Neurostimulation for pain neurosurgical considerations
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Neurostimulation for Pain: Neurosurgical Considerations. Joshua M. Rosenow, MD, FACS Director, Functional Neurosurgery Associate Professor, Department of Neurosurgery Northwestern Memorial Hospital. SCS: Patient Selection. Pain syndrome amenable to stimulation Radicular preferable to axial

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Neurostimulation for Pain: Neurosurgical Considerations

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Neurostimulation for pain neurosurgical considerations

Neurostimulation for Pain: Neurosurgical Considerations

Joshua M. Rosenow, MD, FACS

Director, Functional Neurosurgery

Associate Professor, Department of Neurosurgery

Northwestern Memorial Hospital


Scs patient selection

SCS: Patient Selection

Pain syndrome amenable to stimulation

Radicular preferable to axial

Neuropathic preferable to nociceptive

Failed reasonable medical management

Several pharmacologic classes

Dose titration until adverse side effects or lack of response noted

Surgical disease ruled out

Reoperation vs. stim?

Not surgical candidate?

Pain psychological evaluation

*North, et al. Stereotact Funct Neurosurg 1994;62:267-272.


Patient factors

Patient Factors

Set appropriate expectations!!!!

Takes time, but will be worth the investment

Prepare patients for the procedure

Involve them in the process

i.e. IPG placement


Surgical contraindications

Surgical Contraindications

Thecal sac compression/significant spinal stenosis

Significant spinal deformity

Severe emaciation

Significantly low WBC, plt

Coagulopathy

Ongoing infection

Inability to assess patient response to trial

Psychological contraindications

Patient compliance issues

Medication abuse issues

Unsuccessful trial


General principles

General Principles

Adequate length of trial

Choose appropriate hardware

Simulate everyday life during trial, within limits

Confirm location and ensure stability of electrode

Prevent infection

Prepare for permanent implant

Permanent system should be stable, flexible and convenient

Prepare for revisions


Mac vs geta

MAC vs. GETA

Airway/body habitus

Comorbidities

Procedure to be performed/region of operation

Anticipated intraoperative difficulties

Need for intraoperative verification of coverage

Patient preference

Patient ability/willingness to cooperate

If GETA - consider neuromonitoring for protection and confirmation


Why use paddles

Why use paddles?

  • Previous difficulties with perc leads

  • Preference of implanter

  • ?lower current requirement

  • ?less interference by epidural fat


Paddle trials

Paddle Trials

  • Lumbar fusion or laminectomy precluding percutaneous insertion

  • Inability to access the epidural space percutaneously

    • Bony anatomy

    • Obesity

  • Prior procedure in the region of the implant

    • Tumor resection, etc.


Paddle leads

Paddle Leads


Laminotomy lead placement

Laminotomy Lead Placement

  • Plan incision centered 1 disc space below desired entry point

    • Incision centered on T10-11 will lead to entry at T9-10 and paddle will cover T8-9 bodies

  • Rongeur both upper and lower spinous processes to flatten angle

  • Small central lamintomy through ligamentum flavum

  • Carefully dissect epidural space and insert electrode

  • Avoid pressure on spinal cord

  • Securely anchor to deep tissues


Paddle issues

Paddle issues

Where does the paddle go?

Assessing canal adequacy for paddle

Clearing the epidural space

The paddle won’t go straight


Guess the level

Guess the level!


Communication is key

Communication is key

T9

T10


Preop imaging is essential

Preop imaging is essential

  • You would never do any other spine case without adequate preop imaging – DON’T START NOW

  • Preop imaging makes sure something asymptomatic doesn’t become symptomatic

  • Aids in counseling patient preop if procedure needs to be altered to deal with anatomic issue


Preop imaging is essential1

Preop imaging is essential

  • Where is the cord???

  • The cord may not respect the spinal column midline

  • Paddle may look great on fluoro and not provide adequate coverage


Paddle issues in the or

Paddle issues in the OR

Dissecting epidural space

Careful

You’re a surgeon – use surgical tools

No – paddle lead, passing device

Yes – dural separator, narrow tip malleable brain ribbon

Anywhere but straight

Straight paddle in curved space

Epidural adhesion

Unilateral extension vs. “reach around” laminotomy


Epidural fibrosis

Epidural fibrosis

Careful dissection

Use appropriate instruments

Don’t over-reach

Decompress if you need to do so

Suture paddle to dura if possible

Fibrin glue

Postop abdominal pain


Complication avoidance

Complication avoidance

Don’t be overzealous

Don’t push a bad situation

If it won’t go, it won’t go…

Caution when dissecting laterally – epidural veins

Poor coverage despite radiographic adequacy

check trial fluoros

make sure c-arm aligned in both planes


Don t be that surgeon

Don’t be THAT surgeon

Paddle placed under GETA

Awoke with right thoracic radicular pain

Never had good coverage with stim

Surgeon told him to “wait a year and see if the coverage and pain improve”


Don t make more cases

Don’t make more cases!


To extend or not to extend

To Extend or Not to Extend

  • PRO

    • Adds slack to system

    • May make revision less invasive

    • May be needed to adapt electrodes to IPG

    • Needed for “permanent trial”

  • CON

    • Another electrical connection

    • Another wire that may break

    • Connector adds bulk and may not be suitable for some locations

    • Direct connection to IPG may reduce slack in system and add tension to electrode

  • In either case, there should be a relaxing loop of electrode in the electrode incision site


Ipg considerations

IPG Considerations

  • Location location location

    • Patient comfort

    • Cosmesis

    • Ease of remote interface

    • Ease of recharger interface (if rechargeable)

    • Ease of implant

    • Ease of revision

  • Rechargeable vs. Primary cell


Possible ipg locations

Possible IPG Locations

  • Buttock

    • Cervical or lumbar SCS

    • ONS

    • Peripheral LE stimulation

  • Axillary

    • ONS

    • Cervical SCS

  • Abdomen

    • DBS/MCS

    • ONS

    • SCS

  • Infraclavicular

    • Trigeminal

    • ONS

    • DBS/MCS

    • Cervical SCS

    • UE peripheral stimulation

  • SQ lower extremity


Conclusions

Conclusions

Rational treatment plan improves outcomes

Good patient selection important

Technique is key, as always

Goal: not “do implants” but TREAT PAIN


Neurostimulation for pain neurosurgical considerations

Thank you for coming!

E-mail: [email protected]

Phone: 312-695-0495


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