S1 BVN Access

[masterPain]

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Does anyone have any materials or insights on the best approach to accessing S1? Much appreciated!

 

[Taus]

Definitely a learning curve on this one to stay posterior enough, especially when sometimes handling hard bone, tall medial iliac crest, wide and narrow s1 vert body etc.

Some excellent prior threads on this, most of what I learned was via posts by rolotomassi

Here is cut and pasted from my notes file put together over the 4 years of doing this, just shy of 200 cases:

S1:

• Ferguson/head tilt to square sep,
• If oblique at 30-35 still has crest in way - tilt even more to head to get access.
• can doc a bit laterally to pedicle, walk medially til hit sap in deepest part of groove
• If placement overall very difficult at S1, and started wide angle, le 40+, can advanced ICA much further into vb then much shorter distance for CCA needed.
• Use bevel.
• make sure final entry into VB is close to medial border pedicle..... if too far lateral before J, leaves long path to get to midline.
• can also consider going through iliac crest if its too high/medial

Not specific to this level, but if hard bone, even if you have a big angle, I would still recommend keeping the J retracted, “distal scallop” on Gen 3. it is always a better problem to be too posterior, much much easier to fix, than too anterior. Their generation three equipt is a really nice step up in multiple ways, but all the tricks needed with the earlier generations are still sometimes needed with hard bone or other unfavorable anatomy.

 

[Orin]

• can also consider going through iliac crest if its too high/medial

I haven't had to do this yet but I have brought it in from the contralateral side for a second burn/attempt if I was unsatisfied with the first side's placement

 

[RoloTomassi]

Not much more to add but similar thread:

Thread 'Intracept S1-men'

Mar 19, 2025

Any tricks you all use for S1 intracept in men with a narrow pelvis?

I always use a bevel tip at S1 and crank as hard to direct the tip medially once I clear the medial border of the pedicle. But (depending on bone quality) sometimes it is just impossible to get very close to midline before advancing too far ventral.

I'm getting fairly fast doing intracept at every level....except S1 in men. I was joking with the rep this week, that physicians should be paid double for doing S1 intracept in men!

I'm wondering if you all have any suggestions?

I'm going to be starting kyphoplasty soon...

• bedrock
• Replies: 12
• Forum: Pain Medicine

• 

The new Edge J-stylet will be fully released next year, is designed to turn a bit faster, should help with staying posterior

 

[Taus]

I’m curious to see how it works, especially as supposedly it goes in and out of the trocar easier and is also more robust… I wonder if it goes in straight and then articulates into a rigid curve like merit power curve/Medtronic Kyphoflex… as that thing is really solid and turns on a dime.

 

[RoloTomassi]

Safety tip: while you certainly don't want to go too deep with the introducer, do make sure you are 100% sure you went through the posterior wall. If not true lateral (perfect airplane and wag) can look deeper than you really are, and since you should be hugging the medial wall, first tap of the J can get you in the canal.

 

[Taus]

Safety tip: while you certainly don't want to go too deep with the introducer, do make sure you are 100% sure you went through the posterior wall. If not true lateral (perfect airplane and wag) can look deeper than you really are, and since you should be hugging the medial wall, first tap of the J can get you in the canal.

Yep. I suspect some of the post op radic is from that, when docs are certain they did not breach on access. Sometimes when I start retracted/proximal scallop, J doesn’t go easily into vb and needs mallet to seat it flush with trocar/gearwheel. I go back to AP and get J all way in making certain not through medial pedicle until I’m in VB

 

[PainandGain]

Definitely a learning curve on this one to stay posterior enough, especially when sometimes handling hard bone, tall medial iliac crest, wide and narrow s1 vert body etc.

Some excellent prior threads on this, most of what I learned was via posts by rolotomassi

Here is cut and pasted from my notes file put together over the 4 years of doing this, just shy of 200 cases:

S1:

• Ferguson/head tilt to square sep,
• If oblique at 30-35 still has crest in way - tilt even more to head to get access.
• can doc a bit laterally to med-pedicle, walk medially til hit sap in deepest part of groove
• If placement overall very difficult at S1, and started wide angle, le 40+, can advanced ICA much further into vb then much shorter distance for CCA needed.
• Use bevel.
• make sure final entry into VB is close to medial border pedicle..... if too far lateral before J, leaves long path to get to midline.
• can also consider going through iliac crest if its too high/medial

Not specific to this level, but if hard bone, even if you have a big angle, I would still recommend keeping the J retracted, “distal scallop” on Gen 3. it is always a better problem to be too posterior, much much easier to fix, than too anterior. Their generation three equipt is a really nice step up in multiple ways, but all the tricks needed with the earlier generations are still sometimes needed with hard bone or other unfavorable anatomy.

I’ve done about the same number of cases and I can confirm this is great advice. I describe my technique a little differently but I think we’re doing the same thing essentially.

I tilt to square off the SEP. Oblique until the iliac crest almost reaches the ala. I enter directly lateral to to the L5 TP. Dock and check that I like my lateral and bang across the pedicle. 90% of the time it works every time,

 

[SC Tian]

I book 30-minute slots for 2 levels of Intracept, for S1, Ferguson tilt first, 25-degree rotation to dock with bevel tip, about another 5-degree rotation inside the pedicle. It normally works. If the iliac crest is too high, I will do more cephalic tilt to reach 25 degrees of lateral angle. I have encountered only one difficult case so far. Good luck.