Management of post-cervical laminectomy fusion pain syndrome with a successful trial of spinal cord stimulation.

INTRODUCTION: Spinal cord stimulation has been shown to be beneficial in various postsurgical neuropathic pain syndromes, but the already small cervical epidural space due to epidural fibrosis makes cervical spinal cord stimulator placement very difficult. We present a case of successful cervical cord stimulator implantation in a patient with a history of anterior cervical discectomy and fusion, posterior cervical fusion, and significant epidural fibrosis. METHODS: A 48-year-old woman with a history of type 2 diabetes, nonalcoholic steatohepatitis, and fibromyalgia presented with trauma-induced cervicalgia and bilateral upper extremity radiculopathy. RESULTS: In a 4-day trial of stimulation, she reported an 80% reduction of her pain and significant improvement in her quality of life. DISCUSSION: Although anecdotal evidence and case series have shown spinal cord stimulation to be successful in cervical failed back surgery syndrome, we are the first to discuss the technical challenges and complications associated with epidural fibrosis.

Difficult removal of exposed peripheral nerve stimulator leads: a report of 2 cases.

INTRODUCTION: Peripheral nerve stimulators have emerged as a new generation of advanced modalities to treat chronic pain and avoid opioids. They transmit electrical stimulation through implanted leads and wireless, wearable, external generators. Common complications include infection, nerve damage, and migration of stimulating leads. This article describes 2 cases of complications from lead migration. METHODS: Case 1 describes a 61-year-old man with chronic groin pain who underwent an uncomplicated ultrasound-guided ilioinguinal peripheral nerve lead implantation. Case 2 describes a 54-year-old woman with left shoulder pain who underwent an uncomplicated ultrasound-guided percutaneous lead placement near the axillary nerve through a deltoid approach. Both peripheral nerve stimulators were confirmed with fluoroscopy, and each patient was followed up every 2 months for the following 2 years. RESULTS: Both patients experienced lead migration to the skin resulting in erythema and need for lead removal. Initial unsuccessful removal by traction resulted in retained fragments and need for open surgical removal. DISCUSSION: Neurologic complications of peripheral nerve stimulator implantation are rare, but device-associated complications, specifically lead migration, remain a source of long-term problems that can result in decreased coverage of the intended neural target. CONCLUSION: Thorough patient education, early postimplantation assessment, and extended routine follow-up are necessary to decrease lead-associated complications. If migration does occur, the potential impact of scar tissue on removal should be considered.

Interventional pain physicians' experiences of and attitudes toward surgical privileging.

BACKGROUND AND OBJECTIVES: No consensus guidelines exist on surgical privilege credentialing for nonsurgeons. We queried a group of academic interventional pain physicians about their experiences acquiring such credentials after training, how this process reflected their training, and their current attitudes toward both processes. METHODS: We designed an interactive, computer-based questionnaire and sent this electronically to the directors of all 93 accredited pain medicine subspecialty fellowship programs in the United States. The questionnaire included 17 items regarding interventional pain medicine training, procedures done, experience of credentialing for surgical privileges, and attitudes toward these processes, with 1 additional space for comments. RESULTS: Of the 93 program directors, 46 (49.5%) responded to our questionnaire. Forty-one (89%) of the respondents were anesthesiologists, and 43 (93%) included some form of implantation procedure in their current practice. Most (83%) of the respondents did fewer than 25 implants per year. Experience doing implant procedures during training varied widely among respondents: 43% did fewer than 5 implant procedures during fellowship; 33.3% did at least 15. Most respondents did their own wound closures and did not feel that immediate surgical backup should be required for interventional pain procedures. Most respondents (78%) felt that pertinent surgical training should be mandatory before credentialing, but fewer than 20% reported having been required to have even a proctoring experience before credentialing. CONCLUSIONS: Experience doing implantation procedures during fellowship training and subsequent experience with hospital surgical credentialing seems to vary widely, even among interventional pain physicians associated with academic training programs.