CASE DESCRIPTION
Age/Gender: 68-year-old male
Presentation diagnosis: Skin tear at SCS pocket, five months post-implantation
Indication for SCS: Diabetic neuropathy providing substantial pain relief
PMH: Cirrhosis from nonalcoholic steatohepatitis, type 2 diabetes mellitus, hypertension, atrial fibrillation, myasthenia gravis, carcinoid syndrome;
HPI:
●Patient experienced a fall during while hunting, which led to a wound that gradually opened over time. Presented with bloody and clear drainage but otherwise asymptomatic.
●Physical examination revealed an exposed SCS generator at the right flank incision site, with mild erythema and minimal drainage (Figures 1 and 2).
●Lab tests: Elevated C-reactive protein, back swab cultures cultures were collected and he went through urgent device explantation.
●Treatment: Cefalexin 500mg Q6h for 14 days (positive cultures for gram positive bacteria). Pain intensity (8/10) compared to the pre-explantation level (2/10), localized on his feet and lower back.
●Twelve-weeks after explantation, he received a new SCS, with the pocket placed on the left side.
●Two-week follow-up: He reported a 50-60% improvement in pain, incision site showed no complications.
DISCUSSION
Indications for SCS Removal
●Inadequate pain relief
●Active infection
●Skin opening near the device
Infection Rates and Symptoms
●Infection rates for SCS: 2.4% to 3.1%
●Symptoms: erythema, drainage, fever, swelling, localized pain
●Confirmation: often through positive cultures
Evaluation of Suspected SCS Infection
●Physical Examination
●Laboratory Tests (CBC, ESR, C Protein Levels, Cultures)
●CNS Infection Assessment (Lumbar puncture if indicated)
Management of Infections
●Superficial Infections: (limited to the skin, managed with a short course of oral antibiotics targeting Gram-positive bacteria, close monitoring for complications).
●Deep Infections: (occur below the fascia and require device explantation, extended antibiotic therapy and thorough wound irrigation). Wound closure using non-braided sutures and materials like Vicryl and staples to reduce biofilm formation.
Consultation and Reimplantation
●Consultation with Infectious Disease team for tailored antibiotic therapy and additional interventions.
●Reimplantation considered after at least 12 weeks for tissue recovery.
Impact of Discontinuing Pain Management
●Discontinuation can severely affect patient quality of life and increase overall morbidity.
●In this case, despite effective pain control from the SCS, risks from the skin tear required explantation.
●Successful reimplantation allowed the patient to resume treatment effectively.
