Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Spinal Cord Stimulation Periprocedural Care

  • Author: Anthony H Wheeler, MD; Chief Editor: Kim J Burchiel, MD, FACS  more...
 
Updated: Jan 07, 2015
 

Patient Preparation

Following completion of a SCS percutaneous trial, the leads are pulled, and the skin entry sites are cleaned with chlorhexidine and alcohol. A topical antibacterial agent can be used to cover the puncture sites, then a Tegaderm dressing is applied as an additional barrier.

The permanent trial is scheduled for no sooner than 2-3 weeks, after which any inflammatory or infectious residua should be resolved. This also allows time for recognition of all potential trial complications, so that they be treated and not increase the risk of complication of permanent SCS placement. The required lead length to the IPG pocket site is measured, any imaging studies that would expose an anatomical or technical barrier are requested, and pertinent preoperative blood work should be considered to preclude infectious or bleeding complications.

Limited research using computer modeling analysis suggested that the effect of spine flexion on the distance between an IPG site implanted in the buttock and the midline anchor requires an increased lead length of 9 cm. Therefore, strain relief loops 2.5-3 cm in diameter are placed at appropriate sites to compensate for spinal movement (adjacent the midline anchor and a second loop adjacent the IPG pocket). Each loop requires an additional 9-10 cm of lead length. These strain relief loops reduce kinking, damage, and breakage of the leads.

Conversely, modified direct tunneling techniques that travel diagonally, directly to the IPG pocket, require comparatively reduced lead length. Experts and the literature are unsettled as to a specific "best" approach (eg, gluteal, abdominal, or midline placement in lumbar cases or various axillary sites in cervical placements). Some implanters prefer to tunnel cervical placements to the gluteal, abdominal, or lateral hip region. A common lead length when tunneling directly to the IPG pocket while also allowing for adequate strain relief is 70-cm. For longer permanent leads, most manufacturers provide supplemental extensors.

Proper placement of the IPG site is performed preoperatively. The site should be in a comfortable area within the patient’s reach for recharging. Postural change should be considered so that comfort is achieved both sitting and standing. A model of the IPG is used during pocket formation, a tight fit that requires some soft tissue stretching is preferred to minimize any dead space around the battery. For example, preparing a male patient for a gluteal pocket is best performed with the patient wearing pants so that the surgeon or technologist can locate a site using a model IPG placed over the skin. Preferred placement is below the belt line, yet high enough so that the unit does not impede sitting or reclining.

Similarly, female patients should wear a bra so that the IPG model can be located under the bra line. The IPG model is outlined using an indelible marker for precise location during the procedure (see the image below). The goal is to create a pocket that matches the size of the IPG as closely as possible. The incision site will be placed at the superior edge of the battery pocket. Location should be discussed with and approved by the patient.

Placement of the IPG. Placement of the IPG.

Positioning

For this procedure, the patient lies prone on the fluoroscopic table, which allows free access to the C-arm throughout the entire thoracolumbar spine. The patient’s head should be turned to the side so that most of the neck and back are relaxed. The vertebral column is positioned to minimize cervical or lumbar lordosis as described above, by placing pillows or specialized surgical bolsters or frames under the abdomen or chest that allow adjustable flexion for comfort. Additional pillows and modifications should be used to allow the patient to be comfortable and warm before the patient’s back is scrubbed with antiseptic and draped.[13]

Specific landmarks are used to identify the needle entry point. The most desirable oblique angle for needle placement is 30-45°. After fluoroscopic alignment of the pedicles and vertebral end plates, previously described, anatomic references, including the intralaminar entry site should be horizontal, crisply outlined, and clearly identified. For most percutaneous trials of the lower back and legs, the preferred entry for distal lead placement is usually between the T12-L1 and L2-3 intralaminar spaces.

The medial aspect of the ipsilateral pedicle 1-2 levels below the intralaminar entry target at the 9 or 3 o’clock position are marked as the skin entry site or sites.

