A unique approach to neurostimulation in patients with previous two-segment spine surgery and obstruction of epidural access for spinal cord stimulation: a case series.

INTRODUCTION: Patients with extensive surgery in the lumbar and thoracic spine are often not considered for neurostimulation due to the inability to perform a conventional spinal cord stimulation (SCS) trial. We are presenting six such patients in which spinal-peripheral neurostimulation (SPN) was used via a caudal approach. METHODS: Six patients with intractable low back and leg pain following extensive lumbar and thoracic surgeries, up to at least the T10 level, underwent a stimulation trial with one caudal lead and one subcutaneous lead in order to achieve SPN. RESULTS: In five cases, the trial was successful with coverage of the pain area and at least satisfactory pain relief. All six patients were implanted with a paddle lead(s) and a subcutaneous lead using SPN with good pain control. CONCLUSION: SPN with a caudal lead appears to be a viable option for SCS trial in patients with no possibilities for conventional trial lead placement.

Weaving basic and social sciences into a case-based, clinically oriented medical curriculum: one school's approach.

Southern Illinois University School of Medicine recently completed its fourth year of a resource-session-enhanced, case-based, tutor-group-oriented curriculum. As an example of a curricular unit, the authors describe the implementation of the basic and clinical sciences in one of the four units in year one, and detail that unit's organization, logistics, content, rationale, and other characteristics. The Sensorimotor Systems and Behavior (SSB) unit is preceded by a cardio-respiratory-renal unit and is followed by an endocrine-reproductive-gastrointestinal unit. A Doctoring unit temporally spans each of these three units. The SSB unit is allotted an 11.5-week period that includes an aggregate of 2.5 weeks of available clinical time, 1.5 weeks for examinations and exam study time, and approximately 8.5 weeks for tutor-group sessions, mandatory laboratory sessions, and self-directed learning. Optional resource sessions are offered during a two- to four-hour block on a single morning each week. Clinical training in the SSB unit augments self-directed, laboratory, and tutor-group learning of neuroscience, gross anatomy, cell biology, physiology, biochemistry, behavioral and social science, embryology, limited pharmacology and genetics, and basic clinical neurology for first-year students. Although it is fast-paced and places heavy responsibility for independent learning on the students, the SSB unit culminates in significant achievement in the basic and clinical sciences. The unit provides substantial clinical training and practical experience in physical and neurological examinations that directly integrate with basic science knowledge. The unit reduces lecture-based instruction, demands self-determination, and promotes experience in team effort, professionalism, peer interaction, empathy in clinical medicine, and practical use of basic science knowledge.