Table 2 Recommendations for patients with a SCS system in-situ requiring radiation

General Recommendations

1. All patients with SCS should be identified prior to treatment planning, and appropriate action taken to limit and minimize the exposure of the device to radiation.

2. Adopt a multidisciplinary approach and seek neurosurgical involvement prior to treatment delivery.

3. Obtain detailed product specification from the device manufacturer (e.g. model and serial numbers, expected battery life).

4. Obtain assurance that the SCS is in proper working order prior to treatment planning and delivery.

5. Obtain full written informed consent from the patient

Simulation and Planning Recommendations

1. Ensure the patient is simulated in a comfortable and reproducible treatment position.

2. Do not perform MRI simulation (or other MRI imaging without contacting the device manufacturer) with a SCS in-situ

3. At the time of CT simulation, the radiation therapist must ensure that the entire device is visible on the simulation images if it is within 30 cm of the proposed radiation fields.

4. During treatment planning, calculate the estimated dose which the device will receive.

Treatment Delivery Recommendations

1. The pulse generator should be placed at least 1 cm outside of the direct therapy beam during treatment delivery. For IMRT plans, all segments should be checked to ensure no beam passes through the device.

2. The patient is asked to turn the device to 'off-mode' during the actual treatment delivery. It is acknowledged however, that damage can occur to electronic devices during radiation whether powered on or off.

3. Dosimetric measurements should be taken on 3 separate occasions by placing diodes at the skin surface over the pulse generator under suitable build-up conditions. Extrapolating from the dose limit recommendations for cardiac pacemakers, the recommended total dose limits to the pulse generator should be less than 5 Gy.