Factors in Surgical Placement and System Design to Reduce Pocket Awareness and Optimize the User Experience of Spinal Cord Stimulators – A Comprehensive Review

Brandon Gish,1 Zayd Al-Asadi,2 Abigail T Tisler,2 Robin Mata,3 Harman Chopra,4 Rosa Amelia Garcia,5 Michael E Schatman,6 Vinicius Tieppo Francio,7 Tariq AlFarra,8 Lucas Bracero,9 Marcin Karcz,9 Christopher L Robinson,10 Anuj Shah,9 Alexandra Moreira,11 Aaron D Sciascia,12 Timothy Deer9 1Interventional Pain Management Department, Lexington Clinic, Lexington, KY, USA; 2West Virginia School of Medicine, Morgantown, WV, USA; 3Department of Physical Medicine and Rehabilitation, University of Miami, Miami, FL, USA; 4Physical Medicine & Rehabilitation, Johns Hopkins University, Baltimore, MD, USA; 5Larkin Hospital Health Systems, Miami, FL, USA; 6Department of Anesthesiology, Perioperative Care and Pain Medicine Department of Population Health, Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 7Division of Pain Medicine, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA; 8Mount Sinai Icahn School of Medicine, New York, NY, USA; 9The Spine and Nerve Center of the Virginias, Charleston, WV, USA; 10Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 11Pain Medicine Department, Rush University, Chicago, IL, USA; 12Institute for Clinical Outcomes and Research, Lexington Clinic, Lexington, KY, USACorrespondence: Brandon Gish, Interventional Pain Management Department, Lexington Clinic, 1207 South Broadway, Lexington, KY, 40504, USA, Tel +1 859-258-6101, Email [email protected]: Advancements in spinal cord stimulation (SCS) have enhanced patient outcomes, improved durability, and broadened the range of treatable pain conditions. Technological improvements in battery design have led to smaller implant size, while evolving societal guidelines have played a critical role in optimizing implant safety and quality. This review summarizes recent technological developments in SCS, the impact of such developments on patient satisfaction, and provides an overview of the major systems currently available. We also introduce and explore the emerging concept, “pocket awareness” – referring to a patient’s conscious perception of their implant. Several modifiable factors involving physicians, patients, and manufacturers can influence this awareness, and by extension, patient satisfaction. While pain relief is certainly the primary objective, fostering a comfortable and positive relationship between the patient and their device is essential and merits further clinical attention.Plain Language Summary: Spinal Cord Stimulation (SCS) is a well-established therapy for chronic pain and has evolved significantly since its inception in the 1960s. Advancements in waveform delivery and battery technology have been significant, yet challenges still exist. One remaining gap in care is device and pocket awareness. The design goal of many devices we use regularly is to be seamless and natural without awareness of their existence. Such device integration becomes part of us. While much attention has been given to waveform optimization and energy delivery, sometimes the patient experience is neglected – ease of recharge, intuitive applications, and battery comfort. The success of SCS not only hinges on its ability to alleviate pain but also on optimizing the patient’s interaction with the device. Factors influencing pocket awareness include device features, surgical techniques, anatomical variations, and patient demographics. This review examines such variables, highlighting how pulse generator size, shape, and placement, along with the patient specific factors can influence outcomes. Recent innovations in battery technology and remote monitoring have advanced the cause, offering more convenience and improved programming; however, further addressing pocket awareness remains a critical area for improvement that involves device manufacturers, physicians, representatives, and patient support teams.Keywords: spinal cord stimulation, implantable device, pain, spine, patient satisfaction