Hypodermis Tension Loop: A New Preventative Measure for Lead Migration in the Morbidly Obese.

Electrode migration/displacement is reported to be the most common complication of spinal cord stimulator (SCS) implantation, with the literature reporting incidences from 13.2% to 22.6%. There have been numerous publications describing techniques preventing lead migration, with most involving tying leads to skin and fascia for trial and permanent leads, respectively. However, few have addressed how to prevent migration in the case of hypermobile tissue seen in the morbidly obese. We describe the creation of subcutaneous tension loops to prevent lead migration.

The utility of bone cement to prevent lead migration with minimally invasive placement of spinal cord stimulator laminectomy leads.

BACKGROUND: Lead migration is a significant concern with spinal cord stimulator (SCS) placement with rates ranging from 10% to 60%. OBJECTIVE: To describe a novel technique using bone cement at the laminotomy site to help prevent lead migration after minimally invasive placement of laminectomy paddle leads and to present our short-term results. METHODS: A review of a prospectively maintained database identified all patients who underwent minimally invasive placement of laminectomy leads with the use of bone cement. All procedures were performed between July 2008 and August 2010 with conscious sedation and local anesthetic. Intraoperative testing was performed to confirm good pain coverage. A small volume of bone cement (1-3 cm) was then placed to cover the laminectomy defect. Radiographic and clinical follow-up was assessed. RESULTS: Forty-two patients (mean age, 58.0 years) underwent 42 procedures. Back pain (88.1%) and leg pain (88.6%) were the most common presenting symptoms. No intraoperative complications were noted. Two patients (4.8%) required removal of their devices because of nonhealing wounds. All patients were followed up for a minimum of 6 months, and no cases of clinical or radiographic lead migration were seen at the time of publication. CONCLUSION: We present a novel technique in the hopes of decreasing the incidence of lead migration after minimally invasive placement of spinal cord stimulator laminectomy paddle leads. Our results have been promising thus far with no cases of lead migration.

Rates of lead migration and stimulation loss in spinal cord stimulation: a retrospective comparison of laminotomy versus percutaneous implantation.

BACKGROUND: Neuromodulation has been used to treat neuropathic pain. Leads have been implanted using laminotomy or percutaneous approaches. Laminotomy implantation has been shown to be superior in terms of lead migration when compared to percutaneous implantation. Lead migration has been reported as high as 68% with the percutaneous approach. Because of this, newer anchors have been developed but not tested in vivo. OBJECTIVES: This study tests the hypothesis that newer anchoring systems have improved lead migration rates for percutaneous leads relative to laminotomy leads to the point of parity. This study also analyzed if factors such as laterality of symptoms, lead type, level of implant and diagnosis affect migration rates. STUDY DESIGN: Neurostimulators implanted in the thoracolumbar spine at Henry Ford Hospital between 2006 and 2008 were reviewed for the following: age, sex, diagnosis, lead type, and implant level. Implants were reviewed for the following: age, sex, diagnosis, lead type, implant level, implant method, symptom laterality, loss of stimulation, radiographic lead migration, and time to loss. Loss of capture and lead migration in the laminotomy and percutaneous groups were compared using Fisher's exact test. Variables within each group included: lead type, level of implantation, location of symptoms, and diagnosis. They were compared using Fisher's exact test. Time to loss of stimulation was compared using the Wilcoxon 2-sample test. SETTING: Pain Clinic, Henry Ford Hospital, Detroit, MI. RESULTS: Laminotomies were performed by a single neurosurgeon and percutaneous implants were performed by a single pain medicine specialist. Percutaneous leads were anchored using Titan (Medtronic Corporation, Minneapolis, MN) anchors. Loss of capture was 24% laminotomy and 23% percutaneous with no significant difference between the 2 groups (P = 0.787). Radiographic evidence of migration was 13.63% percutaneous and 12.67% laminotomy with no significant difference (P = 0.999). The average days to loss of stimulation for the laminotomy versus percutaneous were as follows: 124.82 and 323.6 which were not statistically significant. There was no statistical difference in the days to loss of capture between the groups (P = 0.060). There was no significant difference between unilateral or bilateral symptoms in loss of capture within either group (P = 0.263, P = 0.326). There was not enough data to do comparisons by diagnosis. Comparisons of loss of capture based on electrode type was not significant in either group (P = 0.687, P = 0.371). The effect of the spinal level on the lack of recapture rates was not able to be calculated due to the number of levels. LIMITATIONS: Retrospective study. CONCLUSION: Rates of stimulation loss and radiographic lead migration are similar for both laminotomy and percutaneous implantation. Time to loss of stimulation was not statistically different in either group, although there was a trend toward laminotomy leads migrating earlier. Lead type and laterality of symptoms do not affect lead migration rates. The effect of the level of implant and diagnosis was indeterminate.

Occipital nerve stimulation (ONS). Surgical technique and prevention of late electrode migration.

Occipital nerve stimulation (ONS) is an emerging procedure for the treatment of cranio-facial pain syndromes and headaches refractory to conservative treatments. The aim of this report is to describe in detail the surgical intervention and to introduce some useful tricks that help to avoid late displacement and migration of the suboccipital leads. The careful description of the surgical steps may contribute to a standardization of the procedure and make the interpretation of results easier even if obtained in series of patients operated on by different authors.

Prevention of percutaneous electrode migration in spinal cord stimulation by a modification of the standard implantation technique.

OBJECT: Percutaneous spinal cord stimulation (SCS) electrodes are prone to migration even after scar tissue encapsulation. The authors devised a simple technique to eliminate longitudinal migration. METHODS: In 99 patients who received implanted percutaneous electrodes, less than 0.1 cm3 of silicone elastomer adhesive was injected between the anchoring sleeve and the electrode. As a result, no patient required revision surgery due to longitudinal electrode migration over a mean follow-up period of 20.2 +/- 12.3 months (range 1.8-39.7 months). Postimplant SCS-related surgical procedures were required in 15 patients (15%) for the following indications: infection in three patients, expanded area of pain in four patients, lateral migration after the sutures eroded through the supraspinous ligament in one patient, postural changes in stimulation in one patient, receiver-site pain in two patients, technical failure in three patients, and inadequate pain relief in one patient. CONCLUSIONS: With modification of the standard technique for implantation of percutaneous SCS electrodes, no longitudinal migration of electrodes was noted in this series of 99 patients.

Repeated subarachnoid catheter displacement as a complication of spinal infusion using an internal infusion pump.

OBJECTIVE: To present and analyze the case of a woman receiving chronic spinal opioid therapy using an implanted infusion pump who experienced repeated displacement of the subarachnoid catheter despite the use of standard techniques for anchoring the catheter. The solution devised to avoid the problem is described. CASE REPORT: A 53-year-old woman was diagnosed with transverse myelitis 10 years earlier and she developed T7-T10 spinal cord atrophy, and pain below the T7 segment. After unsuccessful noninvasive pharmacological treatment, a spinal opioid infusion protocol was begun. On 3 occasions during the course of therapy, despite the use of standard measures for anchoring the system, catheter displacement into the subcutaneous pouch of the pump occurred. After the last such episode, a specially designed technique was used, anchoring the catheter by means of a silicone piece, and the injection of 2.5 mL of fibrin glue in the epidural space. CONCLUSIONS: The application of fibrin glue (Tissucol; Immuno AG, Vienna, Austria) may be considered as an adjuvant for the fixation of subarachnoid catheters used for intraspinal infusions.