SCS Implant technique

[NJPAIN]

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Midline vertical incision. Who places needles prior to incision and pulls leads in vs who places needles after incision?

Who uses horizontal incision after needle placement?

Looking at modifying my “go to” technique and looking at my options.


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[Aether2000]

My technique was a midline incision directly over the spinous processes marked under fluoroscopy and the next level below the interlaminar window used. Dissection was carried down immediately adjacent to the interspinous ligament, separating the multifidus fascia from the interspinous ligament, then placing through and through suture through the spinous ligament so that both ends of a suture lie on one side. Repeat for the other side (0-ethibond). THEN- placed the epidural needles entering the superior incisions already made on each side, and after advancement of the tip, placed the anchor deep in the incision, and tying to the already placed 0-ethibond. The strain relief loops were placed in the incisions on each side also and the fascia over head was closed with PDS. This technique takes longer than the typical nailing the anchor to the thoracolumbar fascia superficially but I did not have any leads break or migrate using this technique, and patients never complained (especially thin patients) about being able to feel the discomfort of the anchor or coiled strain relief. It is an option for thin patients.

 

[lobelsteve]

mark L1 to L2 (or longer if needed) SP (if back is straight). Mark pocket before draping. Local to skin. 15blade for skin, 11 blade to SS ligament. Create pocket at appropriate depth. Bovie for hemostasis. 14G Tuohys from iside incision to L1 lamina, walk off and LOR to air/lateral fluoro. Put in leads. Run 11 blade down Tuohy to make room for anchor. Tie individual silk 2-0 to SS ligament or deep fascia beneath the Tuohy. Pull the Tuohy, slide anchor in and hold with pickups while using torque wrench. Tie silks over anchor (sandwich between the existing knots). Tunnel with shishkabobber to pocket. Irrigate both wounds. Run leads to IPG and affix with wrench. Put in IPG. Close with 0 vicryl deep, 2-0 superficial, dermabond on skin, telfa with bad to hide it all until follow up.

 

[unchockey21]

Midline vertical incision. Who places needles prior to incision and pulls leads in vs who places needles after incision?

Who uses horizontal incision after needle placement?

Looking at modifying my “go to” technique and looking at my options.


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I make a vertical incision and then place needles. The less than 1% chance of not being able to thread leads during perm after doing so for the trial isn’t enough for me to take the extra step of pulling the leads in. I don’t make my pocket incision until the leads are placed though. I also mark my pocket in preop with the patient sitting up so I can make sure it’ll be below their belt line but above where they sit.

 

[NJPAIN]

Any takers for midline incision followed by needles with leads pulled into wound?


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[Timeoutofmind]

I do paramedian incision and anchor to the thoracolumbar fascia

 

[NJPAIN]

I do paramedian incision and anchor to the thoracolumbar fascia

This has been my approach for several years. However, I am finding it a challenge especially in obese patients where I often have difficulty identifying the thoracodorsal fascia or inadvertently go through it with the Bovie. I do find that a paramedian incision with needles side by side does keep the incision size small.
I’m hoping that starting in the midline at the SS ligament will make it easier to trace the fascia out laterally and provide a better anchoring point.


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[lobelsteve]

This has been my approach for several years. However, I am finding it a challenge especially in obese patients where I often have difficulty identifying the thoracodorsal fascia or inadvertently go through it with the Bovie. I do find that a paramedian incision with needles side by side does keep the incision size small.
I’m hoping that starting in the midline at the SS ligament will make it easier to trace the fascia out laterally and provide a better anchoring point.


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Or you have the SS ligament to put the suture through. Much stronger.

 

[BobBarker]

You can make a tiny, tiny midline incision, too. I have mine less than an inch now. You have to place the needles more superior in the incision so you can see the anchor to sew it down/click the lead. No weitlaners will work because the incision is too small.

@gdub25

 

[NJPAIN]

You can make a tiny, tiny midline incision, too. I have mine less than an inch now. You have to place the needles more superior in the incision so you can see the anchor to sew it down/click the lead. No weitlaners will work because the incision is too small.

@gdub25

Cosmetically must look great but sounds like way too tight a space to work in, for a old guy.


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[Ronin1]

Any takers for midline incision followed by needles with leads pulled into wound?


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That’s how I’ve been doing it for 20 years...sorry. I meant needles first then incision

 

[gdub25]

This whole topic is something I’ve developed quite a strong opinion about over the last couple of years. We as a specialty are a bunch of non-surgeons who were trained by non-surgeons and quite frankly aren’t very good at putting in stimulators. There are different ways to skin a cat, yes, but I also feel that we need to have some higher standards in regards to best practices with this relatively simple procedure. Anchoring to fascia or ligament, sure, there’s pros and cons and probably good arguments for both. Taking 2 hours for an implant. Midline incisions at 4 and 5 inches long. That’s the kind of stuff I wish we could pull together and improve on. With the increasing influx of non-fellowship trained guys: family med, neurology, anesthesiologist burning out in the OR, etc who are jumping into the speciality, we need to separate ourselves. Any of these guys can go to a cadaver course and start doing these cases, we don’t have any argument against it if we can’t show that we are better. The rent NBC article outlining complication rates with SCS should have been a big wake up call I think.

 

[NJPAIN]

The situation with pain docs doing SCS is the same situation as with cardiologists doing pacemakers. Both procedures were traditionally done by surgeons. These procedures ( SCS > PPM ) both require surgical skills. In my opinion, those among us that do the best job with these are those who have a few years of surgical experience. The guys I know who are the best are the ones who washed out of surgical residences and landed in anesthesiology. Unless you trained in a place with attendings with great surgical skills and were fortunate enough to do several implants a week, I think it's very difficult and/or takes a long time to get really good at doing these as defined by gdub25 (small incisions and short OR times). Basic surgical skills are important and hard to acquire if you don't have experienced surgeons teaching you. I have worked hard to learn from watching surgeons, scrubbing with surgeons, reading the literature and doing more of my own implants but that doesn’t come close to what you get from true surgical training. Despite these efforts, I always feel that a stronger foundation in the basics would be tremendously helpful and make me much more comfortable doing implants.There are obviously pain docs with tremendous neuromodulation practices who have developed great skills over years and hundreds of cases.