Maricela Schnur (St Luke’s Hospital, Duluth, USA) highlights a handful of socioeconomic disparities, racial differences, and psychological and psychiatric factors, that currently present difficulties in patient access to spinal cord stimulation (SCS).
Barriers and gaps in the delivery of healthcare have been well-documented. These barriers—which prevent uniform healthcare delivery—are complex and involve a multitude of factors, such as geography, affordability, education and training of the provider, and perceptions of both patients and providers, among others. Most of these factors have not even begun to be fully elucidated.
Unfortunately, these barriers most certainly exist within the field of chronic pain and affect the ways in which SCS is offered to and ultimately undertaken by patients. Three specific areas cause significant gaps in the offering of this modality: socioeconomic disparities, racial differences, and psychological/psychiatric factors.
Over the past decade, SCS has seen a large increase in the advancement of its technology, as well as the indications for its use, with an increase in ease for those providers who are interested in undergoing education and training of these devices. However, the total population of patients undergoing implantation of these devices has not yet been well-studied, and what drives one patient to be offered a device versus another is unclear too.
In the field of chronic pain, post-laminectomy syndrome is a disorder that is treated through a variety of techniques—including SCS. One study, from Mark Jones (Weill Cornell Medical College, New York, USA) et al, retrospectively examined the Medicare limited data set (LDS) from 2016–2019 for those patients given a diagnosis of post-laminectomy syndrome or chronic pain syndrome who then subsequently underwent placement of a spinal cord stimulator device.1 Race/ethnicity and Medicare/Medicaid dual eligibility (examined as a proxy for income) were reviewed, and showed that minorities and dual-eligible patients were less likely to undergo placement of an SCS device. This study highlights the racial and socioeconomic disparities in a large outpatient setting, common to which most spinal cord stimulators are placed.
Two well-known chronic pain physicians as well as racial diversity advocates, Johnathan Goree (University of Arkansas for Medical Sciences, Little Rock, USA) and Stephanie Vanterpool (University of Tennessee Graduate School of Medicine, Knoxville, USA), recently published a plan for concise outreach efforts to directly address these racial and socioeconomic disparities.2 They outline plans for provider outreach, patient outreach and pipeline outreach.
Also included in this plan are increasing educational efforts in the field of neuromodulation for those practicing or planning to start practice in underserved areas. Additional recommendations include medical societies and organisations partnering with community-based outreach platforms or online education to provide patients in these areas with education in neuromodulation offerings, as well as encouraging a diverse student population to go into the field of chronic pain.
In addition to socioeconomic and racial disparities, psychological and psychiatric barriers to SCS also exist. Prior to undergoing SCS, most patients are required to undergo psychological testing to identify barriers that may lead to less-than-optimal outcomes postplacement.3 One possible barrier in this area remains the limited number of providers available to perform presurgical psychiatric assessments as well as the lack of standardisation amongst these assessments. Furthermore, in the patients that require further psychological treatment prior to consideration of SCS, there are significant barriers that lead to delays in accessing the care required to move forward.
Thankfully, since the start of the pandemic, the accessibility and availability of telemedicine visits with medical providers, among many specialities, has increased. This will likely have a positive impact on ease of access for psychiatric care in areas in which finding care providers for mental health has typically been difficult. Additionally, the creation of a uniform process and/or screening tool to evaluate patients may allow other providers, such as those in primary care, that do screenings for depression and other psychiatric illnesses to include this in their preoperative clearance for patients.
These barriers to the placement of spinal cord stimulators are likely just a few areas that need to be examined and intervened upon in order to improve access.
- Jones, M R; Orhurhu, V; O’Gara, B. Racial and Socioeconomic Disparities in Spinal Cord Stimulation Among the Medicare Population. Neuromodulation. 2021; 24(3): 434–40.
- Goree, J; Vanterpool, S. The need for outreach in Pain and Neuroscience. ASPN Newsl. 2020; 5: 5–7.
- Stephens, K A; Ward, A. Patient selection for spinal cord stimulators: mental health perspective. Curr Pain Headache Rep. 2014; 18(3): 398.
Maricela Schnur is an interventional pain physician at St Luke’s Hospital in Duluth, USA. She is the Neuromusculoskeletal Dyad Director and is active in several societies, including the North American Neuromodulation Society (NANS) and Women Innovators in Pain Medicine (WIPM).