2018 FSA Posters

P030: METHODS FOR ADVANCING CERVICAL EPIDURAL SPINAL CORD STIMULATOR LEADS
William Grubb, MD, Oren Ambalu, MD, Supreet Grewal, MD, Oleksiy Lelyanov, DO; RWJMS/Rutgers

A 44 year old female presented to our service for management of radicular arm pain secondary to spinal stenosis.  The patient had participated in a narcotic reduction therapy concurrent with interventional blocks and non-narcotic adjuncts. At the conclusion of therapy, the patient agreed to spinal cord stimulator trial with St. Jude Medical.

After informed consent, the patient was placed prone and a sterile field was established.  The procedure was performed while the patient was given sedation but remained interactive.  Using fluoroscopic guidance, sterile epidural access was established at a T12-L1 interspace and a 90 cm percutaneous St. Jude lead was placed to the C5 level.  Upon difficulty for further advancement, subsequent efforts to place the lead to the desired C2 level were accomplished with the following techniques: 

1) In AP view (picture 1), a curved tip stylet was used to steer towards midline.
2) Continuing in AP view (picture 2), while the lead remained in the patient, the stylet was changed to a straight tip.
3) The lead was gently moved cephalad against slight resistance to the C2 level.
4) Lateral fluoroscopy was use to ensure the lead remained posterior (picture 3).

The SCS trial proved to be successful with significant improvement in the patient's symptoms with no complications. A permanent St. Jude SCS implant was later successfully placed with percutaneous leads using similar techniques.

Discussion: Cervical SCS trials require lead placement to the top of the C2 level. There are few descriptions in the literature to assist with troubleshooting for this placement. We had used a technique of having the patient adjust head position to facilitate the cephalad advancement of the lead. We have recently adopted the technique of changing the epidural stylets while maintaining the lead within the patient. This allows for more precise steering of the lead in the epidural space within the narrow cervical canal.   It is important to confirm the leads are maintaining a posterior position while advanced, by frequently referencing the lateral fluoroscopic image.

References: Kreis; Fishman. Spinal Cord Stimulation; Oxford University Press,Chapter 7; 2009