1 / 25

Paddle SCS Leads: Advantages and Limitations

Paddle SCS Leads: Advantages and Limitations. Joshua M. Rosenow, MD, FAANS, FACS Director, Functional Neurosurgery Associate Professor of Neurosurgery, Neurology and Physical Medicine and Rehabilitation Northwestern Memorial Hospital. Disclosures. Disclosures.

caden
Download Presentation

Paddle SCS Leads: Advantages and Limitations

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Paddle SCS Leads: Advantages and Limitations Joshua M. Rosenow, MD, FAANS, FACS Director, Functional Neurosurgery Associate Professor of Neurosurgery, Neurology and Physical Medicine and Rehabilitation Northwestern Memorial Hospital

  2. Disclosures

  3. Disclosures • I place both paddle and percutaneous leads • I think the current generation of leads/IPGs are all actually rather good • While I am not happy paying ARod to undergo another hip surgery, the Yankees total OPS may have just increased. Of course we still need a catcher and outfielder.

  4. Why use paddles? • Previous difficulties with perc leads • Preference of implanter • ?lower current requirement • ?less interference by epidural fat

  5. Paddle Trial • Lumbar fusion or laminectomy precluding percutaneous insertion • Inability to access the epidural space percutaneously • Bony anatomy • Obesity • Prior procedure in the region of the implant • Tumor resection, etc.

  6. Paddle Trial: Limitation • Limited ability to test multiple locations • For paddle trial – essentially have to guess the level • If good coverage not achieved, the procedure starts to turn into a big deal

  7. Limitation: Guess the level!

  8. Communication is key T9 T10

  9. Paddle Lead: Innovation • Now possible to place 1x8 paddle via percutaneous approach using epidural access dilator • Long term data as to issues/complications not available

  10. Paddle leads: Fallacy “Don’t worry that we didn’t cover that area in the trial, the paddle lead will fix everything.”

  11. Paddle Leads: Contact Proliferation

  12. You CAN mess up a paddle Paddle placed under GETA Awoke with right thoracic radicular pain Never had good coverage with stim Surgeon told him to “wait a year and see if the coverage and pain improve”

  13. Paddle Lead Injuries • Levy, et al Neuromodulation 2011 • Data obtained from manufacturers’ database • 3 years (2007-2010), 44,587 paddle lead implants • 239 (0.54%) neurologic complications. • 21 (0.05%) cases of CSF leak • Epidural hematoma 83 of 44,587 cases (0.19%) • major motor deficit in 52/83 patients (63%) • Permanent motor deficit with or without EDH - ranges from 0.022% to 0.067%.

  14. Paddle Lead Injuries

  15. Paddle Lead Injuries

  16. Preop imaging is essential • You would never do any other spine case without adequate preop imaging – DON’T START NOW • Preop imaging makes sure something asymptomatic doesn’t become symptomatic • Aids in counseling patient preop if procedure needs to be altered to deal with anatomic issue

  17. Complication avoidance Don’t be overzealous Don’t push a bad situation If it won’t go, it won’t go… Caution when dissecting laterally – epidural veins Poor coverage despite radiographic adequacy check trial fluoros make sure c-arm aligned in both planes

  18. Paddle Implant – Anesthesia Technique MAC Allows intraoperative testing Quicker recovery May be more difficult in chronic pain patients • General Anesthesia • Physiologic monitoring to verify midline placement • Does not allow geographic coverage verification • May be better for difficult patients or those requiring more extensive procedures

  19. SCS Electrodes Lead Location HardwareCervicalThoracolumbarThoracicTotal Percutaneous Initial 91 191 9 291 (74.2%) Revision 33 67 1 101 (25.8%) Total 124 258 10 392 (81.3%) Resume Initial 12 15 1 28 (39.7%) Revision 22 19 0 41 (60.3%) Total 34 34 1 69 (14.1%) Specify Initial 1 7 0 8 (36.4%) Revision 4 8 2 14 (63.6%) Total 5 15 2 22 (4.6%) TOTAL Initial 104 213 10 327 (67.6%) Revision 59 94 3 156 (32.4%) Total 163 307 13 483 Rosenow, et al JNS Spine 2006

  20. Electrode Migration Location of electrode HardwareCervical ThoracolumbarThoracicTotal Percutaneous 21 (16.9) 28 (10.9) 0 47 (12.0) Resume II 7 (20.6) 4 (11.8) 1 12 (19.1) Specify 0 1 (6.7) 1 2 (9.1) p=NS Rosenow, et al JNS Spine 2006

  21. Poor Coverage Lead Location (%) HardwareCervicalThoracolumbarThoracicTotal Percutaneous 13 (10.5) 43 (16.7) 2 58 (14.8) Resume II 2 (5.8) 4 (11.8) 0 6 (8.7) Specify 1 (20) 1 (6.7) 0 2 (9.1) P<0.001 Rosenow, et al JNS Spine 2006

  22. Hardware Breakage Hardware Location (%) HardwareCervicalThoracolumbarThoracicTotal Percutaneous 13 (10.5) 12 (4.7) 0 25 (6.4) Surgical 8 (20.5) 2 (4.1) 0 10 (11.0) Extension 8 5 1 14 P=0.004 Rosenow, et al JNS Spine 2006

  23. Conclusion • Paddle leads not perfect • With proper technique, complications can be minimized • Unknown if more contacts really improve outcome

  24. Thank you for coming! E-mail: jrosenow@nmff.org Phone: 312-695-0495

More Related