Spinal Cord Stimulator and Pacemaker: No Absolute Contraindication
Having a permanent cardiac pacemaker or ICD is NOT an absolute contraindication to spinal cord stimulator implantation, but these devices can be safely implanted together with appropriate precautions and testing protocols. 1, 2
Key Evidence and Recommendations
Device Compatibility
The 2012 Canadian Cardiovascular Society guidelines explicitly address noncardiac implantable electrical devices (including spinal cord stimulators) and confirm they can coexist with cardiac devices, though specific perioperative management is required 1. A 2023 systematic review found no statistically significant interference between SCS and pacemaker/ICD devices regardless of SCS lead polarity or indication 2.
Critical Safety Protocol
When implanting an SCS in a patient with an existing cardiac device, you must:
- Interrogate both devices before, during, and after SCS implantation 2, 3
- Test at maximum tolerable SCS settings during the trial period with the cardiac device programmed to maximum sensitivity 2, 3
- Position devices to maximize distance between pulse generators and ensure current pathways are directed away from cardiac devices 1
- Use bipolar electrocautery during implantation when possible; if monopolar cautery is necessary, place the return electrode as far from both devices as possible 1
Device Programming Considerations
Multiprogrammable and bipolar pacemakers are strongly preferred in patients who may need SCS, as they allow reprogramming to minimize inter-device interference 4. Older data suggests interference may occur when SCS output voltage × pulse duration exceeds 1.9-2.0 mVs, though modern devices have improved significantly 4.
Special Considerations for ICDs
ICDs pose additional concerns because multiple ICD shocks can temporarily or permanently damage the SCS 5. After any ICD discharge, the SCS must be interrogated to verify device integrity 5. However, multiple case series demonstrate successful long-term co-implantation without inappropriate ICD shocks when proper testing is performed 3, 6.
Practical Management Algorithm
- Pre-implant assessment: Identify cardiac device type, manufacturer, and current settings
- Trial phase: Increase SCS to maximum tolerated levels while monitoring cardiac device function in real-time
- Permanent implant: Repeat testing intraoperatively with cardiac device at maximum sensitivity
- Post-implant: Schedule regular interrogation of both devices, especially after any ICD therapy
Common Pitfalls to Avoid
- Never assume compatibility without testing - device interference is patient and setting-specific 4
- Don't use short-wave diathermy - it produces radiofrequency currents that can heat electrodes and damage neural tissue 1
- Avoid placing defibrillator paddles near either device - position perpendicular to devices using lowest effective energy 1
- Don't forget to turn SCS off during electrocautery to prevent neural tissue burns and device reprogramming 1
The ASA guidelines note that while they don't specifically address noncardiac implantable devices like SCS, the general principles of electromagnetic interference management apply 7. Recent case reports consistently demonstrate successful co-implantation when individualized testing protocols are followed 3, 6.