heathermed

10+ Year Member
Jul 29, 2009
104
1
Status
When you guys do spinal cord stimulator implants, which ligament, muscle, or fascial layer do you choose to place the anchors in hopes of minimizing lead migration? Ive been taught in fellowship to do lumbodorsal fascia but was wondering what most do that do a lot.

Also was just wondering if you guys like to enter the same space from either side of the spinous process and make a midline incision or enter in 2 adjacent spaces from the same side and make a vertical incision.

Got my first implant this week as an attending. Nervous but excited.

Thank you
 

Stim4me

Membership Revoked
Removed
Account on Hold
Mar 31, 2015
1,795
463
When you guys do spinal cord stimulator implants, which ligament, muscle, or fascial layer do you choose to place the anchors in hopes of minimizing lead migration? Ive been taught in fellowship to do lumbodorsal fascia but was wondering what most do that do a lot.

Also was just wondering if you guys like to enter the same space from either side of the spinous process and make a midline incision or enter in 2 adjacent spaces from the same side and make a vertical incision.

Got my first implant this week as an attending. Nervous but excited.

Thank you
A lot of your questions are going to be patient and anatomy specific... Sometimes you can't enter at the same level , even though that's the goal. Adjacent segmental entry may be necessary as well, again it will be based on your ease off access. After years of implants and primarily entering at a single level bilaterally with a midline vertical incision, I now use a horizontal incision instead, which makes anchoring a ton easier(more surgical access) and saves at least 15 more minutes(you avoid pulling lateral leads midline)....also anchor to the most taut tissue you can find, the newer anchoring sleeves tend to reduce migration(for st Jude ask for leuer lock). Hope that helps, good luck
 

NJPAIN

7+ Year Member
Nov 28, 2011
1,722
711
New Jersey
Status
Attending Physician
It is possible also to enter at the same level on the same side by placing needles directly next to or stacked on one another.
 
OP
H

heathermed

10+ Year Member
Jul 29, 2009
104
1
Status
Great thanks for the tips. Do you mind describing the horizontal incision technique? I tried looking at some books but was unable to find it.

In regards to 2 leads in the same space on the same side, any issues with having enough space for each anchor?

Thank you once again
 

algosdoc

algosdoc
10+ Year Member
May 3, 2005
4,063
1,926
Florida
Status
Attending Physician
I anchor to the interspinous ligament and dissect the multifidus fascia away from the interspinous ligament with electrodissection. The anchors are placed deep just on top of the lamina. This reduces the angle of entry to the epidural space and places the anchors so deep that the patient cannot feel them-a common complaint in thin patients with a thoracodorsal fascia anchoring.
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,822
3,712
Canton GA
www.stevenlobel.com
Status
Attending Physician
I anchor to the interspinous ligament and dissect the multifidus fascia away from the interspinous ligament with electrodissection. The anchors are placed deep just on top of the lamina. This reduces the angle of entry to the epidural space and places the anchors so deep that the patient cannot feel them-a common complaint in thin patients with a thoracodorsal fascia anchoring.
Expert level advice. If new to this: prepare for a lot of bleeding and keep cauterizing. Muscle oozes and bleeds lots. Anchors are easier to slide on when wet. I keep mine in the GU solution (irrigation). I run the 11 blade down the Tuohy so the anchor has a nice straight path through the fascia. If you get a lateral and your anchor is not angled30 degrees from parallel, lead migration will be more likely to occur. If anchor is bent through fascia, lead migration more likely to occur. If you have thin patients, undermine the subq tissues to hide the anchor away from the spinous process.
 

Stim4me

Membership Revoked
Removed
Account on Hold
Mar 31, 2015
1,795
463
if you have two touhy entry sites at the same level, instead of a vertical incision in between the introducers, make a horizontal incision that encompasses both needles. use a weitlaner retractor and metzenbaum device to assist with dissection. I NEVER use a bovie device to dissect around your touhy needles.... I have reviewed a case where a physician bovied the touhy and causes spinal cord injury. Deal with the bleeding, and use pressure, and time to dissect. the IPG battery pocket, bovie all you want.
 
