BJA Education, 16 (8): 258–263 (2016)
doi: 10.1093/bjaed/mkv072
Matrix reference 3E00
Spinal cord stimulation
D M Moore MB MRCPI FRCA1 and C McCrory MD FCAI FIPP2, *
1
SpR 4 Anaesthesia, Department of Anaesthesia and Pain Medicine, St James Hospital, Dublin, Ireland and
2
Consultant in Pain Medicine, Department of Pain Medicine, St James Hospital, Dublin, Ireland
*To whom correspondence should be addressed. Tel: +353 1 4103952; Fax: +353 1 4284069; E-mail: cmccrory@stjames.ie
Key points
• Spinal cord stimulation (SCS) is a cost-effective
treatment of some common neuropathic and is-
chaemic pain syndromes.
• Failed back surgery syndrome is the most common
indication for SCS.
• Appropriate patient selection and education is key
to successful SCS.
• Different stimulation regimens (frequency, pulse
width, amplitude) are used to target the relevant
dorsal column fibres.
• Significant technological advances in SCS (re-
chargeable batteries, accelerometer technology,
new lead design) may improve effectiveness.
Chronic pain conditions that fail to improve with conventional
medical management (CMM) are a significant burden for the
individual and society. While the initial cost of spinal cord
stimulation (SCS) is considered high, both its clinical and cost-
effectiveness are now well established. The position of SCS in
the treatment algorithm has progressed, and for specific neuro-
pathic and ischaemic pain conditions, there is moderate to strong
evidence supporting its use.
Melzack and Wall presented the Gate Control Theory of Pain
in 1965. They proposed that transmission of pain signals could
be regulated at the level of the dorsal horn by inhibitory inter-
neurones activated by A-fibres. In 1967, Shealy and colleagues1
proposed that electrical stimulation of these A-fibres in the dor-
sal columns (DCs) could activate the inhibitory interneurones in
the dorsal horn and influence pain transmission. A bipolar plate
was placed directly over the spinal cord in cancer patients. They
called it ‘Dorsal Column Stimulation’. In more recent years, it has
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been called SCS. The early interventions were effective, but were
associated with multiple complications.
The techniques have evolved to less invasive percutaneous
lead insertion with multiple electrodes in the epidural space.
More advanced implantable pulse generators (IPGs) and pro-
grammable systems have led to improved effectiveness and ver-
satility. This is reflected by a steady increase in the implantation
rates over the last decade in Europe and the USA.
Neuromodulation techniques are also indicated in non-pain-
ful conditions. Sacral stimulation of the S3 nerve is used to man-
age urinary urge incontinence and faecal incontinence. Deep
brain stimulation is used for a multitude of movement and psy-
chiatric disorders. Vagal nerve stimulation may have a role in re-
fractory epilepsy. However, this article will address the role of SCS
in the management of chronic pain conditions.
Anatomy
The DC of the spinal cord is a layered structure with the more dis-
tal, sacral fibres located more medially, and the more rostral fi-
bres in the lateral part of the DC.2 It transmits ascending
proprioceptive and light touch sensations via the A-β fibres.
These are large myelinated fibres which include the dorsal
roots, dorsal root entry zone, dorsal horn, and DC.3 An active elec-
trode placed in the posterior epidural space preferentially depo-
larizes these large myelinated fibres. Knowledge of the spinal
cord anatomy explains why stimulation of more rostral lateral fi-
bres (as in axial back pain) is more challenging than stimulating
caudal medial fibres (radicular leg pain). As the electrical field
moves laterally, there is an increased risk of stimulating unwant-
ed areas, like the dorsal or ventral roots, leading to adverse effects
( painful sensations or muscle contractions). The target level for
stimulation in failed back surgery syndrome (FBSS) after ad-
equate lumbar surgery is generally the lower thoracic spine
(T8–9). This is because the low lumbar nerve fibres enter the
cord at T12 and become established in the DC at the level of T9.
In the case of post-cervical surgery, the target is generally the
mid-cervical (C4–5) level.
