Is spinal cord stimulation effective for managing pain associated with tethered cord syndrome and adhesive arachnoiditis?

Spinal Cord Stimulation for Tethered Cord Syndrome and Adhesive Arachnoiditis Pain

Spinal cord stimulation is not recommended as a first-line treatment for pain associated with tethered cord syndrome and adhesive arachnoiditis due to limited evidence of efficacy and poor outcomes specifically documented in arachnoiditis patients. 1, 2

Efficacy for These Specific Conditions

• Research specifically examining outcomes in patients with arachnoiditis shows significantly poorer results compared to other neuropathic pain conditions, with patients having multiple injured nerve roots responding less favorably to spinal cord stimulation 2
• The American Society of Anesthesiologists (ASA) does not specifically recommend spinal cord stimulation for tethered cord syndrome or adhesive arachnoiditis in their practice guidelines 3, 1
• While spinal cord stimulation is well-established for certain neuropathic pain conditions like failed back surgery syndrome and complex regional pain syndrome, the evidence does not strongly support its use in adhesive arachnoiditis 3, 4

Treatment Algorithm for These Conditions

First-Line Approaches

• Conservative management with appropriate analgesics should be attempted before considering invasive interventions 1
• Physical therapy and activity modification should be part of the initial treatment plan 1, 4

Second-Line Approaches

• For focal pain in limited dermatomes, spinal neurolytic blocks may be more appropriate than stimulation, especially if the pain is one-sided 3
• Epidural steroid injections may be considered, though evidence for long-term efficacy is limited 3

When to Consider Spinal Cord Stimulation

• Only after failure of all conservative treatments 1
• Only if pain is predominantly neuropathic in nature 3, 5
• Only after psychological contraindications have been ruled out 1, 4
• A successful trial stimulation period must be completed before permanent implantation 4

Potential Complications and Considerations

• Hardware-related complications including lead migration and connection issues occur in 10-29% of cases 1, 4
• Infection risk must be carefully considered, especially in patients with pre-existing spinal conditions 1, 4
• The potential need for revision surgery should be discussed with patients 1
• Spinal cord stimulation may not cover all pain areas in complex conditions like tethered cord syndrome and adhesive arachnoiditis 3

Evidence Quality and Limitations

• The Cochrane review on spinal cord stimulation found limited evidence supporting its use even for better-studied conditions like failed back surgery syndrome 6
• Most studies on spinal cord stimulation have small sample sizes and heterogeneous patient populations 6
• There is a specific lack of high-quality randomized controlled trials examining spinal cord stimulation for tethered cord syndrome and adhesive arachnoiditis 1, 2
• The one study specifically examining arachnoiditis patients showed poor outcomes compared to other neuropathic pain conditions 2