Indications for percutaneous and paddle leads for patients with chronic spinal pain: a systematic review

Background/importance Both percutaneous and paddle leads are utilized when implanting spinal cord stimulation (SCS). Both leads appear to be safe and effective, yet, there is a scarcity of guidelines for deciding which type of lead a physician should use. Objective The main goal is to provide an overview of clinical indications for percutaneous and paddle leads for SCS in patients with chronic spinal pain. Evidence review Databases consulted for this systematic review were PubMed, Web of Science, Scopus and Embase. Only studies evaluating SCS in chronic spinal pain patients, with or without previous spine surgery, were eligible. The study protocol was prospectively registered (PROSPERO, CRD42022347329). Findings Of the 102 included studies, 66.67% studies (n=68) implanted percutaneous leads, 30.4% (n=31) paddle leads and 2.9% (n=3) paddle leads with a percutaneous approach. Percutaneous leads are implanted when patients have no anatomic abnormalities, including no previous spinal interventions at the target location or thoracolumbar junction, and no previous experience with SCS or intrathecal drug delivery. Percutaneous leads may be considered for patients without a history of spinal surgery. Paddle leads are preferred when percutaneous lead placement is technically too difficult, including patients with a history of previous spine surgeries, or as a rescue therapy for failed percutaneous trials. Conclusions Lead-specific indications were revealed for patients with chronic spinal pain, yet, the experience of the physician or affiliated department is suggested to have an important role. A clinical flowchart is proposed to help physicians in the decision-making process in daily clinical practice.