Acute back pain in patient with SCS

[NJPAIN]

54 year old with history of leukemia in remission. Left foot crush injury with CRPS. Had SCS placed several years ago. I did the trial and an SCS experienced NS did the implant. Right lead for non-specific LBP and left lead for the foot. Has done well. Last week complained of acute onset intense midline low back pressure. On exam only thing notable is TTP in midline over the horizontally placed anchor. Anchor does appear to be fairly superficial He has intentionally lost 75lbs since implant.
Aside from perhaps some sort of local "irritation" caused by the anchor in the setting of weight loss, any thoughts regarding potential causes linked to the position of that lead at L1? I don't yet know where it started but to me it appears to barely (and perhaps not totally) be in the epidural space. He claims that pain unaffected by turning stim on and off though I have not yet seen that with my own eyes.

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[lobelsteve]

ESR/CRP/CBC/CT TL spine.
Rule out late infection.
Left lead in gutter appears obnoxious.

 

[soccrwz]

lead in the gutter on left

 

[fathead88]

Definitely seen anchors start to bother patients after large weight loss. Typically gets better on its own.

 

[Orin]

54 year old with history of leukemia in remission. Left foot crush injury with CRPS. Had SCS placed several years ago. I did the trial and an SCS experienced NS did the implant. Right lead for non-specific LBP and left lead for the foot. Has done well. Last week complained of acute onset intense midline low back pressure. On exam only thing notable is TTP in midline over the horizontally placed anchor. Anchor does appear to be fairly superficial He has intentionally lost 75lbs since implant.
Aside from perhaps some sort of local "irritation" caused by the anchor in the setting of weight loss, any thoughts regarding potential causes linked to the position of that lead at L1? I don't yet know where it started but to me it appears to barely (and perhaps not totally) be in the epidural space. He claims that pain unaffected by turning stim on and off though I have not yet seen that with my own eyes.

The anchors are poorly placed and cross the spinous process which can cause some irritation.
The battery is over the PSIS.

The experienced implanter may not have been paying attention here.

Agree with checking the labs per Lobel, but also consider an MRI or a bone scan.

 

[NJPAIN]

He is coming in tomorrow. Unless the picture has evolved. I plan to use US and place some LA around the anchor and see if he has improvement. If not, ESR, CRP, CBC and CT with contrast to r/o infection and turf to implanting. NS His lead outside the T7-T12 compatibility range so they wont do an MRI.

 

[Orin]

He is coming in tomorrow. Unless the picture has evolved. I plan to use US and place some LA around the anchor and see if he has improvement. If not, ESR, CRP, CBC and CT with contrast to r/o infection and turf to implanting. NS His lead outside the T7-T12 compatibility range so they wont do an MRI.

I'm with you except for the poking. There's no reason to take that risk until after the labs and imaging come back.

Why deal with the risk of seeding the hardware? Negative labs and you can inject if you need, but for now slap an OTC lidoderm patch on it and pray.

 

[RoloTomassi]

I'm with you except for the poking. There's no reason to take that risk until after the labs and imaging come back.

Why deal with the risk of seeding the hardware? Negative labs and you can inject if you need, but for now slap an OTC lidoderm patch on it and pray.

Agree. I'm very hesitant about injecting anywhere near hardware. Best case is an hour of relief and some diagnostic value, worse case infection and muddies the picture if infection already on ddx

 

[BobBarker]

Don’t inject around the anchors. It needs to be revised.

 

[Espn123]

ESR/CRP/CBC/CT TL spine.
Rule out late infection.
Left lead in gutter appears obnoxious.

Last line made me laugh!

 

[Ferrismonk]

1. Never seen a neurosurgeon do perc leads. Interesting.
2. Decreased irritation/complications is one reason why coming in with both leads side by side makes sense for implants.
3. Gutter lead isn't a big deal if it isn't causing him discomfort and stim still works. Weird though.
4. How common is a latent infection after years?
5. If you don't do the surgical stuff, would turf back to the surgeon for workup/revision.

 

[myrandom2003]

Weight loss- possible lead redundancy ? IPG flipping?

 

[NJPAIN]

1. Never seen a neurosurgeon do perc leads. Interesting.
2. Decreased irritation/complications is one reason why coming in with both leads side by side makes sense for implants.
3. Gutter lead isn't a big deal if it isn't causing him discomfort and stim still works. Weird though.
4. How common is a latent infection after years?
5. If you don't do the surgical stuff, would turf back to the surgeon for workup/revision.

Lots of NS here do perc leads. This NS does all his own trials including DRG
That gutter lead is working great for the foot
I do many of my own implant but try to farm out high risk. This guy was 6’2” 340lbs, leukemia, and on high dose opioids at the time so I sent to NS. The case was a rodeo. Almost jumping of table. Half way through they had to flip him intubate.

When you say side by side you mean both needles on same side ?

 

[Ferrismonk]

Lots of NS here do perc leads. This NS does all his own trials including DRG
That gutter lead is working great for the foot
I do many of my own implant but try to farm out high risk. This guy was 6’2” 340lbs, leukemia, and on high dose opioids at the time so I sent to NS. The case was a rodeo. Almost jumping of table. Half way through they had to flip him intubate.

When you say side by side you mean both needles on same side ?

Yep. Both needles come in same side, maybe a bit more medial or one level below usual, keep shallow angle, and advance as normal. That way you only have one place to cut down to tack both leads to fascia and they'll both slightly paramedian on same side as pocket.

 

[NJPAIN]

Yep. Both needles come in same side, maybe a bit more medial or one level below usual, keep shallow angle, and advance as normal. That way you only have one place to cut down to tack both leads to fascia and they'll both slightly paramedian on same side as pocket.

I used to ALWAYS do it that way. Always left side. Most often one needle next to the other. It was easier as right handed person to work on patient's left. It was WAY easier to get a CLO (use it all of the time) to gauge depth and sliding the second needle next to the first made trajectory and depth easier to gauge. I stopped because I started making the mid line incision first and it just seamed neater to put one lead on each side. Also easier to anchor than two anchors right next to one another. That said, while I wasn't crazy about cutting down around the needles I think that placing the needles through the open incision is harder for me. I seen one very experienced implanter placing leads percutaneously, then ,making a midline incision and pulling the leads midline.