Novel use of intraoperative dexmedetomidine infusion for sedation during spinal cord stimulator lead placement via surgical laminectomy.

BACKGROUND: Spinal cord stimulators are most often placed through a percutaneous approach using minimal sedation and local anesthesia to facilitate intraoperative testing. However, when leads need to be placed using a laminectomy incision additional anesthesia is required which can complicate intraoperative testing. There is no consensus as to the best anesthetic choice when laminectomy-placed leads are required. OBJECTIVE: We present 2 cases where spinal cord stimulator leads were implanted through a surgical laminectomy under sedation using dexmedetomidine infusion and local anesthesia to provide a cooperative patient for intraoperative testing. CASE REPORT: Patient #1: A 40-year-old female with Complex Regional Pain Syndrome secondary to an automobile accident who had good pain control with a spinal cord stimulator until a lead fracture resulted in loss of stimulation. She required a laminectomy-placed lead which was implanted under dexmedetomidine infusion and local anesthesia. Patient #2: A 54-year-old female with Failed Back Syndrome who had good pain control until a lead fracture resulted in loss of stimulation. She underwent a laminectomy-placed lead, new battery pocket, and removal of the old system under a dexmedetomidine infusion and local anesthesia. LIMITATIONS: Report of only 2 cases. CONCLUSIONS: The anesthetic management from a laminectomy-placed spinal cord stimulator can present a difficult choice. A general anesthetic or even deep sedation can provide good operative conditions but limits intraoperative testing or in the case of deep sedation risks losing the airway in the prone position. On the other hand, minimal sedation, which facilitates intraoperative testing, can make the surgical procedure extremely uncomfortable or even unbearable. Dexmedetomidine infusion and local anesthesia provide sedation for the operative portions while rendering the patient alert and cooperative during intraoperative testing.

Vagal nerve stimulation: overview and implications for anesthesiologists.

Vagal nerve stimulation is an important adjunctive therapy for medically refractory epilepsy and major depression. Additionally, it may prove effective in treating obesity, Alzheimer's disease, and some neuropsychiatic disorders. As the number of approved indications increases, more patients are becoming eligible for surgical placement of a commercial vagal nerve stimulator (VNS). Initial VNS placement typically requires general anesthesia, and patients with previously implanted devices may present for other surgical procedures requiring anesthetic management. In this review, we will focus on the indications for vagal nerve stimulation (both approved and experimental), proposed therapeutic mechanisms for vagal nerve stimulation, and potential perioperative complications during initial VNS placement. Anesthetic considerations during initial device placement, as well as anesthetic management issues for patients with a preexisting VNS, are reviewed.