMIS pain interference score was 64.0 ± 6.4 (n = 16). There was a reduction in pain scores, from 7.9 ± 1.7 preop to 5.7 ± 2.5 postop (n = 22, P = 0.004). CONCLUSIONS: Paddle lead SCS implantation is safe for morbidly obese patients. The only minimal-risk complications present were postoperative infections and wound dehiscence. Surgical care can be modified to further reduce the rates of infection and dehiscence.

Spinal cord stimulation: A novel approach to pain management in Dercum's disease.

Background: Dercum's Disease (DD) is a rare chronic pain syndrome in which patients experience extreme burning pain associated with subcutaneous lipomatous tissue deposits. These patients may also present with; weakness, psychiatric symptoms, metabolic derangements, sleep disturbance, impaired memory, and easy bruising. Common risk factors for DD include: obesity, Caucasian race, and female sex. The etiology of DD remains under debate while it has proven highly resistant to treatment (i.e., requiring high doses of opioids for adequate pain management). Case Description: A 48-year-old female with DD and a prior spinal cord stimulator (SCS) placed for chronic back pain, presented with recurrent back pain, and increased falling. Surgery to replace her SCS resulted in improvement in her back pain and a decreased incidence of falls. Furthermore, she noticed significant improvement in the burning pain attributed to her subcutaneous nodules; this most markedly occurred at and below the level of stimulator placement. Conclusion: A 48-year-old female with the extremely rare condition, DD experienced dramatic reduction in her pain following the successful revision of her SCS.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain.

Introduction: Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective: The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results: After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion: The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN).

Introduction: Lumbar spinal stenosis (LSS) is a common spinal disease of aging with a growing patient population, paralleling population growth. Minimally invasive treatments are evolving, and the use of these techniques needs guidance to provide the optimal patient safety and efficacy outcomes. Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for guidance on the prudent use of the innovative minimally invasive surgical therapies for the treatment of symptomatic LSS. The executive board nominated experts spanning anesthesiology, physiatry, orthopedic surgery, and neurosurgery based on expertise, publications, research, diversity and field of practice. Evidence was reviewed, graded using the United States Preventive Services Task Force (USPSTF) criteria for evidence and recommendation strength and grade, and expert opinion was added to make consensus points for best practice. Results: The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for LSS-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using USPSTF criteria and consensus points are presented. Discussion: The algorithm for patient selection in the management of symptomatic spinal stenosis is evolving. Careful consideration of patient selection and anatomic architecture variance is critical for improved outcomes and patient safety. Conclusion: ASPN created a guidance for best practice for minimally invasive surgical treatment of symptomatic spinal stenosis.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Best Practices for Cervical Neurostimulation.

INTRODUCTION: The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on the use of neurostimulation in the cervical region to improve outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for an often-overlooked area of neurostimulation practice. MATERIALS AND METHODS: Authors were chosen based upon their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to the present. Identified studies were graded using the US Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant. RESULTS: The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS: The NACC recommends best practices regarding the use of cervical neuromodulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be utilized as a guide to assist decision making when clinically appropriate.

Peripheral subcutaneous field stimulation for the treatment of spinal cord injury at-level pain: case report, literature review, and 5-year follow-up.

Spinal cord injury (SCI) frequently engenders chronic pain which may be classified as occurring above, at, or below the level of injury. Since patients with SCI may have a complex combination of nociceptive and neuropathic pain, pharmacological interventions often fail. Peripheral subcutaneous field stimulation (PSFS) is a novel neuromodulation surgery for pain in which subcutaneous electrodes designed for spinal cord stimulation are placed subcutaneously in a region of pain. We report the case of a 26-year-old man who was an unrestrained driver in a motor vehicle accident and suffered a complete ASIA A spinal cord injury with paraplegia due to a T4 three-column burst fracture. He underwent successful surgical fixation of the fracture (7/27/12) and developed severe at-level SCI-associated pain which failed all conservative measures. After a successful trial, two octrode leads (Abbott Medical, Plano, TX, USA) were placed for PSFS under general anesthesia and were connected to a right flank rechargeable pulse generator (11/6/13). At 60 months postoperative, the patient continues to use the peripheral field stimulation system on a daily basis and reports near complete relief of his at-level spinal cord injury pain. He noted instantaneous relief of his pain once ideal stimulation programming was achieved and has tolerated complete cessation of all narcotic use. His current programming settings are: Frequency of 50 Hz (Hz), Pulse Width of 350 µs (µsec), Amplitude of 0.00 miliamps (mA), Comf of 7.70 mA, and Perc of 4.50 mA. Chronic pain is a challenging and expensive sequela to manage in SCI patients and newer therapies are needed. Our case suggests that SCI at-level pain may respond durably to PSFS and provides the longest published follow-up on a case of PSFS. Peripheral subcutaneous field stimulation remains an investigational treatment for chronic pain syndrome and larger, long-term follow up studies are needed for the FDA and payers to approve this modality.