258

Mechanism of action
An SCS consists of a power source (IPG) connected to a lead with a
cathode (negative electrode) and an anode ( positive electrode).
The cathode and anode create an electrical field within the bio-
logical tissue that can depolarize the target nerves. Stimulation
of the DC fibres effectively reduces pain in many neuropathic
and ischaemic pain syndromes. The following mechanisms of
action are proposed:
(i) Inhibition of action of wide dynamic range (WDR) neurones:
WDR neurones are important ‘gate-keepers’ in the dorsal
horn during pain transmission. They may be switched off
when stimulated by A-fibres in the DC.4
(ii) Activation of GABAergic inhibitory interneurones in the dor-
sal horn.
(iii) Activation of supraspinal mechanisms: Descending seroto-
nergic neurones and locus coeruleus neurones.
(iv) Suppression of the neuroimmune response: Markers of glial
and immune cell activity, up-regulated in neuropathic pain
states, are down-regulated in SCS patients.5
(v) Suppression of efferent sympathetic fibres.
(vi) Stimulates peripheral release of vasodilatory proteins.
Stimulation patterns
The stimulation parameters are adjusted to achieve the best re-
sults. The standard variables in SCS are the frequency, pulse
width, and amplitude. The pulse width is generally between
100 and 500 μs. The amplitude is usually 2–8 V. The frequency
can vary depending on the stimulation regimen. The stimulation
patterns vary between the different diagnostic groups with FBSS
requiring higher voltages generally in the 3.0–8.0 V range while
other groups would require lower amplitudes, generally in the
2.5–4.0 V range. The same applies to pulse width and frequency
selection with FBSS requiring larger pulse width settings. The
stimulation patterns are individualized.
Power output or amplitude from the IPG may be in the form of a
constant current (CC) or constant voltage (CV). With CC, the voltage
is automatically adjusted with changes in the resistance (imped-
ance) to maintain a CC. The amplitude is given in volts (V). With
CV, the voltage remains constant and as the impedance varies,
the current will change. The amplitude is given in milliamps (mA).
Shorter pulse widths preferentially recruit dorsal roots, and
target specific dermatomes. As the pulse width increases, the
medial DC fibres are recruited preferentially, and a greater area
of the DC is stimulated.
The frequency can vary depending on the stimulation
regimen.
(i) Conventional or tonic stimulation: Uses frequencies of 60–
100 Hz. This produces paraesthesia in the target area. This
is the most common mode of stimulation, but in the last
few years, two more modes have gained in popularity.
(ii) Burst stimulation: Involves five pulses in a burst (500 Hz
pulse frequency in each burst) with a burst frequency of
40 Hz. Burst stimulation produces little or no paraesthesia.
(iii) High-frequency stimulation: Uses frequencies of 5–10 kHz.
This pattern does not generate paraesthesia, but may pro-
duce effective pain relief.
Indications for SCS
The management of chronic neuropathic and ischaemic pain
conditions is challenging. Often, these patients have attended
Spinal cord stimulation
multiple clinicians, tried a variety of pharmacological and inter-
ventional therapies with limited success, and are struggling with
psychological, occupational, and social stressors. The indications
for SCS are as follows.
Failed back surgery syndrome
The majority of SCSs are implanted for FBSS. This is a syndrome
that is often characterized by disabling back and/or radicular
limb pain after adequate spinal surgery, with nociceptive and
neuropathic components, which often responds poorly to anal-
gesic agents or reoperation. Two randomized control trials
(RCTs) compared conventional SCS with either CMM or reopera-
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tion in FBSS. The primary outcome in both studies was significant
pain relief defined as more than 50% reduction in reported pain
scores.
