Spinal Cord Stimulation for Chronic Pain Syndromes: A Review of Considerations in Practice Management

BACKGROUND

Chronic pain syndromes are clinically challenging to treat, and management with opioid medications is increasingly shown to be inappropriate and ineffective. Spinal cord stimulation (SCS) has been demonstrated across numerous high-quality and well-designed studies to be effective in treating various refractory chronic pain. The efficacy and overall success of SCS is highly dependent on compliance to and consideration of various practice patterns.

OBJECTIVE

This manuscript is intended to compile and present comprehensive recommendations for key SCS management principles including: a) patient selection criteria, b) efficacy of SCS for various conditions, c) discussion of SCS waveforms, d) trial and permanent implantation considerations, e) periprocedural management, and f) complications and adverse events.

STUDY DESIGN

An evidence-based narrative review.

METHODS

PubMed, Medline, Cochrane Library, prior systematic reviews, and reference lists were screened by 2 separate authors for all randomized trials, meta-analyses, and observational studies relevant to each of the aforementioned management principles and considered for study inclusion.

RESULTS

All high-level evidence studies that explored the various facets of SCS practice management were included for review.

LIMITATIONS

Both continued investigation into, and practice implementation of, the various facets of SCS management are necessary to optimize patient outcomes.

CONCLUSION

Implementation of and adherence to the evidenced-based recommendations delineated in this publication may help optimize efficacy outcomes and maintain safety profiles for persons treated with SCS interventions.

The institutional impact after enacting student solutions to decrease barriers in reporting unprofessional behaviors

This article was migrated. The article was marked as recommended. A two-year study was conducted to evaluate medical student perceptions on professionalism, including barriers to reporting misconduct and solutions to address barriers. Institutional changes occurred based on Year One findings: 1) a streamlined system (EthicsPoint®) was introduced to simplify the process of reporting and allow anonymous reports; 2) curriculum was revamped to include improved didactics on professionalism, instructions on using the EthicsPoint® system, and clerkship orientations that provided clear expectations of behavior by students, house-staff, and faculty; 3) semi-annually, students were asked to document witnessed misconduct, reassured that reports would be confidential, and reassured about protection from reprisal. In Year Two, we assessed changes in the culture of professionalism after institutional changes. Comparing Year Two to Year One, students demonstrated an increase in perceived confidence in ability to identify unprofessional behavior (p<0.01) and increased trust in protection from reprisal (p<0.01). In Year Two, students were more likely to report misconduct related to derogatory remarks about patients (p<0.01) and informed consent (p<0.01). By enhancing clarity about expectations for professional behavior, encouraging transparency through a streamlined and anonymous reporting process, and fostering trust that allows students to feel protected from reprisal, the culture of professionalism at an institution can be improved.