Spinal Cord Stimulation: Percutaneous Implantation Techniques

 

Description:

 

 

Neuromodulation therapies such as spinal cord, dorsal root ganglion, and peripheral nerve stimulation are used to treat chronic pain syndromes such as intractable back pain, diabetic neuropathy, spinal radiculopathies, and complex regional pain syndrome. Since the publication of the first edition over a decade ago, there has been unprecedented progress in understanding neuromodulation and technological advances in clinical applications.Spinal Cord Stimulation is intended as an essential guide to the clinical fundamentals required for safe and effective implantation of neuromodulation devices. Implantation of these devices is performed by physicians from various disciplines, requiring a multidisciplinary skill set that presents a challenge for surgical and non-surgical pain practitioners alike. This authoritative resource integrates the basic multidisciplinary information necessary for understanding spinal cord stimulation, dorsal root ganglion (DRG), and peripheral nerve stimulation (PNS) with up-to-date implantation techniques for clinicians to use in their daily practice. It also features updated advice for appropriate medical decision making, patient education, safe use of radiation, and managing adverse events, with new chapters dedicated toward DRG stimulation and PNS.

 

Table of Contents:

 

Disclosures of Conflicts of Interest

1. The Development of Spinal Cord Stimulation

Introduction

History

The Gate Theory of Pain Reduction

Mechanism of Action

Equipment Overview

Current Status

Favorable Patient Characteristics

Efficacy

Cost-Effectiveness

Warnings

References

2. SCS Screening Trial: Patient Selection and Preparation

Introduction

Patient Selection

Indications for Spinal Cord Stimulation

FDA-Approved Indications

Budapest Clinical Diagnostic Criteria for CRPS

Off-Label Applications

Related Applications

Unsuccessful Applications

Contraindications

Anatomic Considerations

Epidural Access and Stenosis

Spine Abnormalities

Spondylosis

Previous Spine Surgery

Spinal Stenosis

Medical Considerations

Anticoagulation and Coagulopathy

Infection

Suppressed Immune Response

Tobacco Abuse

Establishing Medical Necessity

Psychosocial Considerations

Psychological Contraindications and Testing

Patient Education

Psychological Preparation

Procedural Information

Informed Consent

References

Appendix A: Sample Letter of Medical Necessity for Spinal Cord Stimulation

Appendix B: Frequently Asked Questions About Spinal Cord Stimulation

Appendix C: Checklist of Patient Education Topics

3. Radiation Safety

Introduction

Background

Terminology

X-Ray Interactions

X-Ray Production

X-Ray Image Formation, Detection, and Presentation

The X-Ray Image Intensifier Detector

The Flat-Panel Digital Detector

Collimation and Filtration of the X-Ray Beam

Recording Radiation Dose Metrics

Image Quality

Distortion Errors

Parallax Error

Vignetting

Pincushion Distortion in Image Intensifier Detectors

“S” Distortion

Advantages of Flat Panel Detectors

Biologic Effects of Radiation

Reducing Exposure to Radiation

Minimizing Effects on the Torso and Legs

Minimizing Effects on the Thyroid

Minimizing Effects on the Hands

Minimizing Effects on the Eyes

Fluoroscopy for Spinal Cord Stimulation

Patient-Informed Consent for Radiation Exposure

Acknowledgments

References

4. Sterile Technique

Introduction

The Importance of Sterile Technique in Infection Control

The Development of Sterile Technique

Surgical Site Infections

Risk Factors for Surgical Site Infection

Principles of Aseptic and Sterile Technique

Terms and Concepts

Cleaning and Antiseptic Agents

Other Principles

Preoperative Preparation: Home Preparation

Prophylactic Antibiotics

Operative Preparation: Scrubbing and Draping

Physician Preparation: Hand Scrubbing, Gowning, and Gloving

References

5. Electricity and Spinal Cord Stimulation

Introduction

SCS Leads

Percutaneous Leads

Surgical (Paddle) Leads

Ohm’s Law (V = IR)

Perception Threshold

Fibrosis

Epidural Space

CSF Layer

Time Since Implant

Other Factors

Anodes and Cathodes

Dorsal Column Anatomy

Frequency, Amplitude, and Pulse Width

Amplitude (Current/Voltage)

Pulse Width (Microseconds)

Frequency (Hertz)

Single Versus Dual Leads

Contact Combinations

Monopolar Stimulation

Bipolar Stimulation

Tripolar Stimulation

Dual or Complex Cathodes, Current Steering, and Interleaving

Electrode Spacing

Pulse Generators

Electrical Stimulation Technology

Power Sources: Rechargeable, Non-rechargeable, and Radiofrequency

Pacemakers and Implanted Pulse Generators: Are They Compatible?