In an average-sized adult, skin entry between L2 and L3 is technically safest because the conus medullaris and spinal cord are cephalad to this level in most adults. When the insertion point is selected, the tip of a metal marker is placed over the point to provide a fluoroscopic landmark. Adjustment of the entry point may be necessary in patients with extremes in body habitus. Entry will be more cephalad in very thin patients and caudal in very obese patients.[13]

Next

Monitoring & Follow-up

The SCS system is retested in the recovery room to assure that no lead migration or fracture may have occurred and that coverage remains adequate. If coverage is not acceptable, then the patient is taken back to the OR for revision. Over the next 24-hours neurological signs and symptoms are monitored. Any postoperative observations, including pain, weakness, or numbness, should be investigated. Paresthesia should be evaluated despite the device being turned off.

Postoperatively surgical wounds are dressed with nonocclusive bandages. Dressing changes are indicated when they become wet or bloody. Wet dressings should raise concern for fat necrosis in obese patients. Although the scientific literature is conflicting, conventional instruction has been to keep the wound dry for 10-14 days or until 1-2 days following suture/staple removal.

The first postoperative check is usually indicated at 3-4 days, whereby, the outer dressing is removed for wound inspection. Loose Steri-Strips are removed, but intact strips are left in place. Loose materials are irrigated with peroxide, and then the wound is gently patted dry with a 4x4 sterile cotton gauze pad. Next, a 4x4 sterile cotton gauze pad is loosely taped over the healing wound. At postoperative days 7-10 days staples/ sutures are removed, the final postoperative visit is usually scheduled at 3 weeks. If the wound shows no signs of infection, the patient may bathe.

Any signs or suspicion of infection should raise caution, and baseline blood studies including a complete blood count, erythrocyte sedimentation rate, and C-reactive protein should be obtained.

Patients are advised to avoid bending, squatting, or reaching above the shoulders for 6-8 weeks following surgery. Patients are asked to avoid twisting, limit lifting to less than 5-8 pounds, and to refrain from sleeping on their stomach. Motor vehicle accidents and trauma, like falls, can threaten lead integrity. Confronting a magnetic environment may induce current flow through coiled electrodes or lead extensions. Magnetic fields are commonly encountered through theft-deterrent devices, metal detectors, airport security procedures, and with medically indicated magnetic resonance imaging studies. Diathermy can cause tissue damage through energy that is transferred into the implanted SCS components resulting in severe injury or death.

During the healing period, the relationship between the implanted electrode surface and adjacent tissues evolves through healing, scarring and systemic/ metabolic factors. Therefore electrode contact and impedance changes can be expected. Manufacturer representatives are expected to stay in touch with postoperative patients to determine SCS efficacy when the system needs to be recalibrated or reprogrammed for improved pain coverage. Over the 6-8 weeks following SCS placement, physicians must manage medication-intake or tapering and patient expectations regarding pain relief.

Previous
 
 
Contributor Information and Disclosures
Author

Anthony H Wheeler, MD Pain and Orthopedic Neurology, Charlotte, North Carolina

Anthony H Wheeler, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, North American Spine Society, North Carolina Medical Society

Disclosure: Received salary from Allergan, Inc. for speaking and teaching; Received none from Gralise for consulting.

Chief Editor

Kim J Burchiel, MD, FACS John Raaf Professor and Chairman, Department of Neurological Surgery, Professor, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University School of Medicine; Attending Neurosurgeon, Section of Neurosurgery, Portland Veterans Affairs Medical Center; Attending Neurosurgeon, Shriners Hospital for Children

Kim J Burchiel, MD, FACS is a member of the following medical societies: American Academy of Pain Medicine, American Association of Neurological Surgeons, American College of Surgeons, American Pain Society, International Association for the Study of Pain, Oregon Medical Association, Society of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

References
  1. Gildenberg PL. History of electrical modulation for chronic pain. Pain Med. 2006. Suppl 1:S7-S13.

