This method can help answer key question in the neurostimulation field, about spinal cord stimulation efficiency for treating low back pain in failed back surgery patients. The main advantage of this technique is that it allows the device position to be standardization for optimal paresthesia coverage for full to back and leg pain areas. With the patient in the prone position use fluoroscopic assistance to identify the incision site between the T10 and T11 spinous processes.
Infiltrate the incision site with five milliliters of a 20 milliliter solution of 0.5%bupivacaine, and 1-to-200, 000 adrenaline. Next, use a surgical blade to make an incision through the skin and dorsal musculature until the thoracic aponeuroses are revealed. Place a retractor into the incision, and dissect the paravertebral musculature on both sides of the T10 superspinous process, and resect the superspinous and interspinous ligaments.
Dissect the T10 lamina five millimeters on each side of the process, and five millimeters in the cranial caudal direction, and perform a partial T10 laminectomy. When enough space has been created for the lead, use fluoroscopic guidance to insert the phantom lead into the epidural space, while keeping the insertion of the flavum ligament on the upper part of the T11 lamina intact. Place the lead as medially as possible, until it is midline to the projection of the T8 to T9 bodies, and fix the lead to the interspinous T11 ligament with a single interrupted stitch.
If the lead is positioned within the midline of the epidural space in the T8 to T9 projection, remove the retractor, and confirm a lack of bleeding. Using simple interrupted stitches of braided synthetic absorbable suture material, close the musculoaponeurotic layer, and connect the two intrinsic external extensions to the two extrinsic external extensions. Tunnel the extensions into the subcutaneous fat, so that the extensions exit the skin 15 centimeters lateral to the incision site.
Use simple interrupted stitches of braided synthetic absorbable suture material to wrap the intrinsic and extrinsic extensions, and to close the subcutaneous layer. If the lead is still positioned within the midline of the epidural space in the T8 to T9 projection, then use finer absorbable 3-0 suture material to make a dermic subcuticular suture, and apply antiseptic and bandages. A few hours after the surgery, connect the external neurostimulator to the extrinsic external lead extensions, and place the clinician programmer onto the external neurostimulator.
Turn on the clinician programmer and the neurostimulation with a pulse width set to 260 milliseconds, at a rate of 60 Hertz. Next, use the guarded cathode configuration to first test a transverse tripolar configuration at the top of the lead. If this configuration provides sufficient paresthesia coverage and/or pain suppression, increase the pulse width to 450 milliseconds to fine-tune the back pain area coverage, and to allow enlargement of the stimulation area, adjusting the pulse rate between 40 and 60 Hertz to obtain the most satisfying paresthesia coverage of the painful area.
Then, use sharp scissors to cut the external extension flush with the skin, to reduce the risk of infection until the next surgical procedure. In this representative, prospective, non-randomized, controlled study of 62 consecutive failed back surgery syndrome patients who were implanted with a multicolumn lead, leg pain, back pain, and daily activity limitations were significantly improved during the entire follow-up period. Once mastered, this technique can be completed in 30 minutes, if it's performed properly.
While attempting this procedure, it's important to use sterile technique, as infection is the biggest complication of this procedure.
