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Neuromodulatory hacking: a review of the technology and security risks of spinal cord stimulation

  • Review Article - Functional Neurosurgery - Pain
  • Published:
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Abstract

Background

Spinal cord stimulation (SCS) is a neuromodulatory technique used to relieve chronic pain. Previous instances of malicious remote control of implantable medical devices, including insulin delivery pumps and implantable cardiac defibrillators, have been documented. Though no cases of neuromodulatory hacking have been recorded outside of the academic setting, an understanding of SCS technology and the possible consequences of manipulation is important in promoting safety.

Methods

We review the components and implantation protocol of a SCS system, the functionality and technological specifications for SCS systems in the global market based on their device manuals, and patient- and clinician-specific adjustable factors. Furthermore, we assess documented instances of implantable medical device hacking and speculate on the potential harms of targeting SCS systems.

Results

SCS systems from Abbott Laboratories, Boston Scientific, Medtronic, and Nevro have unique functionality and technological specifications. Six parameters in device control can potentially be targeted and elicit various harms, including loss of therapeutic effect, accelerated battery drainage, paresthesia in unintended locations, muscle weakness or dysfunction, tissue burn, and electrical shock.

Conclusions

Based on the history of implantable medical device hacking, SCS systems may also be susceptible to manipulation. As the prevalence of SCS use increases and SCS systems continuously evolve in the direction of wireless control and compatibility with mobile devices, appropriate measures should be taken by manufacturers and governmental agencies to ensure safety.

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Abbreviations

AES-CCM:

Advanced encryption standard–counter with cipher block chaining message authentication code

FDA:

Food and Drug Administration

IPG:

Implantable pulse generator

RF:

Radiofrequency

SCS:

Spinal cord stimulation

SDR:

Software-defined radio

References

  1. Amirdelfan K, Vallejo R, Benyamin R, Yu C, Yang T, Bundschu R, Yearwood TL, Sitzman BT, Gliner B, Subbaroyan J, Rotte A, Caraway D (2020) High-frequency spinal cord stimulation at 10 kHz for the treatment of combined neck and arm pain: results from a prospective multicenter study. Neurosurgery 87:176–185

    Google Scholar 

  2. Baber Z, Erdek MA (2016) Failed back surgery syndrome: current perspectives. J Pain Res 9:979–987

    PubMed Central  Google Scholar 

  3. Bendersky D, Yampolsky C (2014) Is spinal cord stimulation safe? A review of its complications. World Neurosurg 82:1359–1368

    Google Scholar 

  4. Boston Scientific (2019) ImageReady MRI Head Only Guidelines for Precision Spectra Spinal Cord Stimulation System. https://www.bostonscientific.com/content/dam/Manuals/us/current-rev-en/91057049-04_ImageReady™_MRI_Head_Only_Guidelines_for_Precision_Spectra™_Spinal_Cord_Stimulator_System_s.pdf. Accessed 27 Mar 2020

  5. Boston Scientific (2019) Precision Spectra Spinal Cord Stimulator System—Information for Prescribers https://www.bostonscientific.com/content/dam/Manuals/us/current-rev-en/92304887-01_Precision_Spectra™_SCS_System_en-US_s.pdf. Accessed 27 Mar 2020

  6. Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Rao R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I (2019) Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med 5:12

    PubMed Central  Google Scholar 

  7. Deer TR, Jain S, Hunter C, Chakravarthy K (2019) Neurostimulation for intractable chronic pain. Brain Sci 9:23

    PubMed Central  Google Scholar 

  8. Garcia K, Wray JK, Kumar S (2020) Spinal Cord Stimulation https://www.ncbi.nlm.nih.gov/books/NBK553154/. Accessed 24 Mar 2020

  9. Kapural L, Yu C, Doust MW, Gliner BE, Vallejo R, Sitzman BT, Amirdelfan K, Morgan DM, Yearwood TL, Bundschu R, Yang T, Benyamin R, Burgher AH (2016) Comparison of 10-kHz high-frequency and traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: 24-month results from a multicenter, randomized, controlled pivotal trial. Neurosurgery 79:667–677

