Explantation Rates and Healthcare Resource Utilization in Spinal Cord Stimulation

Abstract

OBJECTIVES Certain patients ultimately undergo explantation of their spinal cord stimulation (SCS) devices. Understanding the predictors and rates of SCS explantation has important implications for healthcare resource utilization (HCRU) and pain management. The present study identifies explant predictors and discerns differences in HCRU for at-risk populations. METHODS We designed a large, retrospective analysis using the Truven MarketScan Database. We included all adult patients who underwent a SCS trial from 2007 to 2012. Patients were grouped into cohorts that remained explant-free or underwent explantation over a 3-year period, and multivariate models evaluated differences in healthcare resource utilization. RESULTS A total of 8,727 unique instances of trial implants between 2007 and 2012 were identified. Overall, 805 (9.2%) patients underwent device explantation. One year prior to SCS implantation, the explant cohort had significantly higher median baseline costs ($42,140.3 explant vs. $27,821.7 in non-explant groups; p<0.0001), total number of pain encounters (180 vs. 103 p<0.0001), and associated costs ($15,446.9 vs. $9,227.9; p<0.0001). The explant cohort demonstrated increased use of procedures (19.0 vs. 9.0; p<0.0001) compared to non-explanted patients. For each month after initial SCS implantation, explanted patients had a slower decrease in total costs (4% vs. 6% in non-explant; p<0.01). At the month of explant, explant patients were expected to have incurred 2.65 times the total cost compared to the non-explant cohort (CR 2.65, 95% CI [1.83, 3.84]; p<0.001). Medium volume providers had lower rates of explantation at 1-year and 3-years compared to low volume providers (p=0.042). Increased age and Charlson index were independent predictors of explantation during the same periods. CONCLUSIONS In this nationwide analysis, we identified that SCS device explantation is correlated with patients who have higher baseline costs, higher total cost post-SCS implantation, and increased use of procedures to control pain. The higher rates of explantation at 3-years post-implant among low volume providers suggest that variations in provider experience and approach also contributes to differences in explantation rates.

The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation

“…Literature reviews have reported a rate of SCS system removal as high as 23.5% . One analysis of a more than five‐year span from 2007 to 2012 revealed a lower 9.2% explant rate . Recent reviews of explant data also examined the potential reasons for device explantation.…”

New Programming Modes of Spinal Cord Stimulation for Chronic Pain: A Systematic Review of Outcomes with Burst and High-Frequency Technology

“…With explantation rates due to loss of efficacy remaining high for patients with tonic SCS-around 9.2% in one U.S. nationwide study of 8,727 tonic SCS patients 44 -the potential for SCS salvage in these patients is promising. Rates of tolerance are relatively high with traditional tonic SCS for the treatment of chronic pain, with one 10-year study reporting a 29% tolerance rate.…”

Images in Practice: Replacement of an 18-Year-Old Spinal Cord Stimulator Paddle Lead with Cylindrical Leads Under Direct Visualization

“…Typically, if a paddle lead is no longer effective, a revision surgery is performed to place a new paddle, which may increase the risks of abandonment technology and perioperative complications, increased treatment costs, and potential worsening of the patient's overall pain level [4][5][6]. This case describes a 58-year-old woman with a history multiple lower back surgeries who was originally implanted with an 8-electrode (4 9 2) paddle lead via a T11 laminectomy spanning the T10-T11 vertebrae.…”