Spinal Cord Stimulator Complications: Infection, Lead Migration, and Dural Puncture
Spinal cord stimulation (SCS) is an established treatment for certain chronic nerve-related pain conditions. Thin wires, called leads, are placed in the epidural space and connected to a small battery-powered generator. Most patients first have a temporary trial with leads that exit the skin. If the trial helps, a permanent system is implanted under the skin.
Like any implant, an SCS system can have complications. Some involve the hardware, such as a lead that moves or breaks. Others are biologic, meaning they involve the patient's body, such as infection, bleeding, or injury to the dura or spinal cord. When a complication occurs, a review looks at prevention, technique, recognition, and response. This article explains how.
Device-related and biologic complications
Dr. Urits co-authored Biologic Complications Associated with Cylindrical Lead Spinal Cord Stimulator Implants: A Narrative Review (Vu and colleagues, Orthopedic Reviews, 2024). The review explains that biologic complications are less common than device-related complications but may have more severe consequences. It covers infection, seromas, hematomas, dural puncture, nerve or spinal cord injury, and therapy habituation. It concludes that physicians should carefully consider potential complications before SCS trials and implants.
Infection prevention
The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society published recommendations on infection prevention and management (Deer and colleagues, Neuromodulation, 2017). The NACC describes its recommendations as best practices for implanting neurostimulation devices, based on evidence scoring and, where evidence is lacking, expert opinion.
Practice does not always match the guidance. In a survey of pain physicians that Dr. Urits co-authored (Sarrafpour and colleagues, Anesthesiology and Pain Medicine, 2021), 82% and 69% of respondents reported not using nasal swabs for MSSA and MRSA, respectively, before SCS trials and implants. Antibiotic practice also varied. During trials, 47% gave a single dose, 35% gave antibiotics for the length of the trial, and 17% gave none. The authors concluded that a portion of pain physicians do not follow the NACC antibiotic guidance.
Variation in practice is relevant to a standard-of-care analysis, but it does not settle it. An expert considers what the guidance said on the date of care, what reasonable physicians were doing, and whether a particular choice was explained.
Infection review questions often include:
- Were risk factors such as diabetes, smoking, obesity, or skin conditions identified and addressed?
- Were skin preparation, antibiotic timing, and sterile technique documented?
- Were wound checks and instructions for warning signs provided?
- When redness, drainage, fever, or new pain appeared, was the patient seen, tested, and treated promptly, including removal of the device when indicated?
Dural puncture during lead placement
The epidural needle used to place SCS leads can puncture the dura, just as with an epidural for anesthesia. In a survey that Dr. Urits co-authored (Southerland and colleagues, Anesthesiology and Pain Medicine, 2022), most physicians who had a dural puncture during a trial chose to continue at a different level (about 57%), and about 28% chose to abandon the procedure. For permanent implants, about 62% continued at a different level and about 22% abandoned. The authors concluded that both continuing and abandoning were reasonable approaches in contemporary practice and that more data are needed for a consensus. A review therefore focuses on whether the puncture was recognized and documented, whether the decision that followed was reasonable, and whether headache or other symptoms were followed afterward.
Sedation during lead placement
The NACC has recommended that percutaneous SCS leads be placed with the patient awake enough to give feedback. In a survey Dr. Urits co-authored (Hasoon and colleagues, Pain Therapy, 2021), 77% of physicians reported using deep sedation for permanent implants at times, and 45% reported using general anesthesia for 10 kHz implants. The authors noted that the guidance and reported practice "remain at odds." Sedation is covered in more depth in Week 9 of this series.
Lead migration and hardware problems
Leads can move after placement, which may reduce pain relief or change where stimulation is felt. Dr. Urits is the author of Case at a Glance: Radiographic Evidence of Percutaneously Implanted Spinal Cord Stimulator Lead Migration (Pain Management Case Reports, 2020). Lead migration is a recognized device complication and does not, on its own, show substandard care. Review usually asks how the leads were anchored, what activity instructions were given, whether imaging documented lead position over time, and whether revision was offered when appropriate.
Neurologic injury
New weakness or numbness after lead placement can signal a hematoma, direct injury, or another cause. As with other neuraxial procedures, the time from first symptom to examination, imaging, and surgical consultation is often central. Blood-thinner management follows the procedure-specific guidelines discussed in Week 7.
Records that usually matter
- Psychological evaluation and trial selection documentation
- Trial and implant procedure notes, including the level of access, any dural puncture, and sedation used
- Saved fluoroscopic images showing lead position
- Antibiotic administration and skin preparation records
- Device programming records and manufacturer representative notes
- Wound-check notes, phone logs, cultures, imaging, and any explant or revision records
Key takeaways
- Biologic complications are less common than device problems but can be more serious.
- The NACC infection recommendations are a central reference, and surveys show practice varies.
- Dural puncture during lead placement is a known risk, and published practice includes both continuing and abandoning the procedure.
- Recognition and response to infection or neurologic change usually drive the analysis.
References
- Vu PD, Pinkhasova D, Sarwary ZB, et al. Biologic Complications Associated with Cylindrical Lead Spinal Cord Stimulator Implants: A Narrative Review. Orthop Rev (Pavia). 2024;16:123443. Abstract: https://pubmed.ncbi.nlm.nih.gov/39624470/
- Deer TR, Provenzano DA, Hanes M, et al. The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management. Neuromodulation. 2017;20(1):31-50. Abstract: https://pubmed.ncbi.nlm.nih.gov/28042909/
- Sarrafpour S, Hasoon J, Urits I, et al. Antibiotics for Spinal Cord Stimulation Trials and Implants: A Survey Analysis of Practice Patterns. Anesth Pain Med. 2021;11(5):e120611. Abstract: https://pubmed.ncbi.nlm.nih.gov/35075422/
- Southerland WA, Hasoon J, Urits I, et al. Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns. Anesth Pain Med. 2022;12(2):e127179. Abstract: https://pubmed.ncbi.nlm.nih.gov/36158140/
- Hasoon J, Urits I, Viswanath O, et al. Percutaneous Spinal Cord Stimulation Lead Placement Under Deep Sedation and General Anesthesia. Pain Ther. 2021;10(2):1719-1730. Abstract: https://pubmed.ncbi.nlm.nih.gov/34652716/
- Urits I. Case at a Glance: Radiographic Evidence of Percutaneously Implanted Spinal Cord Stimulator Lead Migration. Pain Management Case Reports. 2020. doi:10.36076/pmcr.2020/4/111. DOI: https://doi.org/10.36076/pmcr.2020/4/111 (not indexed in PubMed)
Related: Spinal Cord Stimulation and Neuromodulation Cases
Educational information only. Not legal or medical advice.
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