What is your preferred SCS entry technique?

[Baron Samedi]

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I would love to hear what others are doing. For those who implant, does it differ compared to the trial?

 

[Orin]

I would love to hear what others are doing. For those who implant, does it differ compared to the trial?

Trial is fine bilaterally.
Implant is almost always unilateral at the same level but different levels if there is a struggle.

 

[GoBeers]

trial - bilateral single level, one level below, curved needle.

 

[Status Sciaticus]

Bilateral on both trial and implant.
It doesn't save that much time during the trial, maybe a minute. Unilateral makes it a little more technically difficult which negates the time saved by not anesthetizing the other side.

 

[callmeanesthesia]

For those of you who enter bilateral on implant, how do you make the incision? 1 on each side? (Seems excessive but I’ve seen it) Longer incision in the center and spread it out wide? Place the needles, then make a midline incision and undermine the sides until you reach the needles, and pull the wires into the incision? (Had an attending who did that - it was a pain)

 

[Status Sciaticus]

For those of you who enter bilateral on implant, how do you make the incision? 1 on each side? (Seems excessive but I’ve seen it) Longer incision in the center and spread it out wide? Place the needles, then make a midline incision and undermine the sides until you reach the needles, and pull the wires into the incision? (Had an attending who did that - it was a pain)

midline over the spinous process. finger down to the fascia, then dig laterall on each side with the same finger to make a small pocket to situate the anchor.

 

[SgtThunderfistMD]

For those of you who enter bilateral on implant, how do you make the incision? 1 on each side? (Seems excessive but I’ve seen it) Longer incision in the center and spread it out wide? Place the needles, then make a midline incision and undermine the sides until you reach the needles, and pull the wires into the incision? (Had an attending who did that - it was a pain)

You don't have to do any of that. Midline incision, dissect, weitlaner and epidural access. Should be the same size and location of incision as folks who do unilateral x2 lead access.

 

[Baron Samedi]

For those of you who enter bilateral on implant, how do you make the incision? 1 on each side? (Seems excessive but I’ve seen it) Longer incision in the center and spread it out wide? Place the needles, then make a midline incision and undermine the sides until you reach the needles, and pull the wires into the incision? (Had an attending who did that - it was a pain)

I've done both a single midline incision and smaller bilateral incisions and found no practical difference in terms of total incision length and time.

I've seen a few post op seromas with a single midline but I think that may have been due to excessive undermining.

I did slightly prefer bilateral incisions when training fellows so they could each work on one, but probably wouldn't do it again outside of that setting.

The only benefit of getting access prior to incision is if you can't get access you cut for no reason. This can be negated by recapping how the trial looked and reviewing imaging prior.