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Spinal cord stimulation: Placement and management

Anne Marie McKenzie-Brown, MD
Section Editor
Scott Fishman, MD
Deputy Editor
Marianna Crowley, MD


Spinal cord stimulation (SCS) is a neuromodulation technique that is used to treat neuropathic and sympathetically mediated chronic pain. SCS involves percutaneous or surgical implantation of electrodes in the epidural space, with power supplied by an implanted battery.

This topic will discuss placement of spinal cord stimulators, management of anesthesia for spinal cord stimulator placement, and management of SCS for patients who undergo other surgical procedures. It does not address the technique for laminectomy and surgical lead placement. Evaluation of chronic pain, alternatives for therapy of chronic pain, and SCS for the treatment of specific conditions are discussed separately. (See "Evaluation of chronic pain in adults" and "Overview of the treatment of chronic non-cancer pain" and "Investigational therapies for treating symptoms of lower extremity peripheral artery disease", section on 'Spinal cord stimulation' and "Complex regional pain syndrome in adults: Prevention and management", section on 'Spinal cord stimulation'.)


The complex mechanism of action of spinal cord stimulation (SCS) has not been fully elucidated and is probably multifactorial. The analgesia provided by SCS for neuropathic pain appears to differ from that provided for the relief of ischemic pain [1].

Neuropathic pain relief – SCS was originally thought to work through a gate control mechanism in the dorsal horn of the spinal cord. Thus, spinal cord stimulators were called dorsal column stimulators. According to gate control theory, the substantia gelatinosa in the dorsal horn was a functional "gate system" where pain was modulated. Small (painful A delta and C) nerve fibers and large (A beta) nerve fibers synapse at the "gate." Large fiber activation inhibited the painful small fibers, closing the "gate" and relieving pain [2].

The mechanism for pain relief with SCS is now known to be more complex. Relief of neuropathic pain by SCS is mediated in part by wide dynamic range (WDR) neuron suppression in the dorsal horn. This involves spinal gamma-aminobutyric acid (GABA) systems and their effect on excitatory amino acid (EAA) activity [3-5]. In addition, SCS appears to act at least partly through effects on the brain. Pain relief from SCS can often be realized for days or even weeks after the stimulation has been turned off, suggesting a more central mechanism of action [3,6]. An electroencephalographic (EEG) study of patients with chronic lower extremity neuropathic pain found that long-term SCS influenced both pain thresholds and cortical signaling, further evidence of a more central mechanism of analgesia [7].

