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SCS Patient Selection — FRCA Final MCQ

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HardPain MedicineSCS Patient SelectionFRCA Final

A 55-year-old man has persistent spinal pain syndrome type 2 with severe neuropathic leg pain despite more than 6 months of appropriate conventional management. The specialist multidisciplinary team considers him medically and technically suitable for a spinal cord stimulation trial. Validated psychological assessment identifies a current untreated moderate depressive episode, marked pain catastrophising and fear-avoidance behaviour that are impairing his engagement with rehabilitation. He has realistic expectations and no suicidality, psychosis or substance misuse. What is the most appropriate next step?

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Correct answer: E — Defer the SCS trial, optimise depression and pain-related coping, then reassess

Explanation lettering: E = shown as A · A = shown as C · C = shown as E

C is correct. The patient has an appropriate neuropathic indication for SCS, but active untreated depression and maladaptive pain-related behaviour are modifiable barriers to engagement with trial evaluation and rehabilitation. The trial should therefore be deferred while depression is treated and pain-focused psychological management, such as CBT with graded behavioural activation, is undertaken; candidacy should then be reconsidered by the SCS multidisciplinary team. These findings are not absolute or permanent contraindications, and their predictive value should not be overstated, so B is inappropriate. Proceeding immediately (A) fails to optimise significant identified risks. Intrathecal drug delivery (D) is not a substitute for psychological optimisation and carries its own invasive risks. Escalation to long-term strong opioids (E) is not the preferred alternative to appropriately selected neuromodulation.

Reference: Shanthanna H et al. Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain, section on psychosocial screening, 2023. https://pubmed.ncbi.nlm.nih.gov/37001888/