Can a spinal cord stimulator help with pain management in patients with tethered cord syndrome, adhesive arachnoiditis, and osteomyelitis?

Spinal Cord Stimulation for Tethered Cord, Adhesive Arachnoiditis, and Osteomyelitis Pain

Spinal cord stimulation is not recommended as a first-line treatment for pain related to tethered cord syndrome, adhesive arachnoiditis, or osteomyelitis due to limited evidence of efficacy, particularly for arachnoiditis which has shown poor outcomes compared to other neuropathic pain conditions. 1, 2

Efficacy for Specific Conditions

Tethered Cord Syndrome

• Spinal cord stimulation may be considered as part of multimodal treatment for persistent neuropathic pain in tethered cord syndrome only after failure of other therapies, though evidence is limited to case reports 3
• Anatomical and electrophysiological changes in tethered cord syndrome require specialized intraoperative sensory mapping and more caudal electrode placement for potential effectiveness 3

Adhesive Arachnoiditis

• Historical data shows significantly poorer outcomes with spinal cord stimulation for arachnoiditis patients compared to those with single nerve root injuries 2
• The presence of multiple injured nerve roots in arachnoiditis appears to negatively impact treatment success with neurostimulation 2

Osteomyelitis Pain

• No specific evidence supports spinal cord stimulation for osteomyelitis-related pain 1
• For focal pain in limited dermatomes (which may include some cases of osteomyelitis pain), spinal neurolytic blocks may be more appropriate than stimulation 1

Treatment Algorithm

1. First-line approaches (must be tried before considering SCS):

   • Conventional medical management including appropriate analgesics 1
   • Physical therapy and conservative measures 1

2. Second-line approaches:

   • For focal pain in limited dermatomes: consider spinal neurolytic blocks (especially for one-sided pain) 1
   • For neuropathic components: trial of peripheral nerve stimulation may be considered for peripheral nerve injuries 1, 4

3. Consider spinal cord stimulation only if:

   • Patient has failed all conservative treatments 1, 5
   • Pain is predominantly neuropathic in nature 1
   • No psychological contraindications exist 5
   • Patient understands potential complications through shared decision-making 1

4. SCS trial requirement:

   • A successful stimulation trial must be performed before permanent implantation 1, 5
   • Significant documented pain relief during trial is required to proceed 5

Potential Complications and Considerations

• Hardware-related complications occur in 10-29% of cases, including lead migration and connection issues 5
• Infection risk must be carefully considered, especially in patients with active osteomyelitis 5
• Anatomical changes from tethered cord syndrome may complicate electrode placement and efficacy 3
• Potential need for revision surgery should be discussed with patients 5

Important Caveats

• The evidence supporting neurostimulation for chronic pain has been collected predominantly from retrospective series or methodologically limited prospective studies 1
• Patients with arachnoiditis have historically shown poorer outcomes with spinal cord stimulation compared to other neuropathic pain conditions 2
• Device manufacturer may impact treatment outcomes, with significant variations in efficacy reported between different systems 6
• Falls after implantation are associated with poorer outcomes and should be prevented through appropriate precautions 6