Technical Strategies in Spinal Cord Stimulation for Refractory Angina: A Narrative Review.

Abstract

Refractory angina (RA) is a chronic condition characterized by persistent chest pain that remains even after the patient has received optimal medical and/or revascularization therapy. Spinal cord stimulation (SCS) has emerged as a minimally invasive adjunctive treatment for RA, yet the technical aspects of implanting SCS devices remain highly variable. To synthesize the existing literature on technical strategies used in SCS implantation for RA and to identify common practices and areas of variability in the clinical implementation of the procedure. A narrative review. A comprehensive literature search of the PubMed and Embase databases was conducted to identify studies published between 1987 and 2025. Articles were included if they met the following criteria: 1) they reported on the use of SCS for patients with RA or chronic angina, and 2) they provided technical details regarding one or more aspects of the implantation process, such as epidural access level, lead positioning, or stimulation programming. Eligible articles included randomized trials, cohort studies, case series, and reviews. Lead placement was commonly reported at the upper thoracic or cervicothoracic junction (T1-T2 or C7-T1), with a few exceptions for cervical placement. Intraoperative paresthesia mapping was used in several studies to optimize electrode coverage of reported RA pain, though methodologies were described inconsistently. Of all stimulation paradigms, tonic stimulation remains the most well-studied and validated setting, though subthreshold, high-density, and burst stimulation show potential benefits for select patient populations. Trial phases were described variably, ranging from experiences that involved the implantation of transcutaneous electrical nerve stimulators to ones that included multiday spinal cord stimulators. Significant heterogeneity and inconsistent reporting of technical parameters are described in the literature. Few studies have directly compared outcomes related to various technical approaches or stimulation paradigms. Technical aspects of the implantation of SCS devices for RA remain variable, particularly in terms of lead placement strategies, stimulation paradigms, and trial methodologies. More rigorous studies are needed to guide best practices for SCS use in this population.