Spinal cord stimulation with percutaneous and plate electrodes: side effects and quantitative comparisons

Spinal cord stimulation is limited by the uncomfortable side effects experienced by the patient as the amplitude of stimulation is increased. These side effects include local segmental paresthesias or motor responses, which are objectively demonstrable as frequency-following muscle contractions, attributable to dorsal root stimulation. The authors present evidence for another mechanism of stimulation-evoked discomfort, namely recruitment of small fibers in ligamentum flavum, which occurs when electrodes are inserted percutaneously and their contacts are exposed circumferentially; this does not occur with plate electrodes with insulated dorsal surfaces. In a consecutive series of 79 patients with postsurgical lumbar pain syndromes, percutaneous four-contact electrodes were tested at levels from T-8 through T-12. At one or more levels, 46% of patients described paravertebral, nonradiating discomfort, unaccompanied by frequency-following muscle contractions. This was observed most commonly at the T-8 and T-9 levels. The effect was ameliorated in some cases by using multiple cathodes in parallel, which reduced the current density at individual contacts. In 10 of these patients, this side effect interfered with an otherwise successful trial to such a degree that an insulated plate electrode was selected for permanent implantation at the same level as the percutaneous electrode. This eliminated the uncomfortable side effect completely in all patients. Intraoperative testing with the insulated plate electrode inverted (that is, contacts dorsal) reproduced the side effect in the majority of patients, indicating that structures dorsal to the electrode, such as fibers in ligamentum flavum, mediate the effect. Postoperative testing by computerized techniques demonstrated improved coverage of pain by stimulation paresthesias, with lower stimulation power requirements, using the insulated plate electrode. This technical limitation of percutaneous spinal cord stimulation electrodes, which may confound treatment if unrecognized, has been found to have a straightforward solution which indicates the underlying mechanism.