Pain Medication Remains Necessary for Most Patients with Spinal Cord Stimulators
Yes, you should continue to order pain medications for patients with spinal cord stimulators, as spinal cord stimulation rarely provides complete pain relief and is designed to work as part of a multimodal pain management strategy, not as a replacement for all other therapies.
Understanding SCS as Adjunctive Therapy
Spinal cord stimulation is not a standalone treatment that eliminates the need for pharmacotherapy. The evidence demonstrates:
SCS provides partial pain relief in most responders: Even in successful cases, only 47-59% of patients with Failed Back Surgery Syndrome achieve ≥50% pain relief at long-term follow-up, meaning substantial residual pain persists 1
One-third of patients maintain therapeutic response: In fibromyalgia studies using similar neuropathic pain mechanisms, only 53% of patients maintained therapeutic response at 26 weeks, with many requiring additional interventions 2
SCS efficacy varies significantly: Between 30-50% of patients offered a percutaneous SCS trial fail to obtain satisfactory effect initially, and many patients with good initial effects report reduced benefits over time necessitating additional oral drug therapy 3
Evidence-Based Medication Management Post-SCS
Continue Neuropathic Pain Medications
Gabapentinoids and other neuropathic agents should be continued or optimized even after SCS implantation:
Pregabalin demonstrates sustained efficacy for neuropathic pain with 68-78% of patients showing improvement in fibromyalgia trials, addressing pain mechanisms that SCS may not fully cover 2
Radicular pain "often responds poorly to simple analgesics and neuropathic pain medications" but requires continued pharmacotherapy as part of a stepped care approach 4
Gabapentin shows small, short-term benefits for radiculopathy and should be formally trialed with documentation 5
Intrathecal Baclofen as Adjunct
For patients with inadequate SCS response:
Intrathecal baclofen combined with SCS achieved >50% pain relief in patients who initially had inadequate response to SCS alone, with effects maintained at 32-67 months follow-up 3
The daily baclofen dose approximately doubled during the observation period, indicating ongoing need for medication adjustment 3
Avoid oral baclofen with SCS: Peroral baclofen therapy combined with SCS resulted in common complaints of side effects and therapy termination 3
Clinical Algorithm for Medication Management
Immediate Post-Implantation Period (0-3 months)
Maintain all baseline neuropathic pain medications at current doses 1, 5
Monitor for improved pain control but do not automatically reduce medications based on SCS placement alone
Document pain scores using validated measures (VAS, ODI) to objectively assess combined therapy effectiveness 1, 5
Stabilization Phase (3-6 months)
Consider gradual medication reduction only if: Patient reports sustained >50% pain relief AND functional improvement AND requests medication reduction 1
Reduce one medication class at a time, starting with those causing the most side effects
Never discontinue all pain medications simultaneously
Long-Term Management (>6 months)
Expect need for ongoing pharmacotherapy in most patients, as 67.9% of PHN patients achieved long-term pain relief with SCS but still required analgesic dosage adjustments 6
Regular reassessment every 3-6 months using the "pain—ongoing evaluation pathway" as recommended for post-surgical and post-SCS patients 4
Physical therapy integration is essential: Rehabilitation during periods of pain relief after interventions decreases the number of interventions needed and improves quality of life 4
Critical Pitfalls to Avoid
Do Not Assume SCS Eliminates Medication Need
SCS provides paresthesia-based pain modulation, not complete pain elimination, and patients experience complex, individual responses 7
Patients report that SCS "can offer pain relief that can help patients achieve a meaningful life despite chronic pain" but also has disadvantages requiring ongoing support 7
Monitor for Device-Related Issues
Hardware complications occur in 10-29% of cases, including lead migration (9%), infection (10-29%), and wound dehiscence (14%) 1, 5
Pain medication needs may increase if device malfunction occurs, requiring prompt evaluation
Physical therapy must be carefully coordinated to avoid lead migration and fracture risk 8
Recognize When Additional Interventions Are Needed
If pain control deteriorates despite optimized SCS settings, consider intrathecal baclofen trial rather than simply increasing oral medications 3
Alternative SCS modalities (high-frequency, burst, dorsal root ganglion stimulation) show promise for patients with inadequate traditional SCS response 6
Practical Prescribing Approach
Continue baseline neuropathic pain regimen including:
Gabapentinoids (gabapentin or pregabalin) at therapeutic doses 1, 5, 2
SNRIs (duloxetine) or tricyclic antidepressants as indicated 1, 5
Opioids if already prescribed, with careful monitoring and attempts at dose reduction only after documented sustained improvement 2
Avoid abrupt discontinuation of any pain medications immediately post-SCS implantation, as this creates unnecessary risk of pain crisis and does not reflect evidence-based practice 1, 5
Document medication trials and responses to support ongoing medical necessity and guide future adjustments 1, 5