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Literature review current through: Nov 2017. | This topic last updated: Nov 01, 2016.
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  1. Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anesth Analg 1967; 46:489.
  2. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965; 150:971.
  3. North RB, Kidd DH, Petrucci L, Dorsi MJ. Spinal cord stimulation electrode design: a prospective, randomized, controlled trial comparing percutaneous with laminectomy electrodes: part II-clinical outcomes. Neurosurgery 2005; 57:990.
  4. Zhang TC, Janik JJ, Grill WM. Modeling effects of spinal cord stimulation on wide-dynamic range dorsal horn neurons: influence of stimulation frequency and GABAergic inhibition. J Neurophysiol 2014; 112:552.
  5. Guan Y, Wacnik PW, Yang F, et al. Spinal cord stimulation-induced analgesia: electrical stimulation of dorsal column and dorsal roots attenuates dorsal horn neuronal excitability in neuropathic rats. Anesthesiology 2010; 113:1392.
  6. Foreman RD, Linderoth B. Neural mechanisms of spinal cord stimulation. Int Rev Neurobiol 2012; 107:87.
  7. Weigel R, Capelle HH, Flor H, Krauss JK. Event-related cortical processing in neuropathic pain under long-term spinal cord stimulation. Pain Physician 2015; 18:185.
  8. Prager JP. What does the mechanism of spinal cord stimulation tell us about complex regional pain syndrome? Pain Med 2010; 11:1278.
  9. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery 2005; 56:98.
  10. Eldabe S, Kumar K, Buchser E, Taylor RS. An analysis of the components of pain, function, and health-related quality of life in patients with failed back surgery syndrome treated with spinal cord stimulation or conventional medical management. Neuromodulation 2010; 13:201.
  11. North RB, Kidd DH, Zahurak M, et al. Spinal cord stimulation for chronic, intractable pain: experience over two decades. Neurosurgery 1993; 32:384.
  12. Donnini RM. Use and Effectiveness of spinal cord stimulation. Pract Pain Manag 2010; 1:29.
  13. North RB, Kidd DH, Olin J, et al. Spinal cord stimulation for axial low back pain: a prospective, controlled trial comparing dual with single percutaneous electrodes. Spine (Phila Pa 1976) 2005; 30:1412.
  14. Hunter C, Davé N, Diwan S, Deer T. Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment. Pain Pract 2013; 13:3.
  15. Baranidharan G, Simpson KH, Dhandapani K. Spinal cord stimulation for visceral pain--a novel approach. Neuromodulation 2014; 17:753.
  16. Kapural L, Nagem H, Tlucek H, Sessler DI. Spinal cord stimulation for chronic visceral abdominal pain. Pain Med 2010; 11:347.
  17. Narouze S, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015; 40:182.
  18. Ghaly RF, Lissounov A, Candido KD, Knezevic NN. Are there a guidelines for implantable spinal cord stimulator therapy in patients using chronic anticoagulation therapy? - A review of decision-making in the high-risk patient. Surg Neurol Int 2016; 7:33.
  19. Knezevic NN, Candido KD, Rana S, Knezevic I. The Use of Spinal Cord Neuromodulation in the Management of HIV-Related Polyneuropathy. Pain Physician 2015; 18:E643.
  20. Deer TR, Mekhail N, Provenzano D, et al. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2014; 17:515.
  21. Andréll P, Yu W, Gersbach P, et al. Long-term effects of spinal cord stimulation on angina symptoms and quality of life in patients with refractory angina pectoris--results from the European Angina Registry Link Study (EARL). Heart 2010; 96:1132.
  22. Buchser E, Durrer A, Albrecht E. Spinal cord stimulation for the management of refractory angina pectoris. J Pain Symptom Manage 2006; 31:S36.
  23. de Jongste MJ, Hautvast RW, Hillege HL, Lie KI. Efficacy of spinal cord stimulation as adjuvant therapy for intractable angina pectoris: a prospective, randomized clinical study. Working Group on Neurocardiology. J Am Coll Cardiol 1994; 23:1592.
  24. Dumoulin K, Devulder J, Castille F, et al. A psychoanalytic investigation to improve the success rate of spinal cord stimulation as a treatment for chronic failed back surgery syndrome. Clin J Pain 1996; 12:43.
  25. Celestin J, Edwards RR, Jamison RN. Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis. Pain Med 2009; 10:639.
  26. Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience. Neurosurgery 2006; 58:481.
  27. Pope JE, Falowski S, Deer TR. Advanced waveforms and frequency with spinal cord stimulation: burst and high-frequency energy delivery. Expert Rev Med Devices 2015; 12:431.
  28. De Ridder D, Vanneste S, Plazier M, et al. Burst spinal cord stimulation: toward paresthesia-free pain suppression. Neurosurgery 2010; 66:986.
  29. Shechter R, Yang F, Xu Q, et al. Conventional and kilohertz-frequency spinal cord stimulation produces intensity- and frequency-dependent inhibition of mechanical hypersensitivity in a rat model of neuropathic pain. Anesthesiology 2013; 119:422.
  30. Russo M, Van Buyten JP. 10-kHz High-Frequency SCS Therapy: A Clinical Summary. Pain Med 2015; 16:934.
  31. Kapural L, Yu C, Doust MW, et al. Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: The SENZA-RCT Randomized Controlled Trial. Anesthesiology 2015; 123:851.
  32. Van Buyten JP, Al-Kaisy A, Smet I, et al. High-frequency spinal cord stimulation for the treatment of chronic back pain patients: results of a prospective multicenter European clinical study. Neuromodulation 2013; 16:59.
