World’s First and Only System with 32 Contacts and 32 Dedicated Power Sources is Designed to Provide Pain Relief to a Broad Spectrum of Chronic Pain Patients. On December 7, 2012, Boston Scentific received European Regulatory approval for the Precision Spectra™ spinal cord system.
The IPG pocket gets crowded with two splitters feeding into the can. I recommend creating a dual layer pocket with the deepest layer for the splitters and the superficial pocket for the IPG. This keeps the leads coiled nicely below.
This is a 28 year old male with history of ilioinguinal neuralgia after a hernia repair with nerve involvement. He had a successful trial at T12-L1 for L1-L2 roots and was felt to be a good candidate for permanent implant.
I typically place paddles via a midline laminotomy, but in this case I wanted to preserve the midline structures in this young patient at the thoracolumbar junction. I placed two Exclaim paddles end to end like loading shells in a rifle.
This is a 58 year old man who had a L4-5 fusion for mobile spondylolisthesis with marked improvement in his low back and leg pain, but had persistent midback pain.
Mid back coverage without getting legs is somewhat difficult. I typically start at T6-7 and retreat the lead, but in this case the coverage was lower than expected.
The 16 contact Infinion™ by Boston Scientific allows you to troll the spinal cord after implant to better isolate the sweet spot. As with all of my cases, I have my rep mark the sweet spot for final implantation.
The downside is somewhat awkward splitter that divides the 16 contact lead into two octrodes that fit in an external IPG. As shown here, the Infinion™ trial lead only comes in 50cm lengths. I prefer the longer 70cm length to get the splitter off the midline and over the flank for a more comfortable trial. You have to use a 70cm permanent lead as a trial to do this.
As a trialing lead this gives you the optimum level for permanent implantation.
This case came from a very experienced trialing physician who could not remove the previously placed St. Jude trial lead. He called me when the lead broke three inches from skin insertion after attempting to pull it out in the post-op clinic. He tried numerous positions with the patient flexing and extending, but the lead would not withdraw. I instructed him to pull the lead as much as he could then thorough prep the insertion point and cut the lead with sterile scissors. Then the presumably sterile remainder would withdraw into the wound and the tract would close. The patient was kept on antibiotics and taken to the operating room on week later for retrieval and permanent implantation.
The lead was harvested from a skin incision over the remaining tail and withdrawn. The lead was pinched in the lateral portion of the interlaminar space adjacent to the facet. A Penta paddle was placed at the previous target level and patient tolerated the procedure well.
Patients with previous laminectomies are very difficult to trial due to the extensive epidural scarring. While it is possible to go ventral to the cord and come back dorsal above the scar, this is seldom well tolerated by patients. I prefer to use an open trial technique where I perform a laminectomy immediately above the scar and bring the leads in from a tuoy needle below. That way I can close the wound and then pull the leads at a later date as a typical trial. If the patients goes perm I can insert the paddle at the new laminectomy site with little difficulty if done within a couple of weeks.
This anchor provides excellent purchase on the leads. While used for a paddle here, they are even better suited to percutaneous leads to reduce migration.
There are some great surgery training videos on YouTube. I highly recommend these which illustrate basic suture technique, instrument tie, one-handed tie and two-handed tie. Personally, the instrument tie is the easiest followed by one-handed tie. A lot of surgery training programs say to learn the two-handed tie, but I think it is a waste of time since it is hardly ever used and IMO is harder than the one-handed tie.
Migrated percutaneous leads remain a common complication. I believe most caudally migrated leads are the result of poor suture techniques or broken suture. Review suture techniques here.