Securing SCS trial leads - how are you doing it?

[drg123]

I've seen a variety of ways to secure SCS trial leads:

1. Use skin anchors, suturing to skin, followed by tegaderm or ioban, plus or minus some gauze on top
2. Steri-strip sandwich (like an epidural catheter), following by tegaderms and then maybe some metapore tape
3. IV tegaderm with some metapore tape

Some products I've heard about but not used in real life

StayFIX® Fixation Device

The StayFIX fixation device is specifically designed to stop migration, movement and accidental removal of a percutaneous catheter.

www.merit.com

TrialOn

A simple and intuitive solution, the TrialOn™ Fixation Device aims to standardize how physicians anchor leads for their trial SCS procedures After revolutionizing the permanent SCS implant...

www.sutureconcepts.com

What are you all doing? I'm looking for the fastest and most reliable method. Skin anchor is very secure but adds some time. Steristrip sandwich is annoying and sticky. There isn't much consistency or guidance in the literature.

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[lobelsteve]

2x 2-0 Vicryl for each lead. Then benzoin and steristrips inferior to that. Then 4x4's and tegaderm over the top to the temp box.
All cheap and easy. Above products are nice but not better, just more costly.
Migration will happen, but not from the skin, It happens between ligamentum flavum and skin.

 

[Ducttape]

my suturing skills, besides simple interrupted stitches, is pretty slow. used to take longer for me to place sutures than to do the trial itself.

mastocel, steri strips, put a retention loop, and large tegaderm over, and most importantly make sure your patient can understand what no bending or rotating means. a while ago, had a patient go back to work as boss construction company 3 days in to trial, walking up ladders, carrying "light" boxes, etc. fortunately there was only slight migration. trial was successful, but the first 3 days and first 3 hours at work were best....

 

[Nargosi]

Stayfix w tegaderm overtop

 

[RoloTomassi]

Stayfix is awesome. Not that much, like $13 I think.

 

[DOctorJay]

steri strips at the entry point, then stayfix and tegaderm over top. we did use TrialOn for a bit but they were hard to get.

 

[Painologist]

Suture both anchors down, then steri strips, large tegaderm and metapore tape

 

[BobBarker]

I use steristrips and benzoin on the lead entry then make a retention loop and lay the tails out toward the flank. Then I place skin staples the length of the leads spaced every 5mm. Then cover the entire structure with an extra large Tegaderm.

 

[manowar rules]

I do the ol’ Roman sandal around each lead with a 3-0 nylon. Then strain relief loop, distal part of the lead off to the side with the help of some mastisol. Tegaderm over. The suturing takes a couple extra minutes, but never had a migration issue with it and lead removal is just one scissor snip and pull.

 

[MitchLevi]

I use steristrips and benzoin on the lead entry then make a retention loop and lay the tails out toward the flank. Then I place skin staples the length of the leads spaced every 5mm. Then cover the entire structure with an extra large Tegaderm.

Exact same thing I do. One nylon suture per lead too.

 

[powermd]

Bunch of 4x4 tegs with one under the lead where it exits the skin; Also a teg under the generator box. Tegs to cover it all up. It looks good, doesn't seem to annoy the patient, and stays put.

 

[callmeanesthesia]

One silk suture per lead, benzoin and steri strips over that and down the course of the leads, and a large regarded over that and around toward the battery pack. It’s tedious but the last time I tried a stay-fix (in fellowship) the patient sweated it off and the trial migrated.

In winter it probably wouldn’t matter but it’s over 110 outside and will be for a week or more to come, and that’s not unusual here.

 

[giddyup]

2 silk sutures on each lead at entry site and final one on both leads after strain relief loop. 5 sutures total - usually do while taking last fluoro shots for reps. Cover all that with steri strips then tegaderm. Over 500 trials. Only migration when a patient went to wipe his butt and physically pulled them out. I still don’t understand this.

 

[SC Tian]

I use the anchors from the company for free, suture to skin using 3-0 silk, we routinely checked the lead position at the follow up visit, still over 50% migrated down one vertebrate or more.

 

[drg123]

I use the anchors from the company for free, suture to skin using 3-0 silk, we routinely checked the lead position at the follow up visit, still over 50% migrated down one vertebrate or more.

Wow! Are you also throwing a suture around the anchor itself to lock it into the lead? I'm assuming yes.

 

[SC Tian]

Wow! Are you also throwing a suture around the anchor itself to lock it into the lead? I'm assuming yes.

yes, I sutured the anchor down to the skin using 3-0 silk, fairly quick and easy, anchor does not move, lead proximal to it still migrates down 😉

 

[MitchLevi]

Over 500 trials. Only migration when a patient went to wipe his butt and physically pulled them out.

...just the one migration?

 

[callmeanesthesia]

I get a standing X-ray right after the trial. Most of them migrate a little at least, with no change at the skin surface attachment. In fluffier patients it’s very common to see them come down a full vertebral body. I usually pull down on the patient’s back skin before securing the leads to get a sense of how far it will fall when they stand. If they’ve got a lot of subcutaneous tissue movement, I’ll put the leads an extra half to full level higher to compensate.

 

[MitchLevi]

I trial and implant at mid T7 and the T7-8 disk.

Virtually all trials migrate.

 

[giddyup]

...just the one migration?

Only one pulled out I guess I should say. Some certainly migrated a bit.

 

[TIVAndy]

if you don't do xray at the end of trial you won't know if it migrated or not. i have the luxury of having in office xray - trials almost always migrate - it's just a matter of whether few contacts down or a lot (bigger patients bigger chance)

that being said - i use mastisol steristrip and then add the stayfix. tegaderm on top.

 

[lobelsteve]

Bend test. After securing leads have patient get off fluoro table and bend to 30 degrees flexion. Hop back up on table and get new xray.

 

[paindoc007]

Bend test. After securing leads have patient get off fluoro table and bend to 30 degrees flexion. Hop back up on table and get new xray.

That’s a lot of work…

 

[lobelsteve]

That’s a lot of work…

Im not there for that. Nurse and rep do dressings and bend test.

 

[Orin]

I use a steristrip in the angle of the needle to lay each lead down flat.
...Rarely I'll put a biopatch on underneath the steristrip/lead for high risk patients or longer trials
Create a loop with both leads to the side of the trial unit.
Third steristrip to hold the loop loosely
Dollop of Dermabond on the lead entry site over the steristrips
Tegaderm over the center loops.
...Rarely I'll have to use paper tape or something else in patients that have adhesive allergies
Connect to battery pack and attach to skin with vendor pouch.
Tape/Tegaderm over most of it to make sure there aren't any loose loops to catch on things

Haven't used the Stayfix or TrialOn.
TrialOn looks like it's a product looking for a market that doesn't really exist. StayFix makes sense from a business viewpoint but not sure it's needed here.

There is literature on nerve block and epidural fixation techniques with respect to migration from the anesthesia literature
With the high trial success rate, not sure it matters much but I teach the tighter you fixate it on the skin, the more likely it will retract the lead. The looser you attach it at the skin, the more likely it will slide in is what the epidural catheter literature suggests.

 

[Orin]

Im not there for that. Nurse and rep do dressings and bend test.

I don't do the get up/bend test as I'm HOPD/MAC vs GA for every trial, but how often does this change management?

 

[MitchLevi]

Drop your leads, secure them, done.

They’re def going to migrate 1-2cm (unless your pt is fused to low thoracic levels, at which case they’re less likely to migrate), so put lead one electrode one mid T7 and lead two electrode one T7-8 disk.

When they slip inferiorly you’ll still have electrodes spanning T8-11, which is your target anyways (IMO).