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10 Articles in Volume 10, Issue #1
An Overview of CRPS
Balancing Evidence, Efficacy and Stakeholder Values in Practical Pain Care
Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients
Dextrose Prolotherapy Injections for Chronic Ankle Pain
Genetic Influences on Pain Perception and Treatment
Headache in Children and Adolescents
Hormone Replacements and Treatments in Chronic Pain: Update 2010
Opioid Treatment 10-year Longevity Survey Final Report
Therapeutic Laser in the Treatment of Herpes Zoster
Use and Effectiveness of Spinal Cord Stimulation

Use and Effectiveness of Spinal Cord Stimulation

Spinal cord stimulation has been one of the major advances in the efficacious and cost-effective treatment of chronic pain patients with multiple different pain processes—particularly of cervical and lumbar spinal origin.
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Pre-epidural Adhesions

I have identified a group of patients who have what I feel to be pre-epidural adhesion formation. There has been some speculation that the formation of these adhesions occurs in patients who have had previous surgeries or simply chronic pain conditions. There are some additional theories and thoughts on how chronic pain relates to the formation of these adhesions. I have identified these patients in the following manner. I get a clear loss of resistance that identifies the epidural space. When I try to advance the leads, even though they do advance beyond the tip of the needle, it is not a smooth advance and/or the needle makes immediate turns to the right or left together with some additional resistance. I have found that by taking a shallow angle and advancing minimally, just a millimeter or so at a time, I can advance beyond this section of the pre-epidural adhesions. I have done this on numerous occasions and have found that this simple advancement allows for easy flow of the leads and much easier positioning of the needle distally. This phenomenon may be similar to cases where we enter the epidural space easily, advance without problem, and then suddenly run into “a brick wall.” These are probably some form of the same pre-epidural adhesions. The tap method is used, and I have found it to be effective in advancing beyond these impairments for successful lead placement. This is frequently done with a stiff stylet and I find I can frequently accomplish this with my favorite stiff stylet. Simply advance the needle until it is at the point of impediment and then slightly withdraw about one-half to one centimeter and gently but quickly advance the guidewire, tapping through the adhesions. Typically it is quite easy and only causes the patient any significant discomfort in a select few cases. Fre-quently, when advancing leads through the epidural space, a patient will describe some immediate, but very temporary radiating discomfort, which I believe is due to some form of epidural adhesion causing a pulling or tugging on the nerve roots. The key takeaway here is that whatever discomfort the patient has, it is very temporary. If the patient has persistent pain with either the tap method or advancing through the epidural space, in my opinion, the procedure should be discontinued.

Additional Pearls

Frequently, upon implantation and for a variety of different reasons, the lead will want to angulate right or left. If a patient can tolerate it and you cannot get the needle back to midline, I sometimes use what I refer to as a “bounce” method, which is basically bouncing off a lateral position in the epidural space and letting the lead curve back towards the midline. Following this manipulation, lateral x-rays should be done to assure a posterior position of the lead. Though it has not been previously stated, lateral x-rays are used at various points and routine positioning to assure appropriate posterior positioning. As long as the patient does not experience any significant pain or discomfort toward the abdomen or chest wall—and lateral imaging does not reveal that the lead has moved into the anterior space—I think this is a reasonable approach.

Additionally, to achieve minor adjustments in placement, I have found that the easiest and most effective method, in addition to using a stiff, curved stylet, is manipulating the end of the needle from the stylet tip by turning and twisting so that the stylet points into the desired direction. Twist until the fluoroscopy shows the tip of the lead pointing in the desired direction, then slowly advance and re-fluoroscope. If this is ineffective, an additional method can be used and that is gentle manual manipulation of the needle with the lead completely with-drawn proximal to the tip in the desired direction. While applying gentle manual rotation of the tip, gently advance the needle. Re-fluoroscope and see if you have now achieved the desired effect.

Summary

Spinal stimulation is one of the most important advancements in the treatment of chronic pain patients and has quickly become a key therapy chronic pain treatment for all pain practitioners. Any physician who has a patient with chronic leg or arm pain from multiple etiologies or chronic back or neck pain, should refer their patients to a trained, knowledgeable, and experienced interventional pain practitioner who has substantial experience with spinal cord stimulation.

Appropriate identification of anatomical markers and familiarization with the appropriate approach angulations will help ensure a successful implant procedure. The key points identified for some challenging patient categories might provide you with some helpful techniques and aid in overcoming a few of these challenges. If you have not reviewed the Holsheimer/Barolat study, I highly recommend it as an excellent reference for lead placement.

Disclosure

Dr. Donnini does not have affiliations, sponsorships, or grants from any equipment companies or drug companies.

Last updated on: January 5, 2012
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