tmvguy03

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I had an interesting case, 70yo m chronic LBP, no prior surgery. Had tried injections, PT, meds without significant relief over the past few years. No blood thinners. We elected to trial SCS. Lumbar/thoracic imaging showed some diffuse but mild disc bulging without stenosis.
Very straightforward trial, easy access T12/L1, threaded both leads to T7. Leads were midline and dorsal throughout the trial. No discomfort or barriers at all. After securing the leads the pt reported sensation loss below the waist. He was able to move his legs but very ataxic and he had no sense of leg movement. When he did resist, strength was full but not sustained. Totally asensate to light/deep palpitation.
I immediately removed both leads and contacted EMS for transport to ED. By the time they arrived sensation was improving but not back to normal. I spoke to the ED to give them a heads up, obtained a stat CT on arrival lumbar/thoracic. Negative image. I joined them in the ED 20 min after arrival (connect to my clinic). By that time exam had completely normalized and he was ambulating in the ED. His primary concern was when he could try stim again (!).
I’m updating his MRIs this week (they are only 3 months old), and discussed with NSG doing a surgical trial.

I think it must have been a temporary compressive thoracic myelopathy from the leads, but odd given unremarkable imaging and trial. Has anyone else had this happen? Any other SCS trial issues to learn from?
 
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paindoc007

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That’s wild. Obviously you did the right thing by pulling immediately.. and Yes would love to see final lateral image you obtained
 
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tmvguy03

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Will do, am out of the office tomorrow but will post. The most disconcerting aspect was how routine the trial was. Definitely would classify as an “easy” case.
 

painfree23

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I don’t like accessing at T12-L1. Not saying that was the reason but just feel like the 1-2 problem patients have been when I have entered that high up
 

SSdoc33

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Will do, am out of the office tomorrow but will post. The most disconcerting aspect was how routine the trial was. Definitely would classify as an “easy” case.

No, the most disconcerting aspect was that you did an SCS for LBP.
 
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SSdoc33

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Boston Wave Writer. If you’ve never used for LBP you should try. (*not a consultant with Boston)

sigh. yes, im sure its the holy grail

as far as the numbness/partial motor block, the only thing that makes sense is if you accidentally put some lido into the epidural space. maybe had some in your vial by accident when you got a LOR?
 
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Ferrismonk

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Accidental Local in the epidural space makes the most sense to me, however I wasn't there and not sure how you do everything.
 
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deleted993114

I had an interesting case, 70yo m chronic LBP, no prior surgery. Had tried injections, PT, meds without significant relief over the past few years. No blood thinners. We elected to trial SCS. Lumbar/thoracic imaging showed some diffuse but mild disc bulging without stenosis.
Very straightforward trial, easy access T12/L1, threaded both leads to T7. Leads were midline and dorsal throughout the trial. No discomfort or barriers at all. After securing the leads the pt reported sensation loss below the waist. He was able to move his legs but very ataxic and he had no sense of leg movement. When he did resist, strength was full but not sustained. Totally asensate to light/deep palpitation.
I immediately removed both leads and contacted EMS for transport to ED. By the time they arrived sensation was improving but not back to normal. I spoke to the ED to give them a heads up, obtained a stat CT on arrival lumbar/thoracic. Negative image. I joined them in the ED 20 min after arrival (connect to my clinic). By that time exam had completely normalized and he was ambulating in the ED. His primary concern was when he could try stim again (!).
I’m updating his MRIs this week (they are only 3 months old), and discussed with NSG doing a surgical trial.

I think it must have been a temporary compressive thoracic myelopathy from the leads, but odd given unremarkable imaging and trial. Has anyone else had this happen? Any other SCS trial issues to learn from?


Sounds like it. Was he stenotic in the thoracic spine? No blood in the epidural space? Did you lose bowel function after that happened? Was the angle of the needle more vertical than you would like (fat guy), such that with placement of the lead you got some ventral bowing and pressure with the lead?

I had a guy about seven years ago. L5 radic without radiculopathy s/p lumbar lamy. The rest of the imaging was unimpressive. No anti-coags, no aspirin, no nsaids. Did the stim trial and the guy did great. One of my nurses pulled the lead; he ran and got me in the procedure room and said the guy had a lot of pain after the lead was pulled intact.

Exam: Motor 5/5, sensation intact to lt touch, anal sphincter tone normal, reflexes normal. Took him to the scanner- epidural space was FULL OF BLOOD from sacrum to high cervical. I called up one of neurosurgeon partners and he said not to sweat it, as it was venous and he was neurologically intact. He pointed out that I sometimes get paid to inject blood into the epidural space and said the good news was that perhaps I could charge for a blood patch (funny guy)! We boxed him up and sent him to the hospital for 24 hour observation and his pain resolved without treatment.

