Lead extrusion ten months after spinal cord stimulator implantation: a case report

David Reehl; Thomas Cheriyan; Owais Qureshi; Zhuo Sun; Paramvir Singh; Anterpreet Dua

doi:10.1515/sjpain-2020-0123

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Lead extrusion ten months after spinal cord stimulator implantation: a case report

David Reehl , Thomas Cheriyan , Owais Qureshi , Zhuo Sun , Paramvir Singh und Anterpreet Dua

Veröffentlicht/Copyright: 3. November 2020

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Aus der Zeitschrift Scandinavian Journal of Pain Band 21 Heft 1

Abstract

Objectives

The purpose of this case report is to describe an occurrence of a rare complication of lead extrusion, which was observed 10 months after spinal cord stimulator (SCS) implantation.

Methods

A patient with low back pain and failed back surgery syndrome underwent implantation of a SCS without complications. Ten months after implantation, one SCS lead extruded from her lower back leading to surgical removal of the leads.

Results

After identifying the complication of a SCS lead extruding from the patient’s back, a surgical revision was performed to remove the SCS leads but retain the implantable pulse generator (IPG) in the gluteal region. During the surgery, it was noted that the anchors were in the appropriate position, sutured and fibrosed to a deep fascial layer. There were no complications from the surgical revision and no infectious process was observed.

Conclusions

We report the occurrence and management of a rare complication of SCS lead extrusion after SCS implantation for failed back surgery syndrome. After recognition, removal of the leads with retention of the IPG was able to effectively resolve the complication. The revising procedure was well tolerated but resulted in the recurrence of the patient’s previous low back pain. We believe that knowledge of this case and its management will aid future physicians in the recognition and management of this rare complication of SCS implantation. Furthermore, as there is a paucity of literature discussing the management of lead extrusion after SCS implantation, we hope that this case report will spur additional research on the management of this complication.

Keywords: Case report; Spinal cord stimulator; Chronic pain; Lead extrusion; Spinal cord stimulator complication

Introduction

Among patients with chronic pain in the United States, 75% of them have a diagnoses of chronic back pain in the United States [1]. According to Shmagel et al. [2], 13% of United States adults 20–69 years old experience chronic low back pain. Chronic pain is one of the most disabling illnesses and is associated with depression, reduced quality of life, absenteeism from work, and a lower household income [3]. Spinal cord stimulator (SCS) therapy is one of the treatment modalities available for selected patients with intractable chronic back pain [4]. While surgical complication from SCS implantation are not common, reported complications include surgical site infection, seroma, epidural hematoma and spinal cord injury. We report on a rare case of SCS lead extrusion through the epidermis 10 months after implantation.

Case presentation

We report a rare case of lead extrusion through epidermis ten-months after SCS implantation. A 68-year-old female with a diagnosis of intractable low back pain and multiple failed back surgeries presented to the pain clinic for further management. The patient had already failed conservative management including oral medication, physical therapy rehabilitation, injections/nerve blocks, and multiple surgical procedures with minimal improvement of her symptoms. The patient was subsequently elected for SCS therapy. After a successful trial, the patient received a SCS implant through standard procedure. The patient reported ≥50% pain relief without complications on follow-up at 10 days, one month, two months, and four months after the procedure. At her six-month follow-up, patient noted two 2 mm peri-incisional sores, which were managed by her primary care physician with antibiotics and wound care. Ten months after her SCS implantation, she returned to the clinic with a SCS lead extruding in lower back (Figure 1) with serous discharge present but no signs of infection. She was managed acutely with antibiotics, pain control, and removal of the SCS leads in the operating room for revision. During surgery, it was noted that the anchors were in the appropriate position, sutured and fibrosed to deep fascial layer. The anchors were released, and the leads were removed. The implantable pulse generator (IPG), which was in the gluteal region, was preserved as there was no sign of infection. The incision was irrigated and closed in layers. There were no complications at one-month follow-up.

Figure 1:

SCS lead extruding from patient’s lower back.

Discussion

Although SCS is generally regarded as a safe procedure, Labaran et al. [5] reported a rate of complication requiring SCS removal or reimplantation of 0.3 and 3.4% at 90 days and one year, respectively. The most common complication associated with SCS implantation is surgical site infection, but other less frequent complications include hematoma, seroma, intraspinal abscess, incidental durotomy, and spinal cord injury. Bendel et al. [6] reported an infection rate of 2.45% after SCS implantation and found the most common organism to be Staphylococcus aureus and the most common site to be the pocket for the IPG. It is notable too that 77.6% of these patients required SCS explantation.

In this rare reporting of lead extrusion after SCS implantation, all of the leads required removal due to their proximity to the extruded, contaminated leads. This decision was made in an effort to decrease the risk of infection secondary to the patient’s complication. Because the distant location of the IPG remained intact without signs of infection, the IPG was retained during the surgical revision, and the patient did not develop any complications at this site. Soliman et al. [7] reported a similar case of lead extrusion through the epidermis without infectious signs which was managed successfully with removal of both the leads and the IPG. Additionally, Radhakrishnan et al. [8] reported another case of SCS lead migration and near extrusion through the epidermis. In this instance, the complication was managed with surgical revision for deeper placement of the leads and eventual autologous fat transfer to adequately pad the leads and resolve the complication. In contrast to the management of our patient, IPG extrusion through the epidermis, as reported by Rabi et al. [9] may require removal of the IPG and leads to prevent the complication of infection.

The possible cause of lead extrusion may be hypothesized to be due to inadequate depth of lead burial or excessive loops left at the anchor site, potentially resulting in slow unwinding of loops months or even years later. To prevent this rare complication, meticulous care should be taken to ensure loops of leads are properly seated and anchored to deep fascial layers.

Corresponding author: David Reehl, Medical College of Georgia at Augusta University, Augusta, GA, USA, E-mail: davidreehljr@gmail.com

Research funding: None declared.
Author contributions: All authors have read and approved the paper. All authors were either involved in the patient care or write up of the case.
Competing interests: There are no conflicts of interest for any of the authors.
Informed consent: Written informed consent was obtained from the patient.
Ethical approval: Ethics board approval was not required for case reports and was not obtained.

References

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Received: 2020-08-05

Accepted: 2020-09-21

Published Online: 2020-11-03

Published in Print: 2021-01-27

Artikel in diesem Heft

https://doi.org/10.1515/sjpain-2020-0123

Schlagwörter für diesen Artikel

Case report; Spinal cord stimulator; Chronic pain; Lead extrusion; Spinal cord stimulator complication