The Efficacy of BurstDR Spinal Cord Stimulation for Chronic Abdominal Pain: A Clinical Series.

BACKGROUND: Chronic abdominal pain is a debilitating condition known for its multifactorial nature. Outcomes with spinal cord stimulation (SCS) for abdominal pain syndromes are noticeably absent in the literature. To date, there have been no published reports of novel waveforms of SCS for management of chronic abdominal pain. We assessed the efficacy and durability of BurstDR SCS in reducing abdominal pain and analgesic consumption. CASE DESCRIPTION: We performed a retrospective review of medical records from 3 patients with different etiologies of abdominal pain (postherniorrhaphy pain syndrome, Crohn disease, abdominal neuropathy). All patients underwent thoracic laminectomy for BurstDR SCS paddle lead and pulse generator placement after a successful trial stimulation period. Data were collected with a telephone survey after a minimum duration of >24 months following implantation. Pain scores were measured using a numeric rating scale. Two of 3 patients were entirely pain-free and reported Patient Global Impression of Change scores of 7 after a minimum follow-up of >24 months. While the third patient continued to have chronic as well as episodic abdominal pain, he was able to discontinue all narcotic pain medications and experienced a 33% decrease in frequency and 60% decrease in severity of monthly pain exacerbations. He reported satisfaction and a Patient Global Impression of Change of 6. CONCLUSIONS: BurstDR SCS is a new programming modality, and long-term follow-up is necessary to determine its durability. Despite varying etiologies of abdominal pain, this series suggests BurstDR SCS sustained for >2 years might be effective as a treatment for abdominal pain syndromes. Future studies of SCS would benefit from standardized abdominal pain scores and high-powered studies using global patient registries.

Prevention of Implant-Associated Infection in Neuromodulation: Review of the Literature and Prototype of a Novel Protective Implant Coating.

Background: Implanting hardware into surgical sites increases the rate of infection associated with these sites. Without novel efforts to reduce this rate of infection, we can expect to see an increase in the number of hardware-associated infections as more patients are implanted with these devices. These infections often necessitate the removal of these devices resulting in a significant financial and clinical burden to patients. We developed a prototype antibiotic coating using products that are both low cost and that can be sourced easily. Our study aims to test the effectiveness of this coating against bacteria commonly observed in hospital-associated infections. Methods: The antibiotic coating was prepared by combining one gram of vancomycin and 500 mg of ciprofloxacin in 50 mL of glycerol. The coating was examined for inhibition of growth of Pseudomonas aeruginosa PA14 and Staphylococcus aureus AH2486 and compared with the bacterial growth of the above bacteria in glycerol alone. The growth curves were plotted measuring the bacterial growth at 5 h intervals. Results: The results of the growth curves clearly demonstrate a lack of bacterial growth when these bacteria are combined with glycerol combined with our selected antibiotic agents. Conclusion: There appears to be a limited interest from device companies in developing new strategies for infection prevention associated with neurosurgical hardware, and we propose that this prototype will be an effective and low-cost solution to a large problem.

Covalent Poly(lactic acid) Nanoparticles for the Sustained Delivery of Naloxone.