The incidence of bleeding with stims is 100%. It is just a matter of how much blood. We are placing foreign objects in the spinal canal, which can certainly cause unforeseen problems and one should not be shocked if "a problem" happens- just diagnoses it and treat, if possible.
 
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SommeRiver

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Sounds like it. Was he stenotic in the thoracic spine? No blood in the epidural space? Did you lose bowel function after that happened? Was the angle of the needle more vertical than you would like (fat guy), such that with placement of the lead you got some ventral bowing and pressure with the lead?

I had a guy about seven years ago. L5 radic without radiculopathy s/p lumbar lamy. The rest of the imaging was unimpressive. No anti-coags, no aspirin, no nsaids. Did the stim trial and the guy did great. One of my nurses pulled the lead; he ran and got me in the procedure room and said the guy had a lot of pain after the lead was pulled intact.

Exam: Motor 5/5, sensation intact to lt touch, anal sphincter tone normal, reflexes normal. Took him to the scanner- epidural space was FULL OF BLOOD from sacrum to high cervical. I called up one of neurosurgeon partners and he said not to sweat it, as it was venous and he was neurologically intact. He pointed out that I sometimes get paid to inject blood into the epidural space and said the good news was that perhaps I could charge for a blood patch (funny guy)! We boxed him up and sent him to the hospital for 24 hour observation and his pain resolved without treatment.

The incidence of bleeding with stims is 100%. It is just a matter of how much blood. We are placing foreign objects in the spinal canal, which can certainly cause unforeseen problems and one should not be shocked if "a problem" happens- just diagnoses it and treat, if possible.

Sage wisdom IMO.
 

NOSfan

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After securing the leads the pt reported sensation loss below the waist. He was able to move his legs but very ataxic and he had no sense of leg movement. When he did resist, strength was full but not sustained. Totally asensate to light/deep palpitation.
I immediately removed both leads and contacted EMS for transport to ED. By the time they arrived sensation was improving but not back to normal. I spoke to the ED to give them a heads up, obtained a stat CT on arrival lumbar/thoracic. Negative image. I joined them in the ED 20 min after arrival (connect to my clinic). By that time exam had completely normalized and he was ambulating in the ED. His primary concern was when he could try stim again (!). I think it must have been a temporary compressive thoracic myelopathy from the leads, but odd given unremarkable imaging and trial. Has anyone else had this happen? Any other SCS trial issues to learn from?

Loss of sensation and ataxia without true motor weakness with resolution sounds like a transient insult primarily to the DCML.

Do you have MRI of the thoracic canal (tight?) prior to the trial?

Possible, but doubt local related secondary to posterior spinal artery anatomy.
 

clubdeac

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Sounds like it. Was he stenotic in the thoracic spine? No blood in the epidural space? Did you lose bowel function after that happened? Was the angle of the needle more vertical than you would like (fat guy), such that with placement of the lead you got some ventral bowing and pressure with the lead?

I had a guy about seven years ago. L5 radic without radiculopathy s/p lumbar lamy. The rest of the imaging was unimpressive. No anti-coags, no aspirin, no nsaids. Did the stim trial and the guy did great. One of my nurses pulled the lead; he ran and got me in the procedure room and said the guy had a lot of pain after the lead was pulled intact.

Exam: Motor 5/5, sensation intact to lt touch, anal sphincter tone normal, reflexes normal. Took him to the scanner- epidural space was FULL OF BLOOD from sacrum to high cervical. I called up one of neurosurgeon partners and he said not to sweat it, as it was venous and he was neurologically intact. He pointed out that I sometimes get paid to inject blood into the epidural space and said the good news was that perhaps I could charge for a blood patch (funny guy)! We boxed him up and sent him to the hospital for 24 hour observation and his pain resolved without treatment.

The incidence of bleeding with stims is 100%. It is just a matter of how much blood. We are placing foreign objects in the spinal canal, which can certainly cause unforeseen problems and one should not be shocked if "a problem" happens- just diagnoses it and treat, if possible.
I am amazed at the number of crazy stories you have hawkeye. I think I would've quit a long time ago had I a quarter of the near misses you've had
 
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deleted993114

I am amazed at the number of crazy stories you have hawkeye. I think I would've quit a long time ago had I a quarter of the near misses you've had


Well................. I've been practicing a long time. It's a good thing I was trained by neurosurgeons, otherwise I guess I probably would not have had the guts to proceed on. The good thing is that I have seen a variety of complications, simply from "being in the water" for a while. I actually have a very low complication rate; however, I find complications to be very instructive and share them, as we can all learn from them.

Pain management is swimming in a shark tank; we will all eventually run across some weird complications and you just have to have faith in your training and move along.

The good thing as well is that anytime someone has a complication, I am a good shoulder to cry on, as the chances are that I have seen it, or done it myself!
 
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