DORSAL SPINAL COLUMN STIMULATOR TRIAL

A five-day trial to limit his time off anticoagulation was decided vs our standard seven-day trial time period. The epidural space was accessed on the first attempt with two 14-gauge needles, and two traditional SCS leads were guided in standard fashion in the midline to the top of T8 and T9. The patient was brought to the operating room and a two-lead SCS trial was performed. On the day of surgery, INR was normal at 1.1. The patient’s warfarin was stopped five days before the SCS trial lead placement. The decision was made that bridging with a short-acting anticoagulant was not necessary during the trial period. Notably, the patient was prescribed warfarin and had an expected therapeutic PT/INR, necessitating a thorough discussion with his cardiologist and hematologist to properly manage his anticoagulation during the trial and potential implant time periods. He was diagnosed with FBSS and agreed on a trial of dorsal column SCS. Lumbar magnetic resonance imaging confirmed these findings and did not reveal any spinal stenosis or nerve impingement. Lumbar x-ray revealed intact posterior spinal hardware from 元-L5 with no evidence of loosening and diffuse lumbar degenerative disc disease.

A coagulation panel revealed a prothrombin time (PT) of 34 seconds (normal: 11–12.5 seconds), a partial thromboplastin time (PTT) of 32 seconds (normal: 25–35 seconds), and an international normalized ratio (INR) of 2.6 (normal: 0.8–1.1). Serological tests revealed a normal complete blood count and basic metabolic panel. The remainder of his exam was unremarkable. Motor testing was difficult due to increased pain during the exam but was grossly normal in the bilateral lower extremities.

He displayed slow ambulation with a forward-leaning posture and was able to walk on his heels and toes. His lumbar range of motion was severely impaired due to pain. There was diffuse tenderness to palpation throughout the lower back, which was worse around the surgical scar. Physical exam revealed bruising throughout the bilateral upper extremities and a well-healed midline lumbar incision. He had trialed physical therapy, multiple neuropathic pain medications, and “some back injections,” which did not provide satisfactory pain relief. He denied any weakness but reported occasional numbness and tingling in his left lower extremity. He rated his pain severity at 7/10, and it had overall negatively impacted his quality of life. His pain was located in the lumbar spine with radiation into his left lower extremity. Case PresentationĪ 70-year-old male with a history of atrial fibrillation anticoagulated with warfarin 3 mg per day and chronic low back pain status post–元-L5 laminectomy and fusion three years before presentation was referred to the pain clinic for assessment of ongoing chronic low back pain. We also provide suggestions for safe patient care when the recommended guidelines are not followed. The secondary objective is to review the epidemiology of bleeding complications and appraise the current evidence on anticoagulation management in patients receiving implantable neuromodulation devices. The primary objective of this report is to describe a 63-year-old male with a history of failed back surgery syndrome (FBSS) on chronic anticoagulation who underwent an SCS trial and unintentionally ingested a dose of warfarin during the trial period after appropriately holding the medication before surgery. Furthermore, bleeding risk may be further compounded in patients taking antiplatelet and anticoagulant medications, as well as patients with epidural fibrosis or scarring (e.g., postlaminectomy syndrome). Neuromodulation procedures may be stratified as low-risk (e.g., peripheral nerve stimulation), moderate-risk (e.g., dorsal root ganglion stimulation), and high-risk procedures (e.g., paddle spinal cord stimulation).

Both the NACC and the American Society of Regional Anesthesia (ASRA) have proposed guidelines on bleeding and coagulation management in patients who have neuromodulation devices. In 2012, the INS established the Neurostimulation Appropriateness Consensus Committee (NACC) to appraise the evidence to reduce complications and increase the efficacy of neuromodulation. The International Neuromodulation Society (INS) identified bleeding related to SCS implantable devices as a significant health concern. Pain physicians should be cognizant of the potential risks and sequelae of complications from SCS. Spinal cord stimulation (SCS) has emerged as an impactful interventional modality utilized to treat pain syndromes, movement disorders, spasticity, cardiac ischemia, and spinal cord injury.

Dorsal spinal column stimulator