Not a lot of experience with patients with long lumbar or thoracolumbar instrumentation for SCS. I have a patient coming in that will likely need an SCS trial, Laminectomy L1 to the sacrum with PLIF L2 to sacrum and instrumentation L1 to S1. On x-ray there is kyphoscoliosis above the upper instrumented vertebral body. Obviously needs advanced imaging as only an x-ray precedes her visit. The junctional disc level looks like a disaster on x-ray. So, looking like the lowest reasonable interlaminar entry level would be T10-11.
Regarding SCS for LBP and LE pain due to FBSS, any of you have a "rule of thumb" regarding a level above which you will not attempt a perc trial and will send for a paddle due to concerns about not have enough lead in the epidural space or enough real estate to steer the lead into position?
It is going to be harder. I have done several such patients. What do I do?
1. First of all, tell the patient that their anatomy will make the procedure more difficult than it usually is, but assure them you will try your best but not lead them to disaster. If it doesn't go quickly- bail out. people will forgive you for erroring on the side of caution.
2. Take them to fluoro prior to the stim trial and take a look and see if you can see the interspaces well enough in the thoracic area to place the leads. If there are no views (unlikely, but possible), dont even attempt the trial. Plan in advance which segment will afford the best chance for both needle and lead placement.
3. If they have mostly lower extremity radicular symptoms, I have had a few patients on whom I thought a perc lead would be damn near impossible. In those instances, I chat with the neurosurgeons to do a lamy lead (without a trial) and place it at T8,T9,T10. Oddly, those patients have done pretty well and were appreciative of the effort.
4. Keep in mind that we place cervical leads at C7/T1 or T1/T2 interspaces for those patients we elect not to start L1/L2 and use a long lead. It is more difficult, as the interlam distance is shorter, but not hard with practice. Of course, shallow angles of approach are harder to achieve at the higher interspaces, which can have the problem that goes with a more vertical needle placement.
Primum non nocere (and please, when you pronounce this, the "c" is hard in Latin. It sounds like a "k", not an "s". I have encountered too many people who, in an attempt to display their wit, only reveal half of it, and had to be put down in a mercy killing).