The PROCESS study randomized 100 FBSS patients to either
SCS+CMM or CMM alone.6 The patients were followed up at 6,
12, and 24 months. The SCS group reported improved pain relief,
quality of life, and functional outcomes when compared with the
CMM group. North and colleagues7 randomized 50 FBSS patients
to either reoperation or SCS and followed them over an average of
3 yr. The patients could cross-over to the other treatment if the
initial intervention failed to adequately relieve their pain. SCS
was more effective than reoperation regarding pain relief, patient
satisfaction, and opiate requirements. Patients in the reoperation
group were more likely to cross-over to the SCS group. SCS may be
an alternative to reoperation or opioid therapy in FBSS patients. It
is deemed to be a cost-effective treatment option when com-
pared with CMM (£10 480 per QALY gained) or reoperation
(£9219 per QALY gained).8
The above trials focused on patients with predominantly ra-
dicular lower limb pain. Patients with axial back pain are a
more difficult group of patients to treat with conventional SCS.
Recent data suggest that high-frequency SCS, burst stimulation,
or combined SCS+peripheral nerve field stimulation (PNfS) may
increase the efficacy of neurostimulation in this challenging
group.9–13
HF-SCS may be particularly effective for the management of
patients who have failed conventional SCS or patients with
axial back pain.9 However, the findings of Al-Kaisy and colleagues
contrast with the first double-blind placebo-controlled RCT in
SCS. Perruchoud and colleagues10 compared HF-SCS with sham
in a group of patients established on conventional SCS. HF-SCS
at a frequency of 5 kHz was not significantly better than sham
stimulation in terms of difference to conventional stimulation,
pain control, and quality of life. While these results are equivocal,
preliminary reports from the SENZA-RCT US Pivotal Study (un-
published data at present) would suggest that HF-SCS has a role
in the management of back and leg pain in FBSS.
Burst stimulation may be more effective than tonic stimula-
tion in some chronic radicular pain syndromes.11 Schu and col-
leagues12 randomized patients already receiving conventional
SCS to tonic 500 Hz stimulation, burst stimulation, or a sham
treatment. Burst stimulation does not produce paraesthesia,
and this fact facilitates a double-blind, placebo-controlled study
design. Burst stimulation was significantly better than the
other two treatment arms. RCTs comparing conventional and
burst stimulation directly in FBSS, and in various neuropathic
pain syndromes, are required.
PNfS is achieved with a subcutaneous lead placed directly into
the painful area. The logic behind this is to target the traditionally
difficult to treat areas such as the lumbar spine which often re-
spond poorly to SCS or other simulation regimens. PNfS systems
BJA Education | Volume 16, Number 8, 2016 259
Spinal cord stimulation
are sometimes combined with a conventional SCS to create hy-
brid systems. Observational studies of hybrid systems indicate
an additional benefit with PNfS+SCS, in particular in patients
with nociceptive axial back pain refractory to SCS alone.13 We
did not identify an RCT to support the routine use of hybrid sys-
tems in FBSS.
Complex regional pain syndrome type 1
One RCT investigated the use of SCS in combination with physic-
al therapy (SCS+PT) (n=36) vs physical therapy only (PT) (n=18) for
the management of complex regional pain syndrome (CRPS).14 Of
the 36 patients, trial stimulation was successful in 24. After 6
months, there was a significant decrease in pain in the SCS+PT
group. The pain relief was sustained at 2 yr. A 5 yr follow-up sug-
gested that there was no sustained benefit at this point. However,
this may be due to methodological problems in the follow-up
study, and a long-term retrospective analysis supports the effect-
iveness of SCS for CRPS type 1 over a 5 yr period.15
Taylor and colleagues16 performed a systematic review of SCS
in CRPS in 2006. They identified level A evidence for SCS in CRPS
type 1, and level D evidence in type 2 CRPS. A 12 yr prospective
cohort study supported SCS as an effective pain treatment in
63% of CRPS type 1 patients implanted with an SCS.17 A predictor
of long-term success in this study was a reduction of more than
50% in the pain score after a 1 week stimulation trial.
SCS is also a cost-effective option in CRPS. When compared
with CMM, SCS cost £16 596 per QALY gained.