    PubMed Central  Google Scholar 

  10. Kunnumpurath S, Srinivasagopalan R, Vadivelu N (2009) Spinal cord stimulation: principles of past, present and future practice: a review. J Clin Monit Comput 23:333–339

    Google Scholar 

  11. Marin E, Singelée D, Yang B, Volski V, Vandenbosch GAE, Nuttin B, Preneel B (2018) Securing wireless neurostimulators. CODASPY ’18: Proceedings of the Eighth ACM Conference on Data and Application Security and Privacy 287-298

  12. Marjenin T, Scott P, Bajaj A, Bansal T, Berne B, Bowsher K, Costello A, Doucet J, Franca E, Ghosh C, Govindarajan A, Gutowski S, Gwinn K, Hinckley S, Keegan E, Lee H, Mathews B, Misra S, Patel S, Tang X, Heetderks W, Hoffmann M, Pena C (2020) FDA perspectives on the regulation of neuromodulation devices. Neuromodulation 23:3–9

    Google Scholar 

  13. McCreery DB, Agnew WF, Yuen TG, Bullara L (1990) Charge density and charge per phase as cofactors in neural injury induced by electrical stimulation. IEEE Trans Biomed Eng 37:996–1001

    CAS  Google Scholar 

  14. Medtronic (2017) Medtronic Intellis with AdaptiveStim Technology, Intellis: Rechargeable Neurostimulators—Implant Manual http://manuals.medtronic.com/content/dam/emanuals/neuro/CONTRIB_248485.pdf. Accessed 27 Mar 2020

  15. Medtronic (2017) MRI Guidelines for Medtronic Neurostimulation Systems for Chronic Pain http://manuals.medtronic.com/content/dam/emanuals/neuro/CONTRIB_248483.pdf. Accessed 29 Mar 2020

  16. Medtronic (2019) Medtronic Neuromodulation Clinician Programmer App—Programming Guide http://manuals.medtronic.com/content/dam/emanuals/neuro/M962281A_a_045_view_color.pdf. Accessed 27 Mar 2020

  17. Medtronic (2019) Neurostimulation Systems for Pain—Reference Manual http://manuals.medtronic.com/content/dam/emanuals/neuro/MA00152A_a_182_view.pdf. Accessed 28 Mar 2020

  18. Moore DM, McCrory C (2016) Spinal cord stimulation. BJA Educ 16:258–263

    Google Scholar 

  19. Nelson JT, Tepe V (2015) Neuromodulation research and application in the U.S. Department of Defense. Brain Stimul 8:247–252

    Google Scholar 

  20. Nevro Corp (2015) Patient Manual https://s24.q4cdn.com/932612397/files/doc_downloads/patient_manuals/Patient_Manual-(11052).pdf. Accessed 23 Mar 2020

  21. Oakley JC, Krames ES, Stamatos J, Foster AM (2008) Successful long-term outcomes of spinal cord stimulation despite limited pain relief during temporary trialing. Neuromodulation 11:66–73

    Google Scholar 

  22. Pohl J, Noack A (2017) Universal radio hacker: a suite for wireless protocol analysis. IoTS&P ’17: Proceedings of the 2017 Workshop on Internet of Things Security and Privacy 59-60

  23. Pycroft L, Boccard SG, Owen SLF, Stein JF, Fitzgerald JJ, Green AL, Aziz TZ (2016) Brainjacking: implant security issues in invasive neuromodulation. World Neurosurg 92:454–462

    Google Scholar 

  24. Radcliffe J (2011) Hacking medical devices for fun and insulin: breaking the human SCADA system. Black Hat Information Security Research Conference https://media.blackhat.com/bh-us-11/Radcliffe/BH_US_11_Radcliffe_Hacking_Medical_Devices_WP.pdf. Accessed 29 Mar 2020

