SCS Implant with nearby seroma

[lobelsteve]

Wonderful patient with trial placed today. L2-S1 fusion. No issues getting in and up spine.
If I go to implant and cut open this seroma, should I do anything special other than extra irrigation?
I have drained seromas like this with a 22G before, and I figure with an extra Tuohy I can suck this dry pretty quick in a separate poke.
Planning to avoid it altogether, but if it happens, I want a plan.

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[Laryngospasm]

Wish I had some constructive info.. my smartass comment is to ask the guy/gal that caused it. I believe these can occasionally progress and cause neurological deficits.

 

[SommeRiver]

When do you think you'd come into contact with it?

 

[lobelsteve]

When do you think you'd come into contact with it?

Vertical incision starting off sp of L1. Depends on how deep I get.

 

[BobBarker]

The pseudominingocele is anterior to the spinolaminar line. You aren’t going to get that deep.

 

[SommeRiver]

I could POTENTIALLY see you stabbing it with a poorly placed anchor stitch, but I can't imagine that actually happening in real life. Not only is that rather inferior relative to an implant, it is deep. You're far too experienced to hit that thing.

 

[lobelsteve]

I plan for wcs. Worst case scenario. I’m sure i can stay above and be in dense scar with suture and needles. But just saying....

So when this blows:
1. Irrigate after draining.
2. puncture inferior aspect and put in a drain
3. Open it up, explore, evacuate, close it out.

 

[BobBarker]

It’s CSF. So don’t mess with it.

 

[chibadriver]

It would be interesting to push this over to the neurosurgery forums and see what they say... does that forum exist!?

 

[thecentral09]

How do u know it’s not CSF? I’d do an L1 L2 access, Anatomically I don’t think you will be anywhere near it, but I would avoid it at all costs.

 

[pmrmd]

That’s huge. You have a very unique patient population. I don’t know if it’s all of Georgia or just your orbit but I’m glad my world isn’t yours.

 

[BobBarker]

How do u know it’s not CSF? I’d do an L1 L2 access, Anatomically I don’t think you will be anywhere near it, but I would avoid it at all costs.

Why L1/2? This would put him only closer to the CSF bomb. This one needs to be done at t11/12 preferably.

 

[PittsburghPain]

Why L1/2? This would put him only closer to the CSF bomb. This one needs to be done at t11/12 preferably.

Does Coude needle serve any purpose in a case like this? Hopefully decrease length of vertical incision and allow for steeper needle angle?

If used, how much higher is risk for lead fracture with increased lead angle?

Thoughts and insight from the crowd?

 

[BobBarker]

I don’t think the Coude needle is necessary very often. I haven’t used one on a SCS in probably 4 years. 1.5” incision for this one.

 

[SommeRiver]

Why L1/2? This would put him only closer to the CSF bomb. This one needs to be done at t11/12 preferably.

I have a theory that a T11-12 entry reduces incidence of migration bc the lead isn't as long from the anchor to the end of the lead.

I prefer T11-12 entry.

 

[soccrwz]

For the sake of the argument; could you reach that with a 25G needle and put some contrast in there to determine if continguous with CSF vs contained on fluoro. If contained, drain?

 

[BobBarker]

For the sake of the argument; could you reach that with a 25G needle and put some contrast in there to determine if continguous with CSF vs contained on fluoro. If contained, drain?

Beta 2 transferrin

 

[lobelsteve]

MRI 7/20

FINDINGS

There is mild anterolisthesis of L4 on L5 and L5 on S1. There are
post-surgical changes from anterior lumbar interbody fusion from L2 to S1, as
well as posterior instrumented lumbar spinal fusion procedure from L2 to S1,
with laminectomies. There is a large fluid collection involving the
laminectomy beds, with peripheral T2 hypointensity, which likely represents a
seroma.

MRI 2017

So it is 3 years later and with this info, we can rule out CSF communication based on different signal intensity. Surgery was 2014.

 

[BobBarker]

Geez, professor! Holding back information to facilitate discussion.

again, another reason why we should have CME granting ability on the forum

 

[deleted993114]

Wonderful patient with trial placed today. L2-S1 fusion. No issues getting in and up spine.
If I go to implant and cut open this seroma, should I do anything special other than extra irrigation?
I have drained seromas like this with a 22G before, and I figure with an extra Tuohy I can suck this dry pretty quick in a separate poke.
Planning to avoid it altogether, but if it happens, I want a plan.




View attachment 314484

I would not do that case at all. The tissue around the seroma is not amendable to suturing (similar to a CSF leak). Additionally, that fluid collection is a nidus for infection. There is a reason the seroma formed in the first place, and it is not good.

Think whether the neurosurgeons would operate near this seroma or not and you have your answer. I have certainly scrubbed in on many of their disasters and know to not test the faiths in these situations.

I know there is the compulsion to help people, and you correctly understand you are probably the best person to do the procedure (if it is done). I would step away from this one.

 

[SommeRiver]

I would not do that case at all. The tissue around the seroma is not amendable to suturing (similar to a CSF leak). Additionally, that fluid collection is a nidus for infection. There is a reason the seroma formed in the first place, and it is not good.

Think whether the neurosurgeons would operate near this seroma or not and you have your answer. I have certainly scrubbed in on many of their disasters and know to not test the faiths in these situations.