  • Like
Reactions: Extralong

algosdoc

algosdoc
10+ Year Member
May 3, 2005
4,063
1,926
Florida
Status
Attending Physician
I agree ...never bovie the needle..up to 9000volts. similar thing can happen through electrical induction around the leads or extensions. I do my dissection preparation and anchors first before inserting thr Tuohy needles.
 
  • Like
Reactions: Extralong

EtherBunny

7+ Year Member
Mar 5, 2012
261
177
Status
Attending Physician
When you guys do spinal cord stimulator implants, which ligament, muscle, or fascial layer do you choose to place the anchors in hopes of minimizing lead migration? Ive been taught in fellowship to do lumbodorsal fascia but was wondering what most do that do a lot.

Also was just wondering if you guys like to enter the same space from either side of the spinous process and make a midline incision or enter in 2 adjacent spaces from the same side and make a vertical incision.

Got my first implant this week as an attending. Nervous but excited.

Thank you
Find the interlaminar space that you want to enter, the medial borders of the pedicles of the level below, and the anatomical midline. Plan on entering the fascia at approximately the level of the pedicles of the level below with the Tuohy introducer needles. Plan your incision in the midline. The entry points through the thoracolumbar fascia with the Touchy needles (after the incision has been made) should be in the cephalad third of the incision. Plan your incision length accordingly.

Infiltrate with lido+ epi then make an incision down to the underlying adipose tissue. Continue dissecting with monopolar electrocautery until the underlying thoracolumbar fascial layer is exposed. Use a blunt probe (i.e., your fingers) periodically to feel for the underlying fascial layer. It's easy to inadvertently pierce the fascial layer with electrocautery if you're not careful. Once you've reached the thoracolumbar fascia, do some blunt finger dissection initially (or with a peanut) along the fascial plane bilaterally to create a clean division between the fascia and overlying adipose tissue. You should extend the plane laterally with monopoly electrocautery. This will create some space for the tension relief loops and also make it easier to retract the skin edges laterally with a self-retaining retractor.

Once you're satisfied with the initial dissection and you have hemostasis, place a self-retaining retractor in and expose the underlying fascia. Ideally you should easily be able to palpate the lumbar spinous processes in the midline. You can proceed with accessing the dorsal epidural space with the introducer needles. I typically place one needle on one side and then place the other needle contralaterally, however I have also placed them on the same in some cases. It just depends on how things go during the case.

For anchoring, I typically place a small incision along the line of the introducer needle through the fascia, which facilitates implanting the nose of the anchor THROUGH the fascia. This helps prevent migration. I anchor the leads to the thoracolumbar fascia using non-absorbable suture, with the suture configuration dependent on the vendor. I have anchored the leads to the interspinous ligament deliberately DEEP to the thoracolumbar fascia previously. It works, but I'm not a big fan of the subperiosteal dissection required, because it tends to cause a fair amount of postoperative back pain.

SCS implants are a lot of fun. Don't be too anxious about your first case! You have the skills to do it. Don't rush through the case. You'll be fine.
 

NJPAIN

7+ Year Member
Nov 28, 2011
1,722
711
New Jersey
Status
Attending Physician
I anchor to the interspinous ligament and dissect the multifidus fascia away from the interspinous ligament with electrodissection. The anchors are placed deep just on top of the lamina. This reduces the angle of entry to the epidural space and places the anchors so deep that the patient cannot feel them-a common complaint in thin patients with a thoracodorsal fascia anchoring.
Algos - do you have any intraop photos of this technique? I am visualizing that your incision is more superior and medial than if you anchor to the thoracodorsal fascia, especially if you are entering skin at the level of the pedicle 2 rather than 1 level below your interlaminar entry site. Is that correct?
 
