SCS Tips

[MedZeppelin]

I have two questions:
1.) For the SCS Trials using an Outpatient Fluoro Suite, if no IV were to be placed and only Local used, what would be the best method of Pre-procedure Antibiotic prohylaxis?
Would it be Okay to use an IM shot of Ancef 1-2gm 30 minutes prior to procedure, or perhaps just oral ABX?

2.) For the Implant in the OR, does anyone have any data or experience with using staples, versus a standard subcuticular stitch for wound closure on the implant? I wonder which of the two may be more efficient, and less risk of infection?

Thanks!

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[Jcm800]

I have two questions:
1.) For the SCS Trials using an Outpatient Fluoro Suite, if no IV were to be placed and only Local used, what would be the best method of Pre-procedure Antibiotic prohylaxis?
Would it be Okay to use an IM shot of Ancef 1-2gm 30 minutes prior to procedure, or perhaps just oral ABX?

2.) For the Implant in the OR, does anyone have any data or experience with using staples, versus a standard subcuticular stitch for wound closure on the implant? I wonder which of the two may be more efficient, and less risk of infection?

Thanks!

1) just put a hep lock in and give IV abx. is there a reason you cant start an IV? doesnt mean you have to sedate through it. Definitely not the only way to do it, but I like IV abx for stim trials. i know people who only give oral abx for trials...

2) I staple a lot of times, and use dermabond the times i dont staple. I have no data, but i have not seen any difference from staples, to stitches to dermabond. They staple knee replacements and they staples fusions, so, whats the big deal. i used to do a running sub q but now i do a deep layer of 0-vicryl pop-offs, then a "deep dermal" or "approximating" running 2-0 vicryl, then either dermabond if worked out, or staple if I under-estimated.

dont know if that helps.

 

[Aether2000]

If you are administering parenteral antibiotics, there is no reason NOT to have an IV. If there were anaphylaxis or bradycardia with hypotensioin you need to be able to deal with this immediately, not hope you can place an IV with a patient in the prone position, or having to take time to roll them onto a cart. An IV saline lock costs a few bucks which is far less than litigation for incompetent treatment of cardiovascular or allergic events.

 

[lobelsteve]

1) just put a hep lock in and give IV abx. is there a reason you cant start an IV? doesnt mean you have to sedate through it. Definitely not the only way to do it, but I like IV abx for stim trials. i know people who only give oral abx for trials...

2) I staple a lot of times, and use dermabond the times i dont staple. I have no data, but i have not seen any difference from staples, to stitches to dermabond. They staple knee replacements and they staples fusions, so, whats the big deal. i used to do a running sub q but now i do a deep layer of 0-vicryl pop-offs, then a "deep dermal" or "approximating" running 2-0 vicryl, then either dermabond if worked out, or staple if I under-estimated.

dont know if that helps.

IV ABX is standard of care. If you ever had an infection, a line of jagoffs would be there to testify against you. There is no reason not to have an IV places when performing SCS trial and no reason to give anything less than IV ABX 30-45 min before procedure start time. Reference Hopkins ABX guide.

I do as DocShark does: 0 vicryl deep, 2-0 vicryl superficial, and dermabond the skin. Faster and prettier (as long as you don't dump dermabond into the wound preventing closure. And 2-0 silk for my anchors with swift-loks.

 

[MedZeppelin]

Thanks for the tips everyone!
I'm just trying to get a consensus on what others are doing out there for their trials/implants.
I agree, an IV Heplock makes sense for so many reasons.
Regarding the closure, I've been using a three layer technique of 0-polysorb for "deep"; 2.0-polysorb for "intermediate" and a 4.0-running subQ. That third closure just seems like overkill and time consuming. Just wondered if staples or Dermabond would be the better route...

Are most of you placing the IPG in the buttock region or flank?

Thanks,

 

[lobelsteve]

Thanks for the tips everyone!
I'm just trying to get a consensus on what others are doing out there for their trials/implants.
I agree, an IV Heplock makes sense for so many reasons.
Regarding the closure, I've been using a three layer technique of 0-polysorb for "deep"; 2.0-polysorb for "intermediate" and a 4.0-running subQ. That third closure just seems like overkill and time consuming. Just wondered if staples or Dermabond would be the better route...

Are most of you placing the IPG in the buttock region or flank?

