A Proposed Psychologic Clearance Algorithm for Spinal Cord Stimulation Implantation Supported by a Scoping Review

Objectives: Patients with refractory chronic pain may be considered for spinal cord stimulation (SCS) as an interventional therapy. Studies have shown that psychiatric disorders are associated with worse outcomes. However, this relationship may not be understood by all healthcare professionals. Despite psychologic clearance and proper indication, pain medicine physicians often find themselves questioning the appropriateness of some candidates. The authors conducted a scoping review to identify assessments ascertaining patients with pronounced psychiatric burden that may complicate optimal response, to identify any clearly defined psychiatric contraindications, and to review ways psychiatric comorbidities may be addressed in patients at risk for suboptimal long-term response.

Materials and methods: A scoping review was conducted at the Mayo Clinic using the Center for The Science of Health Care Delivery and the Plummer Library; 62 studies reporting clinical data related to psychiatric conditions and their use in assessing candidates for SCS implantation were deemed relevant. The extracted data underwent qualitative analysis.

Results: Decreased depression and anxiety, increased life quality, and reduction in panic attacks, pain intensity during mania, and opioid use were reported after SCS. Antidepressant-medicated depression showed greater improvement. The exclusion criteria included substance use disorders, delirium, active psychosis, depression with suicidal ideation, significant somatization, and cognitive impairment/dementia. Benzodiazepine or antipsychotic use and presence of anxiety or mood disorders were associated with failed SCS. Numerous psychosocial risk factors and differences in cognitive appraisal, including pain catastrophizing and external locus of control, were associated with negative outcomes. Multiple psychologic interventions were identified, and a psychologic evaluation tool highly correlated to SCS implantation outcomes was developed.

Conclusions: This review indicates a need for a standardized, evidence-based, algorithmic psychologic clearance protocol for SCS implantation. The authors designed such a protocol using multiple assessments targeted at establishing true contraindications and identifying barriers requiring further intervention to optimize outcomes, while ensuring individual accommodation.