Last edited:

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,822
3,712
Canton GA
www.stevenlobel.com
Status
Attending Physician
For T12-L1 entry, my incision starts over SP of L1 to L3, 2-3 inches long in midline.
 

algosdoc

algosdoc
10+ Year Member
May 3, 2005
4,063
1,926
Florida
Status
Attending Physician
For T12-L1 entry, my incision starts over SP of L1 to L3, 2-3 inches long in midline.
The highest routine entry level i use is L2/3 due to presence of the cord above this level. I place a mark over the spinous process of L3 and L4 with a midine incision to the posterior os of the spinous processes of L3 (depth finder) then extending at that depth to the L4 sp. Using a gelpi retractor I then separate the interdigitating fibers of the interspinous lig from multifidus fascia with electrodissection staying close to the midline. Probing the depth of the medial lamina can be done with a hemistat under fluoro. Then a 0-ethibond is placed through and through the interspinous ligament with both tails off one side then repeat the process to the other side. If the spinous processes are abutted and cannot get the anchor stiches in then I use a hand drill through the spinous processes and pass the suture through the drilled holes. Then insert the Tuohys and off you go. Finally the strain relief loop is placed in a pocket created laterally posterior to the multifidus fascia.
 

NJPAIN

7+ Year Member
Nov 28, 2011
1,722
711
New Jersey
Status
Attending Physician
The highest routine entry level i use is L2/3 due to presence of the cord above this level. I place a mark over the spinous process of L3 and L4 with a midine incision to the posterior os of the spinous processes of L3 (depth finder) then extending at that depth to the L4 sp. Using a gelpi retractor I then separate the interdigitating fibers of the interspinous lig from multifidus fascia with electrodissection staying close to the midline. Probing the depth of the medial lamina can be done with a hemistat under fluoro. Then a 0-ethibond is placed through and through the interspinous ligament with both tails off one side then repeat the process to the other side. If the spinous processes are abutted and cannot get the anchor stiches in then I use a hand drill through the spinous processes and pass the suture through the drilled holes. Then insert the Tuohys and off you go. Finally the strain relief loop is placed in a pocket created laterally posterior to the multifidus fascia.
So your anchoring point is essentially right up against the spinous process. I am assuming then that your tuohy needle is likewise up against the spinous process so that the lead is exiting the tissue in the same place you are anchoring. Otherwise, the lead is exiting more laterally and there is a bend in it to bring it closer to the midline where it is anchored. Am I correct??
 

algosdoc

algosdoc
10+ Year Member
May 3, 2005
4,063
1,926
Florida
Status
Attending Physician
So your anchoring point is essentially right up against the spinous process. I am assuming then that your tuohy needle is likewise up against the spinous process so that the lead is exiting the tissue in the same place you are anchoring. Otherwise, the lead is exiting more laterally and there is a bend in it to bring it closer to the midline where it is anchored. Am I correct??
Very close to the spinous process
 

drpainfree

10+ Year Member
May 3, 2009
1,080
172
Status
Attending Physician
The highest routine entry level i use is L2/3 due to presence of the cord above this level. I place a mark over the spinous process of L3 and L4 with a midine incision to the posterior os of the spinous processes of L3 (depth finder) then extending at that depth to the L4 sp. Using a gelpi retractor I then separate the interdigitating fibers of the interspinous lig from multifidus fascia with electrodissection staying close to the midline. Probing the depth of the medial lamina can be done with a hemistat under fluoro. Then a 0-ethibond is placed through and through the interspinous ligament with both tails off one side then repeat the process to the other side. If the spinous processes are abutted and cannot get the anchor stiches in then I use a hand drill through the spinous processes and pass the suture through the drilled holes. Then insert the Tuohys and off you go. Finally the strain relief loop is placed in a pocket created laterally posterior to the multifidus fascia.
What about the patient with lami/fusion up to L1/L2 and no more intact epidural space below? Just to clarify unless I am missing something completely.
 

Stim4me

Membership Revoked
Removed
Account on Hold
Mar 31, 2015
1,795
463
What about the patient with lami/fusion up to L1/L2 and no more intact epidural space below? Just to clarify unless I am missing something completely.
You're sane. Even if a patient is fused to L3 I assume ASD and enter at T12-L1. That way the surgeons doesnt remove you device the next revision surgery...
 

algosdoc

algosdoc
10+ Year Member
May 3, 2005
4,063
1,926
Florida
Status
Attending Physician
Of course the entry level has to be above the level of Prior spine surgery. There are always going to be variations that will be required. That is why it is the art of Medicine.
 

