MRI thoracic spine before a SCS trial

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med7343

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Hi folks
how many of you do a thoracic MRI before a SCS trial?
Thanks
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New MRI before SCS?

I get a number of consults that are around 3-6 months out from spine surgery. Referred for SCS. Non-focal neuro exam. Would you Re-MRI before SCS? Obviously, if I am planning another injection I would...but often they have had a bunch of injections pre-surgery, and at times are not...
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I still don’t think that thread answered the question.

Steve, I think your approach is sound. Perc leads, no need for MRI. Paddle, suggest MRI to surgeon.

Because as someone pointed out, if a perc lead is going to cause a problem, you will know right away and can correct the problem right away.
 
You brutes. Anything less than propofol is uncivilized, and makes it really hard to train the residents/fellows.

Aren't all the fancy talking heads going to asleep neuromonitoring based placement?
 
Orin said:
You brutes. Anything less than propofol is uncivilized, and makes it really hard to train the residents/fellows.

Aren't all the fancy talking heads going to asleep neuromonitoring based placement?
Click to expand...

Let's make the procedure even more expensive
 
On a side note, eyeball your lumbar spine MRIs. At my facility the sag goes up to around t10 or so, sometimes t9. So putting a lead at T8, not really that scary
 
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I always get T spine MRI.
 
Orin said:
You brutes. Anything less than propofol is uncivilized, and makes it really hard to train the residents/fellows.

Aren't all the fancy talking heads going to asleep neuromonitoring based placement?
Click to expand...

I’m actually very interested in using SSEP’s. I’ve heard it’s better than patient feedback.

I think MRI of t-spine was more justifiable when placing a non mri compatible system - but now, not so sure.
 
I always get an T spine MRI before stim trials. Never have an issue getting it authorized, I just say it is to rule out stenosis before placement of a medical device next to the freaking spinal cord, and it always get authorized without a problem. Had two stim candidates over the past decade that could have turned out very badly had I not know about the thoracic anatomy. Well worth it. I'll get a T spine MRI on every SCS case for the rest of my career.

Much more money is wasted on gomers in ICU with screwed up family situations than will ever be spent on T spine MRIs
 
bedrock said:
I always get an T spine MRI before stim trials. Never have an issue getting it authorized, I just say it is to rule out stenosis before placement of a medical device next to the freaking spinal cord, and it always get authorized without a problem. Had two stim candidates over the past decade that could have turned out very badly had I not know about the thoracic anatomy. Well worth it. I'll get a T spine MRI on every SCS case for the rest of my career.

Much more money is wasted on gomers in ICU with screwed up family situations than will ever be spent on T spine MRIs
Click to expand...

Can you share why those two cases would have turned badly?
 
PinchandBurn said:
Never had.

I put for pre procedural planning.
Click to expand...
Diagnosis on rx: thoracic stenosis. “Pre-operative planning for spinal cord stimulator. Please confirm patency of dorsal epidural space”.

3 potential catastrophes averted in short career. 2 Severe stenosis. 1 large avm.
 
Massive DOC with cord compression at T7 discovered on CT in a pt with a pacer.
 
Taus said:
Diagnosis on rx: thoracic stenosis. “Pre-operative planning for spinal cord stimulator. Please confirm patency of dorsal epidural space”.

3 potential catastrophes averted in short career. 2 Severe stenosis. 1 large avm.
Click to expand...

I would speculate 99+/100 times, gently threading a lead at stenotic region would not lead to complication. Resistance, pain, parasthesia, whatever. You’ll know to redirect and/or bail. On the flip side, you’re fine till you’re not. So I get it. Kinda like the old school guys using kenalog in their transforaminals. “I’ve never had an issue”. Nothing wrong w being extra safe
 
Taus said:
Diagnosis on rx: thoracic stenosis. “Pre-operative planning for spinal cord stimulator. Please confirm patency of dorsal epidural space”.

3 potential catastrophes averted in short career. 2 Severe stenosis. 1 large avm.
Click to expand...

