Recommendations for anesthetic management for intraoperative neuromodulation cases

This paper performs a review of current literature as well as uses our single-center experience to discuss pre-operative, intra-operative and, briefly, postoperative management for dorsal column stimulators (DCSs), dorsal root ganglion (DRG) stimulators, peripheral nerve stimulators (PNSs) and intrathecal pumps. Generally, pre-operative antibiotics are recommended with discontinuation within 24 h postoperatively. For dorsal column and DRG stimulation, monitored anesthesia care or general anesthesia with intraoperative neuromonitoring is recommended; for peripheral nerve stimulation and intrathecal pump implementation, monitored anesthesia care is preferred. There is little information on appropriate anesthetic management during these forms of neuromodulation. More research is necessary to articulate specific pre-operative, intra-operative and postoperative management guidelines and recommendations for dorsal column stimulator, DRG stimulation, PNS and intrathecal pump implantation. Lay abstract: Neuromodulation is a procedure wherein the nerves that are responsible for pain are stimulated, for example with electrical pulses, to reduce the pain signals originating from that nerve. The implantation of neuromodulation devices requires surgery. This paper reviews current literature and provides guidelines based on our single center experience to discuss anesthetic management of patients before surgery, during surgery and after the surgery. We review management for different forms of neuromodulation including dorsal column stimulators (DCSs), dorsal root ganglion (DRG) stimulators, peripheral nerve stimulators and intrathecal pumps. We searched various online databases to find papers that discussed anesthetic management around these surgeries. Generally, starting antibiotics before the surgery and then stopping the antibiotics within 24 h after the surgery is recommended. For dorsal column and DRG stimulation, monitored anesthesia care, where patients are awake but very relaxed, or general anesthesia with neuromonitoring during the operation (so that surgeons can check the function of the nerves in real time) is recommended. For peripheral nerve stimulation and intrathecal pump implementation, monitored anesthesia care is preferred. There is little information in the literature on appropriate anesthetic management during these forms of neuromodulation. More research is necessary to articulate specific management guidelines before surgery, during surgery and after surgery for DCSs, DRG stimulation, peripheral nerve stimulator and intrathecal pump implantation.