Seven questions to ask yourself or to ask your patient to answer before implantation of a spinal cord stimulator for chronic pain

Questions yes/no

1. Can I state in simple terms how the stimulation works?

2. Am I able to operate the remote for the stimulator safely?

3. Do I and my family have the resources to take care of the wounds at home, go to follow up appointments and reprogramming sessions as needed for optimal therapy?

4. Do I think that a residual pain or discomfort of 50% from the present pain level is worth the risk (infection, bleeding, mechanical or surgical complications)and expense of surgery (30 to 50 thousand dollars)?

5. Have I been able, in the past, to go to medical appointments and to follow treatment plans in the past?

6. Am I dependent on any substances (coffee, cigarettes, alcohol, marijuana ) at present?

7- Can I identify the strategies I use to cope with pain and anxiety?

The screening of the implantation of stimulators for chronic pain follows Medicare guidelines and best practice guidelines from the Neuromodulation Society. There is a mandated neuropsychological evaluation before the implant and an informed consent process at the surgical office. You can find more information on the society website.

In general the five points below need to be addressed by your treatment team before implantation at the time of your informed consent:

1. Informed consent-technical:

The patient is competent to understand the technology's purpose, methods, and follow-up requirements.

The patient understands that the technology is designed for permanent implantation in the nervous system and will require long-term, at least yearly, upkeep appointments.

The patient has the mental capacity to operate the device safely.

The patient is able to follow recommendations from the device technician and doctors.

2. Informed consent-surgical: 

The patient is competent to understand the surgical risk of a hardware implant, including infection, scarring and transient surgical pain.

3. Identification of co-morbid psychological risks: 

Depression and anxiety as well as addiction risk evaluation tools are to be chosen by the psychologist and the results addressed.

Beck depression inventory in patients with treated or history of depression or with a family history of depression may be obtained.

Addiction risk scoring or opioid risk tool scoring are appropriate. History of childhood trauma, history or family, history of substance abuse, prescription misuse are discussed.

Coping strategies profile (Multidimensional Pain Inventory) and psychiatric disorders (Mini-International Neuropsychiatric Interview) can be used.

4. The patient has historically shown psychosocial stability

Compliance with medical care and treatment plans, reliability in reporting problems to his or her caregivers

5. Clear statement of therapy goals 

The goal stated by the treatment team and by Medicare guidelines for spinal cord stimulation is at least 50% improvement in the VAS (visual pain scale) pain score or in the quality of life score. The patient should state if the goal VAS score or QOL (Quality of Life) score expected is worth the risk and expense of surgery for them.

Recommendations to optimize outcome from a psycho-social point of view should ideally follow the neuropsychological assessment. The need for follow-up psychological or psychiatric care should be clearly stated for the primary care physician and treatment team.