We read with interest the recent letter to Spinal Cord by Soni et al.1 They describe a complex series of events in a patient with a sacral anterior root stimulator (SARS), which culminated in the disuse of the implant. We were very surprised to read that the Authors' concluded from this single case that ‘the indications for implantation of SARS in spinal cord injury are becoming limited’. In principle, we believe that such uncorroborated statements, without a proper scientific basis are both unjustifiable and unhelpful.

In this particular case, anterior body wedge compression fractures of L4 and L5 vertebrae may have resulted from minimal-force trauma of osteopenic bone. This would not be an uncommon incident in a spinal cord-injured patient.2 A previous laminectomy (posterior elements of the vertebrae) may be coincidental. Therefore, the observed fractures may well have occurred even if this patient had not had a SARS implantation. Hence, there need not be a direct causal link between implantation and development of the described complications. However, we concur that when such fractures are identified, the patient should be counselled that further use of the implant (that can elicit hip extension via S2 root stimulation) can exacerbate a spondylolesthetic instability at the fracture level. This can then cause complications such as abdominal spasms or autonomic dysreflexia, which indeed the authors have reported. Our experience (and that of others) is that this is an extremely rare event.3 Those patients at high risk of osteoporosis may benefit from a preoperative DEXA scan, and managed as appropriate if bone mineral density is found to be low. The implantation may then be deferred to a later date.

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