title: Are there a guidelines for implantable spinal cord stimulator therapy in patients using chronic anticoagulation therapy? - A review of decision-making in the high-risk patient.
abstract: BACKGROUND
  Spinal cord stimulators (SCSs) are gaining increasing indications and utility in an expanding variety of clinical conditions. Complications and initial expenses have historically prevented the early use of SCS therapy despite ongoing efforts to educate and promote its utilization. At present, there exists no literature evidence of SCS implantation in a chronically anticoagulated patient, and neuromodulation manufacturers are conspicuously silent in providing warnings or recommendations in the face of anticoagulant use chronically. It would appear as through these issues demand scrutiny and industry as well as neuromodulation society advocacy and support in terms of the provision of coherent guidelines on how to proceed.
  
  
  METHODS
  A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation.
  
  
  METHODS
  A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation.
  
  
  CONCLUSIONS
  Our literature search did not reveal any evidence of SCS therapy among patients with chronic anticoagulation. This case illustrated a complicated clinical case scenario wherein a percutaneous SCS implantation would normally be contraindicated due to severe thoracic spinal stenosis and chronic anticoagulation which could lead to possible paralysis or even a lethal consequences associated with the possible formation of a thoracic epidural hematoma.
authors.affiliation: Ghaly Neurosurgical Associates, Aurora, IL, USA; Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, JHS Hospital of Cook County, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA.
authors.forename: Ramsis F
authors.initials: RF
authors.lastname: Ghaly
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
authors.forename: Alexei
authors.initials: A
authors.lastname: Lissounov
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA.
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Candido
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA.
authors.forename: Nebojsa Nick
authors.initials: NN
authors.lastname: Knezevic
keywords: Chronic anticoagulation; implantable device; neuromodulation; spinal cord stimulator; spinal epidural hematoma