Thanks,

Never met a patient who liked a flank battery, moved several of them for folks implanted by others, and I have a drawer full of batteries that I've found inside of people who didn't want them. Doesn't pay as well but much more rewarding.

 

[emd123]

Does anyone give an oral dose of Bactrim or Doxycyline along with their IV Ancef for MRSA coverage, considering the increase of community-acquired MRSA along with hospital-acquired MRSA? So many patients are colonized with MRSA now it only seems like it would make sense to add some MRSA coverage. Vancomycin definitely seems like overkill for prophylaxis.

 

[ultm8frisbee]

I think most of the ID guys woud tell you to go with Vanc if you where that concerned about MRSA.

Does anyone give an oral dose of Bactrim or Doxycyline along with their IV Ancef for MRSA coverage, considering the increase of community-acquired MRSA along with hospital-acquired MRSA? So many patients are colonized with MRSA now it only seems like it would make sense to add some MRSA coverage. Vancomycin definitely seems like overkill for prophylaxis.

 

[Jcm800]

typically cleocin post-op trial and post perm for me. Vanc before permanent.

 

[Tenesma]

1) IV should be done... it is not NECESSARY... but saves you MANY headaches (speaking from experience)....

2) i don't like staples... unless it is an older patient.... i find that a good dermabond or subq running is much prettier in the long run - and it is amazing how focused patients can get on what their scar looks like (even though they need two sets of mirrors to actually see the scar)...

 

[Jcm800]

1) IV should be done... it is not NECESSARY... but saves you MANY headaches (speaking from experience)....

2) i don't like staples... unless it is an older patient.... i find that a good dermabond or subq running is much prettier in the long run - and it is amazing how focused patients can get on what their scar looks like (even though they need two sets of mirrors to actually see the scar)...

i used to think that subq looked better, but since i started stapling and dermabonding, i look at all the incisions 6 months out or whenever they show up again for something, and they all look identical, regardless of closure style. Its personal preference, but i think most surgeons will tell you that staples taken out early look as good as sub q (unless its a face or a plastic surgeon talking)...

i dont think any of it has any real impact. All of them work.

 

[lobelsteve]

Just did an occipital case with BosSci. Put battery in left axila.

That tunneling tool is not long enough is is obnoxiously large.
It rips through tissues rather than dividing then like the competitors.

 

[Tenesma]

my beef w/ staples - just like interrupteds --- they can leave those little dots on each side of the scar --- w/ subq/dermabond: no dots..

 

[Jcm800]

my beef w/ staples - just like interrupteds --- they can leave those little dots on each side of the scar --- w/ subq/dermabond: no dots..

yes they can, but not usually when you take them out early...

 

[bedrock]

1) IV should be done... it is not NECESSARY... but saves you MANY headaches (speaking from experience)....

Tenesma, can you elaborate on those SCS trials where you regretted not putting in an IV?

I may get ripped for saying this, but I don't ever use perioperative IV abx for SCS trials. (I do 90% of procedures in office) I do use oral abx (first dose 12 hrs before trial, and continued through duration of SCS trial) I've done it this way for a couple years without any difficulties at all. I do use betadine & clorhexidine prep, surgical drape/gown/gloves, etc. for SCS trials

The epidural space is much less prone to infection than the intrathecal or intradiscal spaces. I wouldn't dream of doing a discogram without perioperative IV abx, and certainly reasonable for a pump trial or permanent pump/SCS implant but I haven't seen any literature that proves there is a significantly higher infection risk for SCS trials with PO only abx versus IV periop abx + PO abx post-op.

 

[bedrock]

Bump,

Tenesma, can you tell me why you've regretted not having an IV for an in-office SCS trial?

And for those who do use PO antibiotics for their SCS trials (either just PO abx or PO abx used after periop IV abx), what are you using for PO antibiotics?

 

[Tenesma]

I found that the longer the procedure takes the more the patient's mind starts racing... the more likely they start freaking themselves out...

doing a good and accurate SCS trial is important - and having the procedure cancel due to vagal response to tugging/pulling, etc is a pain in the butt.

a small IV in the hand with some fluid running in an NPO patient is a small price to pay for some sanity... is it overkill? maybe... but it literally costs $2.50...

