ipsilateral spinal cord stimulator lead epidural entry

[heathermed]

hello everyone.

I've always placed my SCS leads one on each side. I heard a lot of people enter ipsilaterally when placing the leads.
I was wondering if anyone can talk me through or perhaps have a picture on how they anchor the leads in such an arrangement? are the leads not right on top of each other?

is there enough space in between them to anchor? the answer must be yes since it's not an uncommon practice but not sure how.

thanks for the advice!

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[fathead88]

Yes the majority of the faculty that we do implants with use an ipsilateral approach. The first needle is placed to enter on the ipsilateral aspect of the epidural space. The second needle is then introduced 1-2 cm caudad and maybe 1 cm medial to the first needle. I much prefer it to using a contralateral approach but that’s probably just because 90% are done ipsilateral here. Anchoring isn’t really an issue.

 

[lobelsteve]

Midline incision, b/l placement. Easier anchoring. One sided reserved for failure of b/l placement.

 

[Orin]

hello everyone.

I've always placed my SCS leads one on each side. I heard a lot of people enter ipsilaterally when placing the leads.
I was wondering if anyone can talk me through or perhaps have a picture on how they anchor the leads in such an arrangement? are the leads not right on top of each other?

is there enough space in between them to anchor? the answer must be yes since it's not an uncommon practice but not sure how.

thanks for the advice!

Paramedian incision, one sided placement towards the IPG side, other side pristine for the IT pump?

The first needle is tighter to the SP below to get to the midline in the nostril of the SP above. The second needle is adjacent to it mostly parallel but can converge some to get tighter to midline. The needle hubs can interact but it's not that challenging to avoid it. Anchoring is easier as the anchors are parallel to each other. With the Medtronic Injex anchors, super easy to use one large bite to anchor both. With the other anchoring systems that have wings or loops for securing in addition to circumferential, it's still pretty easy but they rub up against each other more.

I find it avoids the old back surgery scars, keeps the leads from criss-crossing, and my closures are generally under less tension than when I do midline.

 

[drrosenrosen]

Follow up question: do you cut down before you place needles? I've always done needles first (bilateral) then midline incision

 

[lobelsteve]

Follow up question: do you cut down before you place needles? I've always done needles first (bilateral) then midline incision

Why would you do this?

 

[No Pain All gain]

Paramedian incision, one sided placement towards the IPG side, other side pristine for the IT pump?

The first needle is tighter to the SP below to get to the midline in the nostril of the SP above. The second needle is adjacent to it mostly parallel but can converge some to get tighter to midline. The needle hubs can interact but it's not that challenging to avoid it. Anchoring is easier as the anchors are parallel to each other. With the Medtronic Injex anchors, super easy to use one large bite to anchor both. With the other anchoring systems that have wings or loops for securing in addition to circumferential, it's still pretty easy but they rub up against each other more.

I find it avoids the old back surgery scars, keeps the leads from criss-crossing, and my closures are generally under less tension than when I do midline.

Another trick I use is enter from same side at adjacent segmentsT11-12 and T12-L1. I use the 15cm needle for the cephalad level and reach them both through the same 30mm incision.

 

[heathermed]

great!
thanks for the suggestions.
For some reason, I'm having a difficult time picturing the anchors on the same side in my head. Maybe I'll just have to try it and see.

 

[No Pain All gain]

Depends on the anchors. I use primarily abbot and Medtronic and no issues. In a thin patient without much tissue coverage be careful with locking anchors stacking too close to one another.

 

[Orin]

Why would you do this?

Needles first and then cut can be a smaller incision for some, and better angles for others when you realize you can't get in well at the first level.
Cutting first is what I do 90% of the time as getting down to fascia reduces the need for the long needles with the biscuit poisoning.

 

[Agast]

I used to do bilateral but now I do ipsilateral on the side of the IPG. I think the anchors lay flat nicer. I’ll make my vertical incision approximately 1/2 vertebrae longer inferiorly to accommodate this. You get a feel for how you want to space your tuohys while you’re in there.