Chronic leg ischaemia
Pain associated with chronic leg ischaemia (CLI) is difficult to
manage. Surgical restoration of adequate blood flow to the leg
is desirable, but it is often impossible to achieve. These patients
are referred to as non-reconstructable chronic critical leg ischae-
mia, and their pain is often inadequately controlled with oral
analgesics. Lower limb amputation is sometimes indicated.
In 2013, Ubbink and Vermeulen18 reviewed six controlled
trials comparing the use of SCS+CMM with CMM. The primary
outcome in most of the studies was limb salvage. The review de-
monstrated a significantly higher limb salvage rate in the SCS
group. Also, patients managed with SCS had a significant reduc-
tion in pain score, analgesic use, and Fontaine stage (III to II). The
cost associated with SCS at 2 yr in one study was higher than the
conservative management group (€36 500 vs €28 600). The mech-
anism of action of SCS in CLI may be modulation of nitric oxide or
prostaglandin production, or modulation of the sympathetic ner-
vous system.19
Chronic angina refractory to treatment
Several small RCTs have investigated the role of SCS in chronic
angina refractory to treatment (CART). It compares favourably
with coronary artery bypass grafting (CABG). A systematic review
of these studies suggested that SCS was an effective and safe
treatment option for CART.20 It produced similar symptom con-
trol when compared with CABG, but in some cases, SCS was asso-
ciated with lower morbidity and mortality. Implantation of an
SCS is also a more cost-effective therapy than revascularization
in CART.
Other indications
Multiple case reports and small case series exist describing the
use of SCS in other neuropathic conditions including diabetic
neuropathy, post-herpetic neuralgia, and post-amputation pain
260 BJA Education | Volume 16, Number 8, 2016
syndromes. However, these indications currently lack evidence
and implantation should only be considered on a case-by-case
basis after a successful trial period.
Insertion of an SCS
Patient selection
The success of SCS is heavily dependent on appropriate patient
selection. To date, RCTs in SCS involved patients with persistent
pain (neuropathic or ischaemic) resistant to CMM for more than 6
months. They should have a definite diagnosis or an identifiable
pain generator, and a positive trial of stimulation. Patients with
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major psychiatric disorders, psychological distress, or unreason-
able expectations are not suitable. For these reasons, a preopera-
tive psychological assessment is advised. The patient must have
the cognitive capacity to give informed consent, demonstrate an
ability to understand and use the device properly, and commit to
weaning off inappropriate and/or ineffective medication.
Pre-implantation considerations
(i) Stimulation trial: Before inserting the full system, the im-
planter can site a temporary percutaneous lead under
local anaesthetic and connect it to an external pulse gener-
ator. The patient may report where they feel paraesthesia,
and whether it is covering the painful area. This allows the
implanter to position the electrodes over the appropriate
area. The temporary lead may be left in situ for a few
days. This allows the patient to experience SCS. There is
no consensus on the adequate length of stimulation trial
to accurately predict success of implantation. There is sig-
nificant inter-institutional variation. There may also be
complications during the trial phase such as disconnection
and infection which can distort the patient’s experience.
After a successful trial, the temporary lead is removed
and a permanent lead placed. Occasionally, the coverage
may not be as good with the permanent lead resulting in
disappointment. The accuracy of the trial in predicting suc-
cessful implantation has never been fully established. Re-
cently, there has been a trend towards on-table trial with
implantation on the same visit to theatre in selected pa-
tients with strong indications for SCS such as FBSS and
CRPS.21 A failed trial is declared if it is not possible to stimu-
late the painful area, or the patient finds the paraesthesia is
ineffective or unpleasant. If this occurs, the trial lead is re-
moved and an alternative management plan is discussed
with the patient.
(ii) IPG type: Determine if a rechargeable device (RIPG) or a pri-
mary cell (IPG) is most appropriate. If the patient has a busy
life with limited time for recharging and uses basic pro-
grams with low energy requirements, then a primary cell
is probably more appropriate. Conversely, a patient with
less time constraints who uses complex programs (i.e.
high-energy requirements) should consider a rechargeable
system. RIPGs are growing in popularity.