  25. Russo M, Van Buyten JP (2015) 10-kHz high-frequency SCS therapy: a clinical summary. Pain Med 16:934–942

    Google Scholar 

  26. Sdrulla AD, Guan Y, Raja SN (2018) Spinal cord stimulation: clinical efficacy and potential mechanisms. Pain Pract 18:1048–1067

    PubMed Central  Google Scholar 

  27. Serrano-Muñoz D, Avendaño-Coy J, Simón-Martínez C, Taylor J, Gómez-Soriano J (2018) Effect of high-frequency alternating current transcutaneous stimulation over muscle strength: a controlled pilot study. J Neuroeng Rehabil 15:103

    PubMed Central  Google Scholar 

  28. St. Jude Medical (2015) MRI Procedure Information: For St. Jude Medical MR Conditional Neurostimulation Systems—Clinician’s Manual https://manuals.sjm.com/~/media/manuals/product-manual-pdfs/e/8/e809b699-a364-41bc-8 cc7-b7fc43035ae2.pdf. Accessed 29 Mar 2020

  29. St. Jude Medical (2016) Prodigy Neurostimulation System Programming and Reference: Models 3855, 3856—Clinician’s Manual https://manuals.sjm.com/~/media/manuals/product-manual-pdfs/6/f/6f1f57c7-db55-4ade-8ad4-086bf24eb490.pdf. Accessed 27 Mar 2020

  30. St. Jude Medical (2017) St. Jude Medical Patient Controller for Spinal Cord Stimulation Systems: Model 3875—User’s Guide https://manuals.sjm.com/~/media/manuals/product-manual-pdfs/1/7/17e056d6-6834-4fcc-b454-72a358be72e5.pdf. Accessed 27 Mar 2020

  31. Vallejo R, Bradley K, Kapural L (2017) Spinal cord stimulation in chronic pain: mode of action. Spine 42:S53–S60

    Google Scholar 

  32. Vannemreddy P, Slavin KV (2011) Spinal cord stimulation: current applications for treatment of chronic pain. Anesth Essays Res 5:20–27

    PubMed Central  Google Scholar 

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Acknowledgments

We thank the Abbott Laboratories, Boston Scientific, Medtronic, and Nevro for their input on the functionality and technological specifications of the SCS systems described in this article.

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Authors and Affiliations

  1. Department of Neurological Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ, 07103, USA

    Christopher Markosian, Varun S. Taruvai & Antonios Mammis

Authors
  1. Christopher Markosian
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  2. Varun S. Taruvai
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  3. Antonios Mammis
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Corresponding author

Correspondence to Christopher Markosian.

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Conflict of interest

Dr. Antonios Mammis is a paid consultant for the Abbott Laboratories, Boston Scientific, Medtronic, and Nevro.

Ethics approval

This article does not contain any studies with human participants performed by any of the authors.

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Comments

The vulnerability of electronic implants to external interference - both accidental and intentional - is well-known and has been a concern of patients, physicians, and even fiction writers. Here, the authors analyze features of various spinal cord stimulation devices and provide suggestions for future developments; the similarities and differences among device manufacturers and stimulator types becomes more obvious when the information is well summarized. One of the conclusions that may be drawn from reading the paper - the neuromodulation landscape is both complex and confusing, and is constantly changing. Perhaps the steps in certain standardization of charging and communication, akin to what is being done in creation of standardized connectors and headers, would facilitate creation of universal security protocols and protection from “neurohacking,” giving some peace of mind to current and future neuromodulation recipients.

Konstantin Slavin, MD

Chicago, Illinois, USA

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This article is part of the Topical Collection on Functional Neurosurgery - Pain

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Markosian, C., Taruvai, V.S. & Mammis, A. Neuromodulatory hacking: a review of the technology and security risks of spinal cord stimulation. Acta Neurochir 162, 3213–3219 (2020). https://doi.org/10.1007/s00701-020-04592-3

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