Current Versus Voltage Control

Independently Controlled Current Delivery

Interleaved Pulses in Non-independently Controlled Current/Voltage Delivery Systems

Stimulation Waveforms

Evoked Compound Action Potentials

References

6. Trial of Spinal Cord Stimulation: Basic Considerations

Introduction

Percutaneous Versus Tunneled Trials

Advantages of Percutaneous Trials

Disadvantages of Percutaneous Trials

Advantages of Tunneled Trials

Disadvantages of Tunneled Trials

General Information About Percutaneous Trials

Equipment

Relevant Anatomy of the Epidural Space

Lead Locations in the Spine

Loss-of-Resistance Technique

Mechanics of the Loss-of-Resistance Technique

Fluoroscopic Guidance

Local Anesthesia

Anesthesia

Management During the Trial

Assessment of Trial

References

Appendix: Sample Dictation—SCS Trial

Recommendations

Template

7. Percutaneous Trial of Spinal Cord Stimulation

Introduction

Anterograde Lead Placement for Stimulation of Low Back and Legs

Patient Positioning

Operative Procedure

Anterograde Lead Placement for Stimulation of Upper Extremities

Patient Positioning

Operative Procedure

Lead Manipulation

Intraoperative Lead and Stimulation Testing

Anchoring the Lead Externally

After the Procedure

References

8. Tunneled Trial of Spinal Cord Stimulation

Performing a Tunneled Trial

Creating the Midline Cut-Down Incision

Placing the Leads Prior to the Cut-Down Incision

Operative Procedure

Choosing Incision Location

One-Lead Placement

Two-Lead Placement

Two Needles at Same Vertebral Level on Opposite Sides of Midline

Option A: Placing a Single Vertical Incision Between the Two Needles (Figure 8.1)

Option B: Use a Transverse Incision, Thereby Incorporating the Needles into the Incision (Figure 8.2)

Two Needles on the Same Side at Same or Different Vertebral Levels

Placing the Cut-Down Incision Prior to Lead Placement

Creating the Central Pocket

Anchoring the Lead

The Tunneling Procedure

References

9. Basic Surgical Skills for the Operating Room

Introduction

Surgical Instrumentation

Incising Instruments

Electrosurgery

Monopolar (Unipolar) Electrosurgery

Bipolar Electrosurgery

Cut Versus Coagulation

Grounding Pad (Return Electrode)

Dissecting and Undermining

Sharp Versus Blunt

Retractors

Weitlaner Retractor

Adson Cerebellar Retractor

Senn Retractor and Skin Hook

Army–Navy Retractor

Forceps

Tunneling

Suction Equipment

Sponges

Needles and Sutures

Basic Suture Instruments

Needle Holders (Drivers)

Needle Pickups

Suture Scissors

Suture Material

Suture Handling

Natural Versus Synthetic Material

Absorbable Versus Nonabsorbable Sutures

Monofilament Versus Multifilament Sutures

Suture Size

Surgical Needles

Needle Anatomy

Curved Versus Straight Needles

Taper Point, Cutting, or Reverse Cutting Needles

Conventional Cutting Needles

Reverse Cutting Needles

Skin Adhesive

Wound Closure

Holding the Needle Driver and Grasping the Needle

Interrupted Sutures for the Deep Layer

Continuous (Running) Subcuticular Skin Closure

Avoid Tissue Trauma

Surgeon’s Knot and Square Knot

Two-Handed Surgical Tie

Two-Handed Square Knot

Instrument Tie

References

10. Permanent Spinal Cord Stimulator Placement

Introduction

Temporary Versus Permanent Trial

Permanent Implantation Following a Successful Percutaneous Trial

How Much Additional Length Should Be Added for Strain Relief?

