Challenging case, seeking help from the SDN gurus

[y2janitor]

I have a patient who had a prior SCS paddle lead placed with laminectomy at T11-12. She had the SCS removed in 2014 and had a L2-L5 fusion in 2016. Surgeon states no further surgery indicated. She presented to me interested in having a new SCS trial. My question is: is a new percutaneous trial possible given the prior laminectomy? And if so, can you enter between the fusion and laminectomy? Above the laminectomy?

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[Taus]

Not a stim guru, but Imo I wouldn't try to bypass prior paddle site due to lami. Theoretically could enter T10-11, but I'd feel much more comfortable at T9-10.... though likely too high to get perc leads where needed. If truly a great stim candidate I'd just send for surgical trial.


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[deleted185747]

Crazy idea: do a perc trial without LOR. Bring in needle in usual angle and contact lamina below. Thread lead up over lamina and cephalad staying posterior to dura at the site of laminectomy. How crazy is this? I dunno....

 

[Timeoutofmind]

Crazy idea: do a perc trial without LOR. Bring in needle in usual angle and contact lamina below. Thread lead up over lamina and cephalad staying posterior to dura at the site of laminectomy. How crazy is this? I dunno....

bad idea

Dont want to plow through scar tissue with a lead like that. Bleeding, dural tear, etc

Tough case...if it was my back...what about entering up top (T1/2) and threading lead retrograde down to T8/9! Anyone ever done this? Seems preferable to a paddle trial.

 

[Aether2000]

Definitely not through the lami site- but through the interspinous window one or two levels above the laminectomy.

 

[lobelsteve]

No good way in except T1-T3 retrograde with coude. Advanced technique and easy to say no to this.

Prefer to do on cadaver and let some guru take his chances.

 

[Taus]

I had a few retrograde trials in fellowship from upper thoracic down for similar reasons. Both with (and mostly done by) one of my true guru attendings. Kinda scary and really hard to keep lead dorsal. One aborted. One took 2 hours. Not something I plan on doing ever.


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[DOctorJay]

Send for open trial with guru surgeon.


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[Orin]

Just to play devil's advocate, you could check this by trialing a LESI below the fusion at L5/S1 with a catheter or above without the catheter. Contrast would let you evaluate accessibility on the epidurogram, but you'll probably need a high volume of contrast. Threading a flimsy catheter would let you know if your lead has any route.

I expect though you will find you aren't able to thread a flimsy catheter through the space at the level of the lami and that contrast will show lots of scarring. Sometimes they don't remove that ligamentum flavum in regular laminectomies, but they generally would for a paddle lead placement.

Regardless, once you had that "epidural space" identified though, you could see in a CLO or lateral view if you had any way to access it in the lami area or thread a lead up it.

This seems like a good case for a spine surgeon to refuse before you try anything like the above.

Why was the old paddle removed?

 

[BobBarker]

You can access interlaminar in the typical fashion b/w the laminectomy and fusion sites. The leads will slide past where the paddle lead was typically. Did one last week with a floppy stimwave lead. Would have been easy with a st jude lead.

 

[bedrock]

I'd enter at T12-L1 and try to pass the leads. If no dice, I'd try T10-T11, but at the most superior aspect of that space.

I've tried retrograde from T1-T2, but ran into the same issues Taus described. Never again.

 

[clubdeac]

retrograde sounds like a nightmare....maybe 5 years ago I would've tried it but not anymore

 

[Aether2000]

Retrograde thoracic is probably one of the most dangerous things a person could do given the slope of the lamina, angle of the ligamentum flavum in the interlaminar window, and the proximity to the cord. The needle will need to be nearly orthogonal to the cord and the lead would certainly cause posterior dural displacement to efface and possibly contuse the cord. Passing the lead anterograde past an area of prior laminectomy has the potential to tunnel the lead anterior to scar tissue and into the cord itself. I have successfully placed SCS with a tip as high as T4 for low back and lower extremity pain in situations such as these, entering cephalad to the laminectomy site.

 

[lobelsteve]

Retrograde thoracic is probably one of the most dangerous things a person could do given the slope of the lamina, angle of the ligamentum flavum in the interlaminar window, and the proximity to the cord. The needle will need to be nearly orthogonal to the cord and the lead would certainly cause posterior dural displacement to efface and possibly contuse the cord. Passing the lead anterograde past an area of prior laminectomy has the potential to tunnel the lead anterior to scar tissue and into the cord itself. I have successfully placed SCS with a tip as high as T4 for low back and lower extremity pain in situations such as these, entering cephalad to the laminectomy site.

Do this, or do not do anything.

 

[Ducttape]

Again, why was the previous SCS taken out? Was there a reason such as need for recurrent MRIs? If that's the case, refer directly to surgeon to reimplant at T10-11...

If it is because she just wanted it out, I can see doing a lot of work only for something that will get taken out again in the future.


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[NJPAIN]

retrograde sounds like a nightmare....maybe 5 years ago I would've tried it but not anymore

With age and experience comes wisdom ( as well as incontinence )


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[y2janitor]

Thanks for the responses and suggestions. I plan to enter cephalad to the laminectomy site.