  33. Vallejo R. High-frequency spinal cord stimulation: An emerging treatment option for patients with chronic pain. Tech Reg Anesth Pain Manag 2007; 11:141.
  34. De Ridder D, Plazier M, Kamerling N, et al. Burst spinal cord stimulation for limb and back pain. World Neurosurg 2013; 80:642.
  35. De Ridder D, Vanneste S. Burst and Tonic Spinal Cord Stimulation: Different and Common Brain Mechanisms. Neuromodulation 2016; 19:47.
  36. Desai MJ, Hargens LM, Breitenfeldt MD, et al. The rate of magnetic resonance imaging in patients with spinal cord stimulation. Spine (Phila Pa 1976) 2015; 40:E531.
  37. Deer T, Bowman R, Schocket SM, et al. The prospective evaluation of safety and success of a new method of introducing percutaneous paddle leads and complex arrays with an epidural access system. Neuromodulation 2012; 15:21.
  38. Sastry S, Berger K. Troubleshooting and problem solving: the nuances of the Epiducer. Neuromodulation 2014; 17:93.
  39. Vallejo R, Kramer J, Benyamin R. Neuromodulation of the cervical spinal cord in the treatment of chronic intractable neck and upper extremity pain: a case series and review of the literature. Pain Physician 2007; 10:305.
  40. Barolat G, Massaro F, He J, et al. Mapping of sensory responses to epidural stimulation of the intraspinal neural structures in man. J Neurosurg 1993; 78:233.
  41. Kumar K, Buchser E, Linderoth B, et al. Avoiding complications from spinal cord stimulation: practical recommendations from an international panel of experts. Neuromodulation 2007; 10:24.
  42. Stojanovic MP, Abdi S. Spinal cord stimulation. Pain Physician 2002; 5:156.
  43. Van Buyten JP, Van Zundert J, Milbouw G. Treatment of failed back surgery syndrome patients with low back and leg pain: a pilot study of a new dual lead spinal cord stimulation system. Neuromodulation 1999; 2:258.
  44. Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg 2004; 100:254.
  45. Linderoth B, Foreman RD. Physiology of spinal cord stimulation: review and update. Neuromodulation 1999; 2:150.
  46. Hayek SM, Veizi E, Hanes M. Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database. Neuromodulation 2015; 18:603.
  47. Deer TR, Mekhail N, Provenzano D, et al. 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; 17:571.
  48. Osborne MD, Ghazi SM, Palmer SC, et al. Spinal cord stimulator--trial lead migration study. Pain Med 2011; 12:204.
  49. Justiz R 3rd, Bentley I. A case series review of spinal cord stimulation migration rates with a novel fixation device. Neuromodulation 2014; 17:37.
  50. Wolter T, Kieselbach K. Cervical spinal cord stimulation: an analysis of 23 patients with long-term follow-up. Pain Physician 2012; 15:203.
  51. North RB, Kidd DH, Olin JC, Sieracki JM. Spinal cord stimulation electrode design: prospective, randomized, controlled trial comparing percutaneous and laminectomy electrodes-part I: technical outcomes. Neurosurgery 2002; 51:381.
  52. Henderson JM, Schade CM, Sasaki J, et al. Prevention of mechanical failures in implanted spinal cord stimulation systems. Neuromodulation 2006; 9:183.
  53. Dragovich A, Weber T, Wenzell D, et al. Neuromodulation in patients deployed to war zones. Anesth Analg 2009; 109:245.
  54. Bedder MD, Bedder HF. Spinal cord stimulation surgical technique for the nonsurgically trained. Neuromodulation 2009; 12 Suppl 1:1.
  55. Follett KA, Boortz-Marx RL, Drake JM, et al. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology 2004; 100:1582.
  56. Rudiger J, Thomson S. Infection rate of spinal cord stimulators after a screening trial period. A 53-month third party follow-up. Neuromodulation 2011; 14:136.
  57. Costigan SN, Sprigge JS. Dural puncture: the patients' perspective. A patient survey of cases at a DGH maternity unit 1983-1993. Acta Anaesthesiol Scand 1996; 40:710.
  58. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth 2003; 91:718.
  59. Petraglia FW 3rd, Farber SH, Gramer R, et al. The Incidence of Spinal Cord Injury in Implantation of Percutaneous and Paddle Electrodes for Spinal Cord Stimulation. Neuromodulation 2016; 19:85.
  60. Smith CC, Lin JL, Shokat M, et al. A report of paraparesis following spinal cord stimulator trial, implantation and revision. Pain Physician 2010; 13:357.
  61. Franzini A, Ferroli P, Marras C, Broggi G. Huge epidural hematoma after surgery for spinal cord stimulation. Acta Neurochir (Wien) 2005; 147:565.
  62. Meyer SC, Swartz K, Johnson JP. Quadriparesis and spinal cord stimulation: case report. Spine (Phila Pa 1976) 2007; 32:E565.
  63. Deer TR, Stewart CD. Complications of spinal cord stimulation: identification, treatment, and prevention. Pain Med 2008; 9:S93.
  64. Kemler MA, de Vet HC, Barendse GA, et al. Effect of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final follow-up of patients in a randomized controlled trial. J Neurosurg 2008; 108:292.
  65. Falowski SM, Celii A, Sestokas AK, et al. Awake vs. asleep placement of spinal cord stimulators: a cohort analysis of complications associated with placement. Neuromodulation 2011; 14:130.
  66. Lind G, Meyerson BA, Winter J, Linderoth B. Implantation of laminotomy electrodes for spinal cord stimulation in spinal anesthesia with intraoperative dorsal column activation. Neurosurgery 2003; 53:1150.
  67. Fedoroff IC, Blackwell E, Malysh L, et al. Spinal cord stimulation in pregnancy: a literature review. Neuromodulation 2012; 15:537.
  68. Saxena A, Eljamel MS. Spinal cord stimulation in the first two trimesters of pregnancy: case report and review of the literature. Neuromodulation 2009; 12:281.