Patient Selection

Appropriate patients for neurostimulation implants must meet the following criterion: the patient has a diagnosis amenable to this therapy (i.e., neuropathic pain syndromes), the patient has failed conservative therapy, significant psychological issues have been ruled out, and a trial has demonstrated pain relief.10 However, pure neuropathic pain syndromes are relatively less common than the mixed nocice-ptive/neuropathic disorders, including failed back surgery syndrome (FBSS) (Figure 7.6a, b). Also, many patients with chronic pain will have some depressive symptomatology, but psychological screening can be extremely helpful to avoid implanting patients with major psychological disorders. An interesting study by Olson and colleagues11 revealed a high correlation between many items on a complex psychological testing battery and favorable response to trial stimulation. This is to say, an overall mood state is an important predictor of outcomes.

A careful trial period is advocated to avoid a failed implant. Trials of different lengths have been advocated; the risks of a longer trial are mainly infection, whereas the risks of too short a trial are misreading success. The author utilizes a five- to seven-day trial with the use of oral antibiotics. We encourage the patient to be as active as possible in their usual environment, with the exception of limiting bending/twisting movements. Despite advances in (1) the understanding of diagnoses that respond to neurostimulation, (2) an increased understanding of and improved psychological screening, and (3) improved multi-lead systems, clinical failures of implanted neurostimulator devices remain too common. Pain practitioners must critically evaluate their own outcomes and adhere to the strict selection criterion outlined above.

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