  2. Rossi U. The history of electrical stimulation of the nervous system for the control of pain. Simpson BA, ed. Electrical stimulation and the relief of pain of pain: pain research and clinical management. New York: Elsevier Science; 2003. 15: 5-16.

  3. Melzack R, Wall RD. Pain mechanisms: a new theory. Science. 1965. 150:171-9.

  4. Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anesth Analg. 1967 Jul-Aug. 46(4):489-91. [Medline].

  5. Linderoth B, Foreman Rd. Mechanisms of spinal cord stimulation in painful syndromes: role of animal models. Pain Med. 2006. 7(suppl):s14-26.

  6. Fukshansky M, Burton AW. Spinal cords stimulation.

  7. Oakley J, Prager J. Spinal cord stimulation. Spine. 2002. 22:2574- 83.

  8. Linderoth B, Foreman R. Physiology of spinal cord stimulation: Review and update. Neuromodulation. 1999. 3:137-44.

  9. Krames ES. Neuromodulatory devices are part of our "tools of the trade.". Pain Med. 2006. 7:Suppl 1 S3-S5.

  10. Vallejo R, Benyamin RM, Kramer J, Bounds D. Spinal cord stimulation. Manchikanti L, Singh V him (eds). Interventional Techniques in Chronic Spinal Pain. Paducah, Kentucky: ASSIP Publishing him; 2007. 655-664.

  11. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan. 10(1):7-111. [Medline].

  12. Cameron T. The safety and efficacy f spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg. 2004. 100:254-267.

  13. Kreis PG, Fischman SA. Spinal cord stimulation: percutaneous implantation techniques. New York: Oxford University Press; 2009.

  14. Lee AW, Pilitsis JG. Spinal cord stimulation: indications and outcomes. Neurosurg Focus. 2002. 58(3):481-96.

  15. British pain Society. British Pain Society. Spinal cord stimulation for the management of pain: recommendations for best clinical practice. London: 2005.

  16. Kumar K, Toth C, Nath RK, Laing P. Epidural spinal cord stimulation for treatment of chronic pain--some predictors of success. A 15-year experience. Surg Neurol. 1998 Aug. 50(2):110-20; discussion 120-1. [Medline].

  17. Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience. Neurosurgery. 2006 Mar. 58(3):481-96; discussion 481-96. [Medline].

  18. Simpson A, Meyerson BA, Linderoth B. Spinal cord and brain stimulation. McMahon SB, Koltzenbburg M, eds. Wall and Melzack’s textbook of pain. 5th ed. Elsevier Churchill Livingstone: Philadelphia; 2006. 569.

  19. Fogel GR, Esses SI, Calvillo O. Management of chronic limb pain with spinal cord stimulation. Pain Pract. 2003 Jun. 3(2):144-51. [Medline].

  20. Augustinsson LE. Spinal cord electrical stimulation in severe angina pectoris: surgical technique, intraoperative physiology, complications, and side effects. Pacing Clin Electrophysiol. 1989 Apr. 12(4 Pt 2):693-4. [Medline].

  21. Augustinsson LE. Spinal cord stimulation in peripheral vascular disease and angina pectoris. J Neurosurg Sci. 2003 Mar. 47(1 Suppl 1):37-40. [Medline].

  22. Jacobs Mj, Jorning PJ, Joshi SR, et al. Epidural spinal cord electrical stimulation improves microvascular blood flow in severe limb ischemia. Ann Surg. 1998. 207:179-83.

  23. Barolat G. Techniques for subcutaneous peripheral nerve field stimulation for intractable pain. Krames ES, Peckham PH, Rezai, AR, eds. London: Elsevier LTd: Neuromodulation; 2009. 1017.

  24. Haque R, Winfree CJ. Spinal nerve root stimulation. Neurosurg Focus. 2006. 21(6):1-7.

  25. Alo’ KM, Yland MJ, Redko V, et al. Lumbar and sacral nerve root stimulation (NRS) in the treatment of chronic pain: a novel anatomic approach and neurostimulation technique. Neuromodulation. 1999. 2(1):23-31.

