How does the eSCS application process work?

Evaluation and imaging: Magnetic resonance imaging (MRI) and neurophysiological tests (such as H-reflex measurements) are performed prior to surgery to determine the extent of spinal cord damage.

Trial implantation: Before placing a permanent device, a short-term trial application is conducted using temporary electrodes. This is a minimally invasive outpatient procedure used to evaluate the patient’s response to therapy.

Permanent implantation: If the trial is successful, electrodes are permanently placed in the epidural space, and the neurostimulator is implanted under the skin.

Programming: Stimulation parameters (frequency, amplitude, electrode configuration) are personalized according to the patient’s needs.

Rehabilitation period: Following surgery, the patient is generally directed to an intensive physical therapy and rehabilitation program within one to two weeks.

This treatment is generally considered reversible; if the patient decides to discontinue, the electrodes and generator can be surgically removed.

Risks and Potential Complications

As with any surgical procedure, there are certain risks associated with eSCS application:

• Infection
• Epidural bleeding, hematoma
• Electrode migration or erosion through the skin
• Cerebrospinal fluid (CSF) leak
• Spinal cord compression and, rarely, paralysis
• Allergic/immune reaction to the implanted material
• Persistent pain or seroma/hematoma formation at the device site
• General surgical risks, including bleeding, infection, blood clot formation, and reactions related to anesthesia.

Critical Importance of Post-Surgical Physical Therapy

The success of epidural spinal cord stimulation surgery depends not only on the correct placement of the device, but equally on the intensity and continuity of the post-surgical physical therapy and rehabilitation process. Especially in patients aiming for motor function recovery following spinal cord injury, stimulation alone is not sufficient; the increase in neural excitability provided by electrical stimulation must be supported by a task-oriented, repetitive, and intensive exercise program in order to translate into functional movement.

There are several fundamental reasons for this:

1. Repetition is essential for neuroplasticity: Even after damage, the spinal cord possesses a certain capacity for reorganization. While epidural stimulation functions like a “key opening the door” to this capacity, repeated and properly timed movement practice across the brain-spinal cord-muscle axis is required for permanent and functional motor gains to form. Exercise performed without stimulation yields limited benefit, while stimulation performed without exercise remains similarly limited; the combination of both produces stronger results in the literature.
2. Combination of exoskeleton-assisted gait and resistance training: Recent randomized controlled trials report that applying epidural stimulation together with exoskeleton-assisted gait training and resistance training provides improvements in voluntary motor control, as well as body composition, cardiovascular autonomic profiles, and bladder function. This demonstrates that physical therapy is not an “additional treatment” independent of the device, but an integral component of the therapy itself.
3. Preservation of muscle strength and cardiovascular conditioning: Preventing muscle atrophy, loss of bone density, and cardiovascular deconditioning caused by prolonged immobility is necessary to make the neural gains achieved through stimulation physically usable. During this process, physiotherapists plan both strength training and balance, posture, and coordination studies in an individualized manner.
4. Rehabilitation of bladder, bowel, and autonomic functions: Beyond motor recovery, the effects of epidural stimulation on urodynamic function and autonomic control are also being investigated; consolidating gains in these areas likewise requires the collaborative effort of a multidisciplinary rehabilitation team (physiotherapist, urologist, occupational therapist).
5. Continuity and patient motivation: Rehabilitation programs typically last for months, and regular participation by the patient is the determinant of the outcome. Follow-up periods in clinical protocols are planned for 6 months, 12 months, or even longer periods; this highlights that physical therapy must be approached not as a one-time intervention, but as a long-term process.
6. Individualized program design: Because every patient’s injury level, residual motor/sensory function, and general health status differ, the physical therapy program must be adjusted specifically for the patient simultaneously with the stimulation parameters. This coordination generally requires the joint work of neurosurgery, physical medicine and rehabilitation (PM&R) specialists, and physiotherapists.

In summary, neglecting or discontinuing physical therapy early after epidural spinal cord stimulation surgery can prevent the neurophysiological potential offered by the device from turning into a functional gain. Therefore, it is recommended that patients view the post-surgical rehabilitation process as an indispensable part of treatment that is at least as important as the surgery itself.