Spinal Cord Stimulator Trial in a Patient on Chronic Warfarin Therapy

Background: Spinal cord stimulation (SCS) is a rapidly growing interventional treatment modality in chronic pain. Pain physicians are faced with the decision on how to manage patients on anticoagulation therapy given the risk of epidural hematomas. Case Report: We describe a patient with a history of atrial fibrillation and prior pulmonary embolism on chronic anticoagulation. The patient was planned to undergo an SCS trial, but was unable to discontinue all anticoagulation during the length of the trial. Utilizing a multidisciplinary approach, the patient discontinued warfarin 5 days prior to the procedure and began a therapeutic dose of low molecular weight heparin (LMWH). The final dose of LMWH was given 24 hours before the trial procedure. The patient then started prophylactic dosing of LMWH 24 hours after the trial procedure and continued that regimen for the course of the SCS trial. The last dose of prophylactic LMWH was given 24 hours before removal of the trial leads and the patient restarted 3 days of therapeutic LMWH along with resuming his normal anticoagulation regimen after lead removal. The patient was able to undergo a successful SCS trial and will be pursuing a SCS implant with further anticoagulation management. Conclusion: This case demonstrates a possible strategy for managing patients who requiring anticoagulation therapy during the course of their SCS trial phase. Although a single-electrode array proved to be efficacious, using 2 electrode arrays improves the anatomic coverage of the painful areas and allows for greater optionality in electrode selections to avoid plasticity. Key words: Spinal cord stimulation, anticoagulation, chronic pain, post laminectomy syndrome