I know there is the compulsion to help people, and you correctly understand you are probably the best person to do the procedure (if it is done). I would step away from this one.

Do you mind explaining why that tissue won't hold an anchor?

I'm not contesting what you said; I genuinely want to know bc I would do the case at T11-12.

I would rather learn why I shouldn't on an internet forum than to find myself in this situation in real life and make a bad decision.

 

[Orin]

I've surgically decompressed seromas around devices. They do well. I have found the need to remove the seroma lining but the tissue under there is good for anchoring. I would agree with tapping it and testing for CSF markers before you get into it. There are some that argue for ruling out infection as well with seromas. Drainage and external pressure to oppose the tissue planes it off are easy to do in clinic.

 

[deleted993114]

Do you mind explaining why that tissue won't hold an anchor?

I'm not contesting what you said; I genuinely want to know bc I would do the case at T11-12.

I would rather learn why I shouldn't on an internet forum than to find myself in this situation in real life and make a bad decision.

As noted immediately above, a weird capsule with very friable tissue forms around the seroma. If you are going to anchor anything, you have to remove that tissue. Further, fascial stitches in the tissue surrounding a seroma do not hold. The tissue looks really weird and shiny.

I really, really try to stay out of trouble. Most say I "push out the envelope" for interventions, but I really do not take risks and this would be a high risk patient that I would send to a university or let the neurosurgeons play with. Weeks and weeks of dealing with someone who has incisions break down would be a drag and convince you not to do such cases in the future.

Minimize risk

 

[SommeRiver]

As noted immediately above, a weird capsule with very friable tissue forms around the seroma. If you are going to anchor anything, you have to remove that tissue. Further, fascial stitches in the tissue surrounding a seroma do not hold. The tissue looks really weird and shiny.

I really, really try to stay out of trouble. Most say I "push out the envelope" for interventions, but I really do not take risks and this would be a high risk patient that I would send to a university or let the neurosurgeons play with. Weeks and weeks of dealing with someone who has incisions break down would be a drag and convince you not to do such cases in the future.

Minimize risk

Thanks man.

That's exactly why I asked...So I don't have to find out the hard way.

 

[deleted993114]

Thanks man.

That's exactly why I asked...So I don't have to find out the hard way.

Yep-

Fortunately, I was a part of a neurosurgery group for most of my career and had the opportunity to scrub in on cases (usually on the weekends or in the evening when I was not in clinic). Lots of good information there and I can tell you these seromas and pseudo-meningoceles are best to be avoided. The tissue has reduced tensile strength and does not hold sutures well, nor does it heal well. I've had my ass kicked seven ways to Sunday over my career and hopefully and I give information to others to avoid problems. Keep in mind that pain was new then and we were finding things out that people had not known before. It wasn't that we were stupid (I'm probably the exception there)- there just was not a large body of good information on pain management out there.

Stay away!

You make your own luck during your career and it is far more important to know WHAT NOT TO DO, rather than knowing WHAT TO DO.

PS- NEVER scrub in on a posterior cervical laminectomy- it will scare the crap out of you and you won't want to do cervical epidurals anymore.

 

[paindoc007]

PS- NEVER scrub in on a posterior cervical laminectomy- it will scare the crap out of you and you won't want to do cervical epidurals anymore.

Why?

 

[Agast]

Why not send for paddle lead placement?

 

[SommeRiver]

Why?

Probably bc it is not only tight but vascular as well.

...another opportunity for me to plug the 25g cervical epidural technique I learned from reading Lobel's posts.

I read his posts, saw the pics, tried it on my own, and now I cannot imagine doing an epidural with LOR, especially if I'm using a 20 or 22g needle.

You do a few dozen with the 25g I swear you'll think the old technique is barbaric. I do probably 5-7 cervical epidurals per week, and I've been using this technique for over a year now.

Zero issues. Faster. Safer. Less painful (not that a traditional CESI is painful).

 

[lobelsteve]

Probably bc it is not only tight but vascular as well.

...another opportunity for me to plug the 25g cervical epidural technique I learned from reading Lobel's posts.

I read his posts, saw the pics, tried it on my own, and now I cannot imagine doing an epidural with LOR, especially if I'm using a 20 or 22g needle.

You do a few dozen with the 25g I swear you'll think the old technique is barbaric. I do probably 5-7 cervical epidurals per week, and I've been using this technique for over a year now.

Zero issues. Faster. Safer. Less painful (not that a traditional CESI is painful).

manuscript nearly complete. N now 450

 

[epidural man]

I’m not convinced that fluid isn’t CSF.

It would be good to hear a radiologist explain why having a different appearance on MRI rules it out 100%.

 

[SommeRiver]

I’m not convinced that fluid isn’t CSF.

It would be good to hear a radiologist explain why having a different appearance on MRI rules it out 100%.

That MRI signal intensity bruh.

 

[10KHertz]

Steve, if you had a successful trial and entered at T11-12 (or possibly at T12-L1) then go to implant and place the IPG slight infero-and way lateral in the flank region . Stay away from a inferior and central paraspinal IPG placement. If you somehow get serious drainage, I wouldn’t drain it unless your deep erector spinae sutures don’t contain the flow. There is a chance you can create a new fistula track to the superficial tissues, which can be problematic . I’d have a neurosurgeon colleague as back up (discuss the case)...

 

[SommeRiver]

Just refer for a paddle and forget about it.