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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.

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Paddle SCS Leads: Advantages and Limitations

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  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

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