The opioid epidemic currently plaguing the United States has been exacerbated by an alarming rise in fatal overdoses as a result of the proliferated abuse of synthetic mu opioid receptor (MOR) agonists, such as fentanyl and its related analogues. Attempts to manage this crisis have focused primarily on widespread distribution of the clinically approved opioid reversal agent naloxone (Narcan); however, due to the intrinsic metabolic lability of naloxone, these measures have demonstrated limited effectiveness against synthetic opioid toxicity. This work reports a novel polymer-based strategy to create a long-acting formulation of naloxone with the potential to address this critical issue by utilizing covalent nanoparticle (cNP) drug delivery technology. Covalently loaded naloxone nanoparticles (Nal-cNPs) were prepared via the naloxone-initiated, ring-opening polymerization (ROP) of l-lactide in the presence of a bifunctional thiourea organocatalyst with subsequent precipitation of the resulting naloxone-poly(l-lactic acid) polymer. This protocol afforded well-defined nanoparticles possessing a drug loading of approximately 7% w/w. The resulting Nal-cNPs demonstrated excellent biocompatibility, while exhibiting sustained linear release kinetics in vitro and blocking the effects of high dose (10 mg/kg) acute morphine for up to 98 h in an in vivo rodent model of neuropathic pain.

Deep Brain Stimulation of the Hypothalamus Leads to Increased Metabolic Rate in Refractory Obesity.

OBJECTIVE: Obesity has become a worldwide epidemic, with very few long-term successful treatment options for refractory disease. Deep brain stimulation (DBS) of the bilateral lateral hypothalamus (LH) in refractory obesity has been performed safely. However, questions remain regarding the optimal settings and its effects on metabolic rate. The goals of our experiment were to determine the optimal DBS settings and the actual effect of optimal stimulation on energy expenditure. METHODS: After bilateral LH DBS implantation, 2 subjects with treatment refractory obesity underwent 4 days of metabolic testing. The subjects slept overnight in a respiratory chamber to measure their baseline sleep energy expenditure, followed by 4 consecutive days of resting metabolic rate (RMR) testing at different stimulation settings. On day 4, the optimized DBS settings were used, and sleep energy expenditure was measured again overnight in the room calorimeter. RESULTS: During daily testing, the RMR fluctuated acutely with changes in stimulation settings and returned to baseline immediately after turning off the stimulation. Optimal stimulation settings selected for participants showed a 20% and 16% increase in RMR for the 2 participants. Overnight sleep energy expenditure measurements at these optimized settings on day 4 yielded a 10.4% and 4.8% increase over the baseline measurements for the 2 participants. CONCLUSIONS: These findings have demonstrated the efficacy of optimized DBS of the LH on increasing the RMR acutely and maintaining this increase during overnight sleep. These promising preliminary findings have laid the groundwork for the possible treatment of refractory obesity with DBS.

Spinal Cord Stimulation in Adult Tethered Cord Syndrome: Case Report and Review of the Literature.

BACKGROUND: Spinal cord stimulation (SCS) is an evidence-based treatment for chronic neuropathic pain; however, there is a dearth of evidence investigating this modality in patients with tethered cord syndrome. CASE DESCRIPTION: We present a case of 55-year-old woman with history of lipo-myelomeningocele repair and multiple detethering surgeries who presented with chronic low back and leg pain accompanied by progressive gait dysfunction. After a successful trial, she underwent SCS paddle lead placement that resulted in decrease of her visual analog scale for pain from 9/10 to 0-2/10 as well as daily opioid intake from 90 to 199 mg morphine-equivalent doses to 40 to 60 mg morphine-equivalent doses. On last follow-up she reported 70%-85% relief of her low back and leg pain, better ambulation, and improved quality of life. CONCLUSIONS: The literature review identified 2 other case reports of SCS in tethered cord syndrome with similar improvement in pain alleviation.

Spinal Cord Stimulation for Loin Pain Hematuria Syndrome: Clinical Report.

Loin pain hematuria syndrome (LPHS) is a rare condition characterized by cryptogenic debilitating flank pain and microscopic or macroscopic hematuria. The pathophysiology of LPHS remains poorly understood, and diagnosis is made largely by exclusion of alternate pathology. Management strategies can vary widely and include chronic opioid medication and a variety of invasive procedures, including regional nerve blocks, transcutaneous electrical nerve stimulation, local capsaicin infusion, and surgical renal denervation. Neuromodulation may provide a new paradigm of treatment for LPHS, potentially sparing patients from long-term complications of opiate therapy and invasive surgery. This report demonstrates the first case of successful symptomatic management of LPHS using spinal cord stimulation.

High Thoracic Disc Herniation Causing Horner Syndrome with the Intraoperative Finding of Conjoined Nerve Root Compression: A Case Report.

