Paddle SCS Leads: Advantages and Limitations
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Northwestern University Department of Neurosurgery
Paddle SCS Leads:
Advantages and LimitationsJoshua M. Rosenow, MD, FAANS, FACSDirector, Functional NeurosurgeryAssociate Professor of Neurosurgery, Neurology and Physical Medicine and RehabilitationNorthwestern Memorial Hospital
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Northwestern University Department of Neurosurgery
DisclosuresCorporate Ownership, Equity, Stocks, Bonds None
Corporate Consultant Contracts – Boston Scientific Neuromodulation Yes
Corporate Fiduciary or Board Positions None
Non-Profit Board Positions –Medical Advisory Board, Epilepsy Foundation of Greater Chicago
Yes
Grants – Co-investigator on grants from brain research foundation, NMH Dixon Fund, DoD, NIDDR, Christopher Reeve Foundation
Yes
Patents None
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Northwestern University Department of Neurosurgery
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.
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Northwestern University Department of Neurosurgery
Why use paddles?
Previous difficulties with perc leads
Preference of implanter
?lower current requirement
?less interference by epidural fat
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Northwestern University Department of Neurosurgery
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.
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Northwestern University Department of Neurosurgery
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
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Northwestern University Department of Neurosurgery
Limitation: Guess the level!
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Northwestern University Department of Neurosurgery
Communication is key
T9
T10
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Northwestern University Department of Neurosurgery
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
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Northwestern University Department of Neurosurgery
Paddle leads: Fallacy
“Don’t worry that we didn’t cover that area in
the trial, the paddle lead will fix everything.”
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Northwestern University Department of Neurosurgery
Paddle Leads: Contact Proliferation
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Northwestern University Department of Neurosurgery
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”
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Northwestern University Department of Neurosurgery
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%.
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Northwestern University Department of Neurosurgery
Paddle Lead Injuries
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Northwestern University Department of Neurosurgery
Paddle Lead Injuries
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Northwestern University Department of Neurosurgery
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
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Northwestern University Department of Neurosurgery
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
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Northwestern University Department of Neurosurgery
Paddle Implant – Anesthesia TechniqueMAC
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
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Northwestern University Department of Neurosurgery
SCS Electrodes
Lead Location
Hardware Cervical Thoracolumbar Thoracic Total 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
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Northwestern University Department of Neurosurgery
Electrode Migration
Location of electrode
Hardware Cervical Thoracolumbar Thoracic Total 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
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Northwestern University Department of Neurosurgery
Poor Coverage
Lead Location (%)
Hardware Cervical Thoracolumbar Thoracic Total 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
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Northwestern University Department of Neurosurgery
Hardware Breakage
Hardware Location (%)
Hardware Cervical Thoracolumbar Thoracic Total 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=0.004Rosenow, et al JNS Spine 2006
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Northwestern University Department of Neurosurgery
Conclusion
Paddle leads not perfect
With proper technique, complications can be minimized
Unknown if more contacts really improve outcome
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Northwestern University Department of Neurosurgery
E-mail: [email protected]
Thank you for coming!
Phone: 312-695-0495
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Northwestern University Department of Neurosurgery