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[Compound acetabulum fracture caused by overstimulation with a PISCES system]
1Neurochirurgische Abteilung Krankenhaus Ludmillenstift, Meppen.
Zentralblatt Fur Neurochirurgie
|January 1, 1990
Summary
Spinal cord stimulation effectively managed intractable pain from spondylolisthesis. However, a device malfunction caused overstimulation, leading to severe injury and highlighting the need for neurostimulator safety precautions.
Area of Science:
- Neurology
- Biomedical Engineering
- Pain Management
Background:
- Intractable radicular pain from spondylolisthesis L5/S1 often presents a therapeutic challenge.
- Previous treatment with PLIF-fusion surgery provided no relief for the patient's condition.
- Spinal cord stimulation (SCS) using a PISCES-system was initiated for pain management.
Observation:
- The patient experienced gradual battery exhaustion of the SCS device, leading to increased output to maximum levels.
- Upon battery replacement, the patient sustained an electric shock.
- This event resulted in acute opisthotonus and a comminuted fracture of the left acetabulum due to maximal muscle innervation.
Findings:
- Spinal cord stimulation demonstrated efficacy in alleviating severe radicular pain.
- A critical safety concern emerged regarding involuntary overstimulation due to device malfunction or battery issues.
- The patient's injury underscores the potential risks associated with neurostimulator system failures.
Implications:
- There is a critical need for enhanced safety protocols and further research into preventing involuntary overstimulation in neurostimulator systems.
- Improved battery monitoring and fail-safe mechanisms are essential for patient safety during SCS therapy.
- This case highlights the importance of comprehensive patient education regarding device operation and potential risks.