CASE: A 29-year-old man presented with right medial arm pain with paresthesia, as well as right-sided ptosis, miosis, and anhidrosis. Magnetic resonance imaging revealed a right paracentral disc herniation at the T1-T2 level. The patient underwent a hemilaminectomy with a medial facetectomy through a posterolateral approach to the T1-T2 disc space, followed by a discectomy. Intraoperative findings were notable for a conjoined nerve root. CONCLUSION: Although high thoracic disc herniation is rare, its diagnosis should be considered when patients present with radicular arm pain and Horner syndrome. A high index of suspicion should be maintained for nerve root anomalies to limit iatrogenic injury and to ensure successful decompression.

Fentanyl Initiated Polymers Prepared by ATRP for Targeted Delivery.

The targeted delivery of polymers to neurons is a challenging yet important goal for polymer based drug delivery. We prepared a fentanyl based atom transfer radical polymerization (ATRP) initiator to target the Mu opioid receptor (MOR) for neuronal targeting. We incorporated our recently discovered rigid acrylate linking group into the initiator to retain a high degree of binding to the MOR and grafted random or block copolymers of poly(oligo(ethylene oxide) methacrylate)-block-(glycidyl methacrylate). Trifluoroethanol promoted amine ring opening of the glycidyl methacrylate was used for post-polymerization modification of the fentanyl initiated polymers to attach a near-infrared fluorescent dye (ADS790WS) or to build a targeted siRNA delivery system via modification with secondary amines. We examined the biocompatibility, cellular internalization, and siRNA binding properties of our polymer library in a green fluorescent protein expressing SY SH5Y neuroblastoma cell-line.

The proposed use of cervical spinal cord stimulation for the treatment and prevention of cognitive decline in dementias and neurodegenerative disorders.

Cervical spinal cord stimulation is a well-established treatment for intractable neuropathic upper extremity pain. More than 20years ago it was demonstrated that cervical spinal cord stimulation could engender an increase in cerebral blood flow. Cerebral blood flow has been shown to be decreased in many patients with dementia and in various neurodegenerative disorders such as Alzheimer's disease and Parkinson's disease. Furthermore, there is evidence that reduced cerebral blood flow worsens neurodegenerative disease and may also predict which patients progress from mild cognitive impairment to full blown Alzheimer's disease. Thus, the identification of decreased cerebral blood flow in patients with early cognitive problems may offer clinicians a window of opportunity to intervene and prevent further brain damage. Further evidence that supports augmenting cerebral blood flow as an effective strategy for preventing and treating cognitive brain dysfunction comes from experimental studies with omental transposition. The author proposes cervical spinal cord stimulation as a titratable, programmable extracranial neuromodulation technique to increase cerebral blood flow for the purposes of improving cognitive function and preventing cognitive deterioration in patients with dementias and neurodegenerative disorders.

Deep Brain Stimulation for Obesity: From a Theoretical Framework to Practical Application.

Obesity remains a pervasive global health problem. While there are a number of nonsurgical and surgical options for treatment, the incidence of obesity continues to increase at an alarming rate. The inability to curtail the growing rise of the obesity epidemic may be related to a combination of increased food availability and palatability. Research into feeding behavior has yielded a number of insights into the homeostatic and reward mechanisms that govern feeding. However, there remains a gap between laboratory investigations of feeding physiology in animals and translation into meaningful treatment options for humans. In addition, laboratory investigation may not be able to recapitulate all aspects of human food consumption. In a landmark pilot study of deep brain stimulation (DBS) of the lateral hypothalamic area for obesity, we found that there was an increase in resting metabolic rate as well as a decreased urge to eat. In this review, the authors will review some of the work relating to feeding physiology and research surrounding two nodes involved in feeding homeostasis, nucleus accumbens (NAc) and hypothalamus, and use this to provide a framework for future investigations of DBS as a viable therapeutic modality for obesity.

Traumatic Conus Medullaris Syndrome: A Case Report and Review of the Literature.

CASE: A twenty-six-year-old man was diagnosed with conus medullaris syndrome (CMS) after sustaining a traumatic L1 burst fracture. Surgical decompression and stabilization was performed within ninety-six hours of admission; postoperatively, normal bladder function rapidly returned. CONCLUSION: CMS is difficult to diagnose because of the clinically variable presentation. There is no consensus regarding the natural history of conus medullaris injury or regarding the necessity, approach, or timing for decompression. Higher-level evidence is needed to guide treatment for acute traumatic CMS.