Presented at the 2013 AAPM Annual Meeting « Back

Spinal Cord Diseases: Diagnostic Challenges in Patients with Spinal Cord Stimulation Systems

David C. Morales, MD, travelzone444dcm@yahoo.com¹, Emil Gaitour, MD², Natalya V. Shneyder, MD³, Charles Brock, MD¹, Edwin B. George, MD PhD³, (1) Department of Neurology, University of South Florida, Tampa, Florida, (2) James A. Haley VA Hospital, Tampa, Florida, (3) Wayne State University, Detroit, Michigan

Introduction: MRI is a useful diagnostic tool in most cases of spinal cord disease (SCD). Unfortunately, MRI is contraindicated in patients with an implanted spinal cord stimulator (SCS). SCSs relieve pain in failed back syndrome, complex regional pain syndrome, peripheral neuropathy, and severe ischemic limb pain. Approximately 20,000 SCSs are implanted yearly. Some physicians believe MRI risks in SCS patients are minimal under certain circumstances. Materials and Methods: 40-year-old man presented with urinary urge incontinence. Five years prior, he had multiple hernia repairs. Three years later, an epidural SCS was implanted for severe bilateral ilioinguinal neuropathic pain. Over two years, he developed erectile dysfunction and bowel incontinence. Urodynamic studies displayed elevated intravesicular pressures, low capacity and flow. Lumbar CT revealed SCS lead entry at epidural space L1-2 terminating at T10. Mild spinal canal stenosis noted at L3-4, prominent narrowing of distal thecal sac at L5-S1 with epidural fat. His urologist, gastroenterologist, and neurologist suspected that he gradually developed cauda equina syndrome secondary to SCS. Removal of SCS was considered; alternatively, we advised to inactivate the SCS for one month. Results and Conclusions: Patients with SCD and SCS have an incredibly large differential of etiologies related and unrelated to SCS. Before removal of the SCS it’s important to consider CT scan, CT myelography, electromyogram, nerve conduction studies, and CSF analysis. Management strategies depend on the desire to keep the SCS and the severity of SCD symptoms. More research is needed to provide final recommendations. References: 1) Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. Jan 2007; 10(1):7-111. 2) Cameron T. The safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg. 2004;100:254-267. 3) Krames ES. Neuromodulatory devices are part of our "tools of the trade." Pain Med. 2006;7:Suppl 1 S3-S5, (4) Vallejo R, Benyamin RM, Kramer J, Bounds D. Spinal cord stimulation. In: Manchikanti L, Singh V him (eds). Interventional Techniques in Chronic Spinal Pain. Paducah, Kentucky: ASSIP Publishing him; 2007:655-664. 5) Jose De Andres, Juan Carlos Valı´a, German Cerda-Olmedo, Carolina Quiroz, Vincente Villanueva, Vincente Martinez-Sanjuan, Oscar de Leon-Casasola. Magnetic Resonance Imaging in Patients with Spinal Neurostimulation Systems. Anesthesiology 2007; 106:77 6) G. Levin, A. Orlando Ortiz, D. Katz: Noncardiac Implantable Pacemakers and Stimulators: Current Role and Radiographic Appearance. AJR April 2007 vol. 188 no. 4 p.984-991 7) B. M. Greenberg Treatment of Acute Transverse Myeliyis and Its Early Complications Continuum (Minneap Minn). 2011 Aug;17(4):733-43. 8) B.P. Goodman Diagnostic approach to Myeloneuropathy Continuum (Minneap Minn). 2011 Aug;17(4):744-60 9) Per Flisberg, Owain Thomas, Bo Geijer, Ulf Schott: Epidural lipomatosis and congenital small spinal canal in spinal anaesthesia: a case report and review of the literature. Journal of Medical Case Reports 2009, 3:128 November 16, 2009.

Funding: None