 

[Jcm800]

i did an SCS trial maybe 2 weeks ago, and my nurse couldnt get the IV, she tried 3 times, finally on my 4th attempt i got it. Old guy with bad diabetes. we told him we were gonna start an IV, he said "good luck"

anyway. as soon i got it, she started the Abx. when i was in the room starting the procedure, i asked if she made sure the IV was super secure. She said no, she took it out, since he got the abx, and it was "positional"

i think she is getting senile. oi vey. i cant believe i had to address this with her...

try getting one quick in that guy...

common sense cannot be taught.

 

[Calilove]

I usually implant the IPG in the flank region (if right handed patient.... right flank) with great results. I've heard more patients complain about sitting on the IPG if planted in the buttock. Flank implants are easier to perform with less worry about an uncomfortable patient...

 

[voltron]

generator in buttock
I use 0 silk ties for the anchors
Close interrupted with 2-0 vicryl for the deeper layer then I staple. I asked a couple of plastics friends if they recommended closing in 2 layers for the deep stuff, they said for the depth of our incisions probably not needed. Rarely if its deep I'll do another running layer above the interrupted. I always use IV abx for trials just cause I think it would be really hard to defend an infection in court...if it ever progressed to that.

 

[Mister Mxyzptlk]

I use the buttock for both SCS and pumps. Preop I have them sit up and we mark out where the glutes hit the surface, the PSIS, etc.

I close pump pockets with staples. Don't trust dermabond to hold if they get a tense seroma.

 

[ultm8frisbee]

I use the buttock for both SCS and pumps. Preop I have them sit up and we mark out where the glutes hit the surface, the PSIS, etc.

I close pump pockets with staples. Don't trust dermabond to hold if they get a tense seroma.

Pump in the buttock? Seems like they would be sitting sideways.

 

[hyperalgesia]

The buttock area was practically built to accommodate hardware. It is a natural pocket grounded and protected by solid structure. No matter what kind of posture the patient takes, the device maintains the same position, relative to it's bone boundaries. Not so in the flank.

 

[Jcm800]

Pump in the buttock? Seems like they would be sitting sideways.

I have never put a pump in the buttock area...i have seen a few, and they were not pretty.

 

[Pain_doc]

the pump...or the butt?

 

[MedZeppelin]

Anybody sending patients home with a back brace for a short period of time after implants to reduce lead migration?

 

[Mister Mxyzptlk]

I was kind of shocked the first time I saw a butt pump, but they are much easier to implant. In several patients I have moved the pump from the abdomen to the butt and they prefer it.

Take a used pump or a demo pump and put it in your back pocket AFTER you've sat down so it's situated above where your butt contacts the seat. Try it with different chairs. It might not be ideal for sitting in a hard pew on Sunday but otherwise I think the cosmetic result is better and it's more comfortable. And they don't flip.

 

[lobelsteve]

Anybody sending patients home with a back brace for a short period of time after implants to reduce lead migration?

I try to put all implants in a TLSO x6weeks. It limits their movements and should reduce migration.

 

[Jcm800]

I try to put all implants in a TLSO x6weeks. It limits their movements and should reduce migration.

i dont, but i bet i could make a lot of money DME if i did...

 

[MedZeppelin]

Thanks for all the responses.

Are any of you who implant solo practice? I'm in a situation where I can perform trials and implants, but I'm in a totally solo, independent situation, with no backup call....

I have some hesitation to perform implants in this situation...also, the local hospital prefers I have a backup person.

Have any other solo practitioners overcome this scenario?

Thanks,

 

[lobelsteve]

Thanks for all the responses.

Are any of you who implant solo practice? I'm in a situation where I can perform trials and implants, but I'm in a totally solo, independent situation, with no backup call....

I have some hesitation to perform implants in this situation...also, the local hospital prefers I have a backup person.

Have any other solo practitioners overcome this scenario?

Thanks,

Don't implant and take a week vacation the following day. No issues in 3 years.

 

[epidural man]

I have two questions:
2.) For the Implant in the OR, does anyone have any data or experience with using staples, versus a standard subcuticular stitch for wound closure on the implant? I wonder which of the two may be more efficient, and less risk of infection?

Thanks!

Recent data (BMJ 2010) shows a 3-4 times increased infection rate with staples over major joints. Also, staples are more expensive (consider the staple removal kit, time to remove, etc).

Also, for the 2nd layer and subcuticular, its better to use a non-braided suture (no polysorb or vicryl) as they have clearly been shown to increase infection rate (which makes sense).