Pre-SCS thoracic MRI
Started by Taus
nice pick up
Post pic in pic forum
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Id say no stim trial for that.
Were there any hints on the lumbar mri?
Were there any hints on the lumbar mri?
Nope. Cut off at 11-12
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Thanks Taus.
Great example of why you should order thoracic MRI before any and all SCS trials.
I cut it off at T9 as her name was on there. Symptoms from stenosis. But SCS would also not be good choice in this lady. My lumbar film goes pretty high.
Attachments
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Check out the hemangioma on that chick.
Needs surgery not SCS
Send to surgeon for myelomalacia
Sorry, should have provided more background. 40ish patient with left radicular low back pain in L5 and S1 distribution s/p L5-S1 decompression and fusion. No myelopathic findings on exam. Will definitely have spine surgery evaluate the patient but doubtful this is contributing to her pain. Thanks as always for the input. Will keep you updated as the case progresses.
Even if no myelopathic findings on exam, and even if not contributing to pain, I send to surgeon as there spinal cord is being damaged. They can discuss R/B of doing something versus not.
Sorry if this has been asked before. But what’s everyone’s cutoff of stenosis for SCS? I have a cervical with diameter right at 10mm, I’m hesitating whether this Is safe to proceed w the trial or not. Thanks
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Just did this exact case
Trial went ok...little uncomfortable for patient during placement but not bad
Made perm incisions...placed percs leads awake as is my practice... because of the small amount of increased scar tissue from the trial and it already haven been tight it was very difficult to advance the leads. Kinked two styletts. She was having a little bit of axial pressure but not too bad. But then all the sudden started having severe bilateral foot pain, neuropathic. Really intense. Allodynia. Motor intact. Did not resolve with pulling the leads back. Took everything out. Closed the incisions. No improvement after watching her in recovery for 45 minutes and with generous pain meds and gabapentin. Shipped from outpatient ASC to hospital. Stat mri scanned her. Nothing on the scans. Symptoms have largely improved at 10 days. But still some neuropathic pain. Fingers crossed things resolve completely.
I read a guideline that said <14mm relative contraindication and <10 absolute.
Wish I would have sent her for a paddle trial.
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It happens. Maybe hit her with steroids early on next time, through a catheter ideally at the highest site you were at, but something to quiet down the trauma site.
Agreed. Have seen it twice. Once in fellowship and once to my partner. Epidural dex, IV dex, gabapentin, medrol dose pak. Both eventually resolved. Took a good 6-8 weeks on the one.
What’s the learning point from this for all of us?
I use 11mm as my cutoff and need to see 2mm total csf about the cord.
I'd probably do it, but if patient complains or you meet resistance, I may choose to abort earlier than I normally would.
At least one lead will
pass easily and then stack the 2nd lead with tip just below the stenosis
pass easily and then stack the 2nd lead with tip just below the stenosis
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That’s why I do these awake
Everything awake. 100% agree.
I do allow sedation, but the patient is always awake enough to follow commands and complain.