(iii) Site of the IPG: It is important for the comfort of the patient
to determine the best location for the IPG. Avoid placing
under the belt line, or in areas of allodynia. The most com-
mon sites for IPG implantation are the gluteal region or an-
terior abdominal wall.
(iv) Lead type: Two main types of lead exist. A cylindrical lead
can be placed percutaneously via an epidural needle sys-
tem. Alternatively, a paddle lead can be placed in the epi-
dural space via a laminectomy and sutured to the dura.

The majority of SCS leads are placed percutaneously. There
is also a hybrid percutaneous paddle lead now available.
(v) Psychological evaluation by a mental health professional:
Significant psychiatric disorders or psychological distress
are contraindications to implantation. A mental health
professional should screen all potential SCS recipients,
identify and treat any mental health issues, and make a
recommendation to the pain physician on the suitability
of implantation.
(vi) Optimization of co-morbidities: Diabetes mellitus, system-
ic infection, coagulopathies, or low platelets (<100 000
mm−3).
(vii) Screen for methicillin-resistant Staphylococcus aureus: If
positive, the patient should undergo eradication therapy
(follow local policy guidelines).
Factors that are contraindications to implantation or raise con-
cern for the implanter are listed in Table 1. Most factors are rela-
tive contraindications, and the ultimate decision to proceed
should be made by an informed patient and their consultant.
SCS implantation
The procedure should be undertaken in a standard operating the-
atre environment with appropriate monitoring, X-ray screening,
and trained personnel. The patient should receive prophylactic
antibiotics within the hour pre-procedure, and staff should pay
meticulous attention to sterility. The procedure may be per-
formed under local, spinal, or general anaesthesia (GA). If GA is
used, somatosensory-evoked potentials may be required to con-
firm that the correct level of paraesthesia is achieved. Alterna-
tively, the implanter can use X-ray images to match the trial
leads position. Figure 1 shows two eight-electrode percutaneous
leads in the posterior epidural space.
IPG programming
After implantation, a number of programs can be uploaded to the
IPG. The frequency, amplitude, and pulse width can be varied to
optimize the SCS efficacy. The patient can then use a hand-held
telemetry programmer at home to switch the IPG on and off, and
to switch between programs.
Postoperative management
The patient is assessed to ensure that appropriate paraesthesia
or pain relief is achieved and they can use the system effectively.
Table 1 Contraindications or cautions to SCS
No definite diagnoses or pain generator
Spinal stenosis (with effacement of CSF, cord compression, or both) at the site of lead placement
Significant psychological or psychiatric disorder
Evidence of substance abuse
Pacemakers or defibrillators (consult with cardiology team)
Require frequent MRIs in the future (e.g. active malignancy)
Anticoagulation therapy or coagulopathy
Significant cognitive impairment (unable to appreciate the goals and limitations of SCS)
Concerns of secondary gain (e.g. ongoing litigation, compensation, etc.)
Driving with a conventional SCS switched on is not recommended (especially in operators of heavy goods vehicles—this should be discussed in
the pre-trial counselling)—an HF-SCS system (HF10) is approved for driving in Europe
Pregnancy (some patients continue stimulation, but it is not licensed in pregnancy)
Failed trial in conventional SCS
Spinal cord stimulation
If no complications are identified after operation, they may be
discharged home. Any signs of neurological deterioration post-
implant should prompt an urgent CT scan to rule out epidural
haematomas or spinal cord injury from the SCS lead. Other com-
plications occur over the medium to long term. Lead migration
and fracture have been significant problems in the past. However,
the incidence of these complications is falling with the introduc-
tion of new anchoring techniques and more resilient leads.
Table 2 lists the more common SCS complications.
Special considerations
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(i) MRI compatibility: The use of MRI in patients with a SCS in
situ is controversial. It may lead to unintended stimulation,
lead heating which could cause tissue damage, movement
of the system with loss of pain relief, and/or damage to the
system. If imaging is required in these patients, the medical
team should consider another modality (CT scan). If MRI is
indicated, it may be possible to keep the leads out of the mag-
netic field. Newer SCS systems are MRI compatible with lead
shielding that resists significant heating and tissue damage.
