Introduction

Despite the well-known efficacy of spinal cord stimulation (SCS) in chronic pain management, patient selection in clinical practice remains challenging. The aim of this review is to provide an overview of the factors that can influence the process of patient selection for SCS treatment.

Materials / Methods

A sequential decision-making model is presented within a tier system that operates in clinical practice.

Results

The first level incorporates the underlying disease as a primary indication for SCS, country-related reimbursement rules, and SCS screening–trial criteria in combination with underlying psychological factors as initial selection criteria in evaluating patient eligibility for SCS. The second tier is aligned with the individualized approach within precision pain medicine, whereby individual goals and expectations and the potential need for preoperative optimizations are emphasized. Additionally, this tier relies on results from prediction models to provide an estimate of the efficacy of SCS in the long term. In the third tier, selection bias, MRI compatibility, and ethical beliefs are included, together with recent technological innovations, superiority of specific stimulation paradigms, and new feedback systems that could indirectly influence the decision-making of the physician.

Discussion

This tier system can be considered a sequential decision-making model operating in daily routine care; however, often only the first and sometimes the second tier are openly discussed with the patient. In light of a free, fully informed decision-making process, patients should be fully informed about each tier in order to make an independent decision on whether or not to be considered adequate candidates for SCS and to initiate a treatment trajectory.

Conclusions

Both patients and physicians should be aware of the different aspects that influence patient selection in relation to SCS for pain management to make an independent decision on whether or not to initiate a treatment trajectory with SCS.

References

None.

Learning Objectives

1. To learn about individualised pain medicine in relation to a trajectory with neuromodulation.

2. Be aware of the ethical considerations and bias that is present during patient selection.

3. To gain insight in a sequential decision-making model to improve patient selection with transparancy for both patients and clinicians.