Panic Attacks After Spinal Cord Stimulator Implantation

To the Editor: We present the case of a 45-yr-old male patient with chronic pain, considered an excellent candidate for implantation of a spinal-cord stimulator, who developed panic attacks shortly after the spinal cord stimulation was implanted. His panic symptoms persisted even when the stimulator was turned off. Removal of the implanted stimulator resolved his symptoms. The patient had no significant medical history other than radicular low back pain and severe right knee pain, due to a work-related injury. The patient underwent open right knee reconstruction along with physical therapy (for his knee and back), several lumbar epidural steroid injections, and treatment with opioids and pain adjuvants. Because of the severity of the patient’s radiculopathy and his limited response to treatment, we offered a spinal-cord stimulator trial. During regular preoperative evaluation, a clinical pain psychologist interviewed the patient to screen him psychologically before surgery and to review the patient’s understanding of the procedure’s implications. During the interview the patient did not reveal any signs of depression, suicidal ideation, or anxiety. The trial was performed for 1 wk without any complications. The patient experienced good pain relief and it significantly improved his ability to function. He was very pleased with the results of the trial and requested implantation of the dorsal column spinal-cord stimulator. Two months later we implanted it without complications. We confirmed the lead wires to be in the dorsal epidural space, with the lead tips implanted at the T9–10 level. During the procedure the patient confirmed receiving appropriate lower back and lower limb stimulation, without any stimulation in the chest or abdomen. Two weeks after the stimulator had been implanted, the patient noted severe, increased anxiety, chest tightness, and insomnia. He was examined by his internist, who recommended a full cardiac evaluation, consisting of an electrocardiogram, a stress test, and an echocardiogram. All three tests were unremarkable. Since the chest pain did not improve, a coronary angiogram was performed. All cardiac testing was unremarkable. The patient was prescribed sertraline lansoprazole, metoprolol, and alprazolam by his internist, while remaining on extended release oxycodone and oxycodone/acetaminophen. The patient stated “I can’t stand the idea of having this inside of me.” After thorough discussion with the patient, we reaffirmed that his symptoms were not of a cardiac nature. Because the panic symptoms occurred with the stimulator both on and off and did not improve with medications, we removed the stimulator at the patient’s insistence. Immediately his anxiety resolved and did not recur, even though the pain returned. The patient discontinued the psychiatric medications. This potential complication, panic symptoms after implantation of a stimulator, should be considered in every candidate regardless of absence of a psychiatric history. Robert Sheu, MD Department of Pain Medicine and Palliative Care Beth Israel Medical Center New York, NY Department of Physical Medicine and Rehabilitation and Department of Anesthesia, Albert Einstein College of Medicine Bronx, NY Marc Goloff, PhD, ABPP Department of Pain Medicine and Palliative Care Beth Israel Medical Center New York, NY Santiago Esteban, BS Universidad Austral Pilar Argentina Department of Pain Medicine and Palliative Care Beth Israel Medical Center New York, NY Nityanada Podder, MD Department of Pain Medicine and Palliative Care Beth Israel Medical Center New York, NY Ricardo A. Cruciani, MD, PhD Department of Pain Medicine and Palliative Care Beth Israel Medical Center New York, NY Departments of Neurology and Anesthesiology Albert Einstein College of Medicine Bronx, NY [email protected]