  26. Dijkema HE, Weil EH, Mijs PT, Janknegt RA. Neuromodulation of sacral nerves for incontinence and voiding dysfunctions. Clinical results and complications. Eur Urol. 1993. 24(1):72-6. [Medline].

  27. Barolat G. Epidural spinal cord stimulation: anatomical and electrical properties of the intraspinal structures relevant to spinal cord stimulation and clinical correlations. Neuromodulation. 1998. 1:63-71.

  28. Stanton-Hicks M. Peripheral nerve stimulation for pain, peripheral neuralgia and Complex Regional Pain Syndrome. Krames ES, Peckham PH, Rezai, AR, eds. Neuromodulation, London: Elsevier Ltd. 2009. 397.

  29. Weiner RL, Alo’ KM. Occipital neurostimulation for treatment of intractable headache syndromes. Krames ES, Peckham PH, Rezai, AR, eds. Neuromodulation. London: Elsevier Ltd; 2009. 409.

  30. North RB, Wetzel FT. Spinal cord stimulation for chronic pain of spinal origin: a valuable long-term solution. Spine (Phila Pa 1976). 2002 Nov 15. 27(22):2584-91; discussion 2592. [Medline].

  31. North RB, Shipley J, Prager J, et al. Practice parameters for the use of spinal cord stimulation in the treatment of chronic neuropathic pain. Pain Med. 2007. 8(4):S200-75.

  32. Deer TR, Masone RJ. Spinal cord stimulation: Indications and selection. Deer T, ed. Atlas of implantable therapies for Implantable therapies for pain management. New York: Springer 2011;

  33. Vallejo R, Benyamin RM, Kramer J Bounds D. Spinal cord stimulation. Manchikanti L, Singh V, eds. Interventional techniques in chronic spinal pain. Paducah, Kentucky: ASSIP Publising; 2007.

  34. Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis. 2003 Oct 15. 37(8):997-1005. [Medline].

  35. Nichols RL. Preventing surgical site infections: a surgeon's perspective. Emerg Infect Dis. 2001 Mar-Apr. 7(2):220-4. [Medline].

  36. Centers for Disease Control and Prevention. Guide for Hand Hygiene in Health-Care Settings. Recommendations of the Health care Infection Control Practices Advisory Committee and the HIPAC?SHEA?APIC?IDSA Hand Hygiene Task Force. MMWR. 2002. 51:1-45.

  37. Bjerke N, Hobson DW, Seal LA. Preoperative skin preparation: a systems approach. Infect Control Today. 2001. 1-5.:

  38. Barolat G. Experience with 509 plate electrodes implanted epidurally from C1 to L1. Stereotact Funct Neurosurg. 1993. 61(2):60-79. [Medline].

  39. Stojanovic MP, Abdi S. Spinal cord stimulation. Pain Physician. 2002 Apr. 5(2):156-66. [Medline].

  40. Feirabend HK, Choufoer H, Ploeger S, Holsheimer J, van Gool JD. Morphometry of human superficial dorsal and dorsolateral column fibres: significance to spinal cord stimulation. Brain. 2002 May. 125(Pt 5):1137-49. [Medline].

  41. North RB, Kidd DH, Petrucci L, Dorsi MJ. Spinal cord stimulation electrode design: a prospective, randomized, controlled trial comparing percutaneous with laminectomy electrodes: part II-clinical outcomes. Neurosurgery. 2005 Nov. 57(5):990-6; discussion 990-6. [Medline].

  42. Simpson BA. Electrical stimulation in pain relief Series,. Elsevier: Philadelphia; 2003. Vol. 15:

  43. Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain. 2000 Dec 1. 88(3):287-94. [Medline].

  44. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov. 94(2):149-58. [Medline].

 
Previous
Next
 
Tuohy needle and stylist.
Cross-section anatomy of spinal cord.
Spine and epidural space.Gray's Anatomy
Knot types.
Placement of the IPG.
Midline pocket suture
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.