title: Spinal cord stimulation: a review of the safety literature and proposal for perioperative evaluation and management.
abstract: BACKGROUND
  There is currently no consensus on appropriate perioperative management of patients with spinal cord stimulator implants. Magnetic resonance imaging (MRI) is considered safe under strict labeling conditions. Electrocautery is generally not recommended in these patients but sometimes used despite known risks.
  
  
  OBJECTIVE
  The aim was to discuss the perioperative evaluation and management of patients with spinal cord stimulator implants.
  
  
  METHODS
  A literature review, summary of device labeling, and editorial were performed, regarding the safety of spinal cord stimulator devices in the perioperative setting.
  
  
  METHODS
  A literature review was performed, and the labeling of each Food and Drug Administration (FDA)-approved spinal cord stimulation system was reviewed. The literature review was performed using PubMed and the FDA website (www.fda.gov).
  
  
  RESULTS
  Magnetic resonance imaging safety recommendations vary between the models. Certain systems allow for MRI of the brain to be performed, and only one system allows for MRI of the body to be performed, both under strict labeling conditions. Before an MRI is performed, it is imperative to ascertain that the system is intact, without any lead breaks or low impedances, as these can result in heating of the spinal cord stimulation (SCS) and injury to the patient. Monopolar electrocautery is generally not recommended for patients with SCS; however, in some circumstances, it is used when deemed required by the surgeon. When cautery is necessary, bipolar electrocautery is recommended. Modern electrocautery units are to be used with caution as there remains a risk of thermal injury to the tissue in contact with the SCS. As with MRI, electrocautery usage in patients with SCS systems with suspected breaks or abnormal impedances is unsafe and may cause injury to the patient.
  
  
  CONCLUSIONS
  Spinal cord stimulation is increasingly used in patients with pain of spinal origin, particularly to manage postlaminectomy syndrome. Knowledge of the safety concerns of SCS and appropriate perioperative evaluation and management of the SCS system can reduce risks and improve surgical planning.
authors.affiliation: Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA. Electronic address: walshk4@ccf.org.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Walsh
authors.affiliation: Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, 500 Euclid Ave., Cleveland, OH 44195, USA; Center for Spine Health, Neurological Institute, Cleveland Clinic, 500 Euclid Ave., Cleveland, OH 44195, USA.
authors.forename: Andre G
authors.initials: AG
authors.lastname: Machado
authors.affiliation: Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Center for Spine Health, Neurological Institute, Cleveland Clinic, 500 Euclid Ave., Cleveland, OH 44195, USA.
authors.forename: Ajit A
authors.initials: AA
authors.lastname: Krishnaney
mesh_terms: D006801:Humans; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy; D062187:Spinal Cord Stimulation / Q000009:adverse effects*
keywords: Electrocautery; Neuromodulation; Neurostimulation; Peri-operative evaluation and management; Spinal Cord Stimulator Safety; Spinal cord stimulation