Stim4me

Membership Revoked
Removed
Account on Hold
Mar 31, 2015
1,795
463
Of course the entry level has to be above the level of Prior spine surgery. There are always going to be variations that will be required. That is why it is the art of Medicine.
The Point is go several levels above the survey site , one just one level, even if that means entry above the conus.
 
OP
H

heathermed

10+ Year Member
Jul 29, 2009
104
1
Status
I've been taught to do simple interrupted sutures for my deep dermal layer and a running subcuticular to do the skin. I was wondering if anyone has tried other suturing techniques ie horizontal mattress, vertical mattress. I'm especially interested if there is an alternative to interrupted for the deep layers.

thank you
 

BobBarker

Member
10+ Year Member
Dec 13, 2005
2,972
1,011
Status
Attending Physician
I know some people do a deep runner but most would not recommend that. Plastic surgeon at the Boston course taught a superficial monocryl runner. Don't even tie the ends. After you are done suturing you can lift up the free suture ends to tighten it. Then just dermabond the incision. That technique works great.
 

Sig123

10+ Year Member
Sep 9, 2009
100
49
Status
Attending Physician
I've been taught to do simple interrupted sutures for my deep dermal layer and a running subcuticular to do the skin. I was wondering if anyone has tried other suturing techniques ie horizontal mattress, vertical mattress. I'm especially interested if there is an alternative to interrupted for the deep layers.

thank you
1) I like simple, interrupted 2-0 Vicryl for my deep dermal layer as opposed to running. With interrupted, you never have to worry if a suture comes loose since it won't impact the other, surrounding sutures. With running, if something comes loose, theoretically the entire runner is at risk.
2) Horizontal or vertical mattress can be used to close skin that is under high tension -- so typically not needed with what we do except in rare occasions. I've been using Dermabond more often these days and focus on ensuring the deeper layers are nicely closed -- skin should then just lay flat with minimal or no tension that can easily be sealed w/ Dermabond
 
  • Like
Reactions: Stim4me

Stim4me

Membership Revoked
Removed
Account on Hold
Mar 31, 2015
1,795
463
1) I like simple, interrupted 2-0 Vicryl for my deep dermal layer as opposed to running. With interrupted, you never have to worry if a suture comes loose since it won't impact the other, surrounding sutures. With running, if something comes loose, theoretically the entire runner is at risk.
2) Horizontal or vertical mattress can be used to close skin that is under high tension -- so typically not needed with what we do except in rare occasions. I've been using Dermabond more often these days and focus on ensuring the deeper layers are nicely closed -- skin should then just lay flat with minimal or no tension that can easily be sealed w/ Dermabond
Equally 4.0 skin sutures is overkill , unless youre implanting a model...
 
Last edited:
  • Like
Reactions: Sig123

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,822
3,712
Canton GA
www.stevenlobel.com
Status
Attending Physician
0 vicryl deep, 2-0 superficial, dermabond on skin. Interrupted.
Staples over midline if patient does not mind. Cannot staple over battery.
 

Stim4me

Membership Revoked
Removed
Account on Hold
Mar 31, 2015
1,795
463
Cant charge or program through staples.
Never had an issue with staples, nor has rep complained. Good to know if future issue.
2.0 deep, 3.0 superficial, staples at skin. Interrupted. Have noticed interrogation issue intraop with "magnetic mound".
 

Papa Lou

ASA Member
5+ Year Member
Jul 7, 2013
295
69
Status
Attending Physician
I know some people do a deep runner but most would not recommend that. Plastic surgeon at the Boston course taught a superficial monocryl runner. Don't even tie the ends. After you are done suturing you can lift up the free suture ends to tighten it. Then just dermabond the incision. That technique works great.
With this technique when you see these patients at follow up you just cut both ends at skin and that's it?
 

BobBarker

Member
10+ Year Member
Dec 13, 2005
2,972
1,011
Status
Attending Physician
Do nothing. Just let the monocryl dissolve. Super easy.