(ii) Diathermy: This should be avoided in patients with an SCS. If
necessary, bipolar diathermy should be used. If unipolar dia-
thermy is warranted, the reference plate should be posi-
tioned as far away from the SCS system as possible.
(iii) Cardiac pacemakers and defibrillators: Pacemakers may per-
ceive SCS signals as cardiac activity and may not pace in de-
mand mode. The implanter should communicate with the
patients’ cardiology team if a pacemaker is in situ. The pace-
maker may be re-programmed to reduce its sensitivity to
extra-cardiac electrical activity.
(iv) Pregnancy: A growing number of females of child-bearing
age are having spinal surgery with resulting FBSS in this
age group. The safety profile and management of SCS in
pregnancy is a relatively new clinical concern, and several
case reports and case series detailing the management of
these women have been published.23 We are not aware of
data to suggest any adverse obstetric outcomes in women
with an active SCS. Conversely, there are no prospective
data at present to support safety in the obstetric population.
(v) Neuraxial analgesia/anaesthesia: There is a risk of damage
or infection of the SCS leads when performing a neuraxial
technique. It is possible to perform a neuraxial technique,
after discussion with the pain team, under strict sterile con-
ditions and with radiological guidance. However, other an-
aesthetic and analgesic options should be considered first.
BJA Education | Volume 16, Number 8, 2016 261
Spinal cord stimulation

Early systems supported a single four-contact lead. Now, multi-

lead systems with up to 32-contacts are available. Surgically
placed paddle-leads with up to five electrode columns are also
available. Postural changes can pose significant problems for pa-
tients with an SCS. They may report more intense stimulation
when lying supine and inadequate stimulation when mobilizing.
This is related to the mobility of the spinal cord within the cere-
brospinal fluid. Some manufacturers are incorporating acceler-
ometer technology to adapt the systems output for different
postures. New wireless devices remove the need to implant
large IPGs, and reduce the risks associated with the conventional
implantation techniques.
There is a growing interest in paraesthesia-free stimulation

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with burst and high-frequency regimens. These are more accept-
able to patients, and may provide equal, if not better, symptom
control. However, there is a need for adequately powered RCTs
to support their use.
While not strictly SCS, stimulation of the dorsal root ganglion
(DRG) is a promising new neuromodulation technique. The DRG
plays a central role in neuropathic pain syndromes, and has be-
come a target in the management of dermatomal neuropathic
pain. Early reports from observational studies are promising,
with good pain relief reported in leg and foot regions in patients
with dermatomal neuropathic pain.25 RCTs are awaited to con-
firm these results.

Conclusion
There has been an explosion in the variety of SCS devices, stimu-
lation regimens, and clinical applications. However, the evi-
dence-base is lagging behind. Further RCTs are required to
stratify the use of this technique and identify the best patient po-
Fig 1 Two percutaneous leads are positioned in the posterior thoracic epidural pulations. Currently, the evidence base supports conventional
space [anteroposterior view () and lateral view ()]. They are positioned at the SCS in patients with FBSS, CRPS, CLI, and CART. Further evidence
level of T8–12 in a patient with FBSS. is required to definitively establish the role of HF-SCS and/or
burst stimulation in FBSS patients refractory to conventional
Table 2 Common SCS complications22 stimulation. The roles of hybrid systems and DRG stimulation
remain to be established. Appropriate patient selection and edu-
Hardware-related (27–30%) cation with specialist physician training are crucial for best
Lead migration (13%) outcomes.
Lead fracture (9%)
Hardware malfunction (3%)
Biologic (3–5%) Declaration of interest
Infection (3–5%) None declared.
CSF leak (0.3%)
Symptomatic hematoma (0.3%)
Other (3–4%) MCQs
Procedural pain
Device-pocket pain The associated MCQs (to support CME/CPD activity) can be
accessed at https://access.oxfordjournals.org by subscribers to
BJA Education.
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