Similar. Had two patient issues avoided. one with severe stenosis and one with a large AVM
 
I would suspect that if insurance denied it, and there was a problem, the patient would have a pretty good case against the insurance company.
 
med7343 said:
Hi folks
how many of you do a thoracic MRI before a SCS trial?
Thanks
Click to expand...
I always scan the T spine ahead of time. It's mainly for med-mal risk reduction. Although unlikely with perc leads, during fellowship we (not my patient, another fellow and attending) had a case where the T spine wasn't imaged and after the perc implant ended up at a local ER unable to move his legs. I turns out there was critical T spine stenosis from a mass and the perc leads were enough to apply pressure and after some edema and tissue damage developed he was paraplegic. Plus, I refer out to surgeons for implants now, and they always want them, so I just do it. I list, "Chronic back pain, rule out critical T spine canal stenosis prior to spinal cord stimulator" and that gets it approved more often than not.
 
Using propofol

it can be done safely

bolus for numbing up; then not so useful as it can have disinhibition ; let it wear off and establish Ability to converse with the patient before getting your loss of resistance And threading the catheter
 
EMD 123

can u Tell us more about the time course of the patients decompensation? Why do you think it did not happen after the trial? I’ve heard from spine surgeons that they believe the threshold for inflammation in the thoracic epidural space is changed for sometime by our trial lead placement

I think that even if system is MRI compatible, You may not get as good of an MRI image due to the artifact, so pre-implant T spine MRI may provide better visualization then you could get in the future
 
After having to abort 2 trials due to inability to thread past the lower thoracic, and then finding the thoracic stenosis. I started routinely getting T spine MRIs. Not too big a deal to order it along with the psych eval, and the peace of mind is nice.
 
joshmir said:
Using propofol

it can be done safely

bolus for numbing up; then not so useful as it can have disinhibition ; let it wear off and establish Ability to converse with the patient before getting your loss of resistance And threading the catheter
Click to expand...
sounds longer than just numbing the patient and moving along
 
callmeanesthesia said:
After having to abort 2 trials due to inability to thread past the lower thoracic, and then finding the thoracic stenosis. I started routinely getting T spine MRIs. Not too big a deal to order it along with the psych eval, and the peace of mind is nice.
Click to expand...
So if there’s any stenosis, moderate even you don’t attempt the trial?
 
callmeanesthesia said:
After having to abort 2 trials due to inability to thread past the lower thoracic, and then finding the thoracic stenosis. I started routinely getting T spine MRIs. Not too big a deal to order it along with the psych eval, and the peace of mind is nice.
Click to expand...
Post the pics. It is easy to get past most stenosis no matter what the MRI says. Problem is not the stenosis, it is mashing the cord to get past the stenosis. Most inability to advance is ligamentous and if you advance under lateral you can see the tip getting hung up on flavum. It is not always a smooth surface.
 
lobelsteve said:
Post the pics. It is easy to get past most stenosis no matter what the MRI says. Problem is not the stenosis, it is mashing the cord to get past the stenosis. Most inability to advance is ligamentous and if you advance under lateral you can see the tip getting hung up on flavum. It is not always a smooth surface.
Click to expand...
I agree with this. I don’t think getting a thoracic mri will change much to be honest...unless it’s severe severe canal stenosis
 
lobelsteve said:
Post the pics. It is easy to get past most stenosis no matter what the MRI says. Problem is not the stenosis, it is mashing the cord to get past the stenosis. Most inability to advance is ligamentous and if you advance under lateral you can see the tip getting hung up on flavum. It is not always a smooth surface.
Click to expand...
That is exactly what it was, and why I say depends on the shape. There was hypertrophied ligamentum flavum deforming the posterior canal. Every time I tried to advance past that area the tip dove anterior and the patient yelped. Was not able to go around it laterally and get back midline either.
 
Do you guys think age would change your idea about pre-scanning? For example, would you prescan a failed back patient who is 40 y/o?
 
From my experience, if I can’t get two leads placed during a thoracic stim trial , I will get the thoracic MRI prior to a perc implant or referral for a paddle implant.

You guys remember perc paddles by st Jude? I stopped implanting them because the volume of younger FBSS has declined in my area. I never liked perc paddles in multilevel spinal stenosis patients ....
 
I pick up something that changes the plan 3% of the time
 
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