Anesthesia

Anterograde Permanent Lead Placement at the Lumbar, Thoracic, and Cervical Levels

Creating the Midline Pocket Incision

Placing the Leads Prior to Cut-Down Incision and Midline Pocket Creation

Operative Procedure

Choosing Incision Location

Placing the Midline Pocket Cut-Down Incision Prior to Lead Placement

Creating the Central Pocket

Anchoring the Lead

Permanent Implantation Following Successful Tunneled Trial

Explantation of Temporary Extension

Where to Place the IPG Pocket

Placing the IPG

The Tunneling Procedure

After the Procedure

References

Appendix 1: Sample Dictation Template

Consent

Procedure

Disposition

Template

Postoperative Instructions for Patients Having Spinal Stimulator Implants, Revisions, and Explants

Sample Preoperative Orders: Spinal Cord Stimulator Implant

Sample Preference Card

Preparation

Instruments

Supplies

Equipment

Sutures

Drugs

Dressings

11. Wound Healing, Postoperative Wound Management, and Discharge Education

Introduction

Normal Wound Healing

Phases of Wound Healing

Phase 1: Hemostasis and Inflammation

Phase 2: Proliferation and Fibroplasia

Phase 3: Maturation and Remodeling

Identifying the Patient at Risk for Wound Complications

Malnutrition, Chronic Disease, Immune Compromise, and Lifestyle Factors

Postoperative Care

Showering

Postoperative Antibiotics

Suture and/or Staple Removal

References

12. Complications and Adverse Events

Postoperative Complications in the Modern World

Training

Complications and Adverse Events

Anesthesia Complications

Monitoring

Local Anesthetic Toxicity

Inadvertent Subarachnoid Injection: The Total Spinal Block

Surgical Complications

Infection

Preoperative Prevention

Postoperative Infection

Hematoma

Preoperative Prevention

Postoperative Hematoma

Epidural Hematoma

Epidural Abscess

Hematoma of the Midline or IPG Pocket

Midline or IPG Pocket Seroma

Dural Punctures and CSF Hygromas

Prevention

Responding to a Dural Puncture

Dehiscence

Skin Erosion

Perforated Viscus: Tunneling

Cord Injury and Nerve Damage

Anxiolysis and Sedation

Stenosis

Hardware Malfunction

MRI Compatibility

Explantation

Conclusions

References

13. Peripheral Nerve Stimulation

Introduction

Clinical Anatomy of the Peripheral Nervous System

Mechanism of Action

Indications for PNS Therapy

Peripheral Nerve Trauma

Hemiplegic Shoulder Pain (HSP)

Low Back Pain

Chronic and Acute Postsurgical Pain

Complex Regional Pain Syndrome (CRPS)

Other (Groin Pain, Intercostal Pain, Sacroiliac Pain, Chronic Migraine)

Equipment and Implantation Procedures

Patient Selection

Safety and Risk

Diagnostic Local Anesthetic Blocks and Trials

Approaches to Nerves

Common Nerve Targets

Approach to the Suprascapular Nerve

Approach to the Axillary Nerve

Approach to the Sciatic, Common Peroneal, and Tibial Nerves

Tunneling

Conclusions

References

Appendix A: Sample Dictation—PNS Percutaneous Trial/Temporary Implant with Ultrasound

Recommendations

Template

Appendix B: Sample Dictation—PNS Permanent Implant with Ultrasound

Recommendations

Template

14. Dorsal Root Ganglion Stimulation

Introduction

Clinical Anatomy and DRG Stimulation

Patient Selection

Technique

Patient Position

Needle Placement for T10 to L3

Case Example

Needle Placement for L4 to L5

Needle Placement for S1 and S2

Case Example

Sheath Delivery T10 to S2

Placing the Epidural Strain Relief Loop

Removal of the Delivery System

References

Index

 

An aparitie	12 Jun 2023
Autor	Paul G. Kreis, Scott G. Pritzlaff, David J. Copenhaver, Scott M. Fishman
Dimensiuni	222 x 286 x 16 mm
Editura	Oxford University Press
Format	Hardcover
ISBN	9780190095086
Limba	Engleza
Nr pag	216