Thoracolumbar Spinal Cord Stimulation

Chapter 19 Thoracolumbar Spinal Cord Stimulation

Ruby E. Kim, Michael B. Furman

Spinal cord stimulation is typically used as a last resort for patients who no longer have any other treatment options. It is typically used for patients who have had prior lumbosacral surgery. It is best for patients with a larger component of neuropathic appendicular as opposed to axial pain. Other indications include complex regional pain syndrome, painful peripheral neuropathy, and phantom limb pain. In Europe, spinal cord stimulation has been described for vascular claudication and angina.

The technique described in this chapter follows the algorithm that has been described elsewhere in this book. In particular, we make use of a trajectory view to identify the oblique and tilt angle (i.e., the entry point) for the placement of the introducer needle. Note that the angle of the needle is as shallow as possible so that the stimulator lead will smoothly exit the needle into the posterior epidural space, riding along the patient’s midline until the electrodes reach the level at which the patient’s pain symptoms are covered, which is often between T7-T8 for axial pain and between T8-T10 for appendicular pain. To obtain that smooth exit, the needle needs to have a shallow angle relative to the patient (i.e., as parallel to the patient’s body as possible). Because we are using trajectory, contralateral oblique, and lateral safety views, it is not necessary to step off of the lamina with our described technique.

Note: Please see page ii for a list of anatomical terms/abbreviations used in this book.

Trajectory View

Confirm the targeted interlaminar space with the anteroposterior view. (We target T12-L1 here).

Pearl: The safest needle entry point is at L2-L3, below the cauda equina. The dura is more distensible here, which averts needle injury to the spinal cord. Then, the lead may be advanced to the appropriate level. This consideration may be important with obese patients in which an acute needle angle to the coronal plane may not be possible.

With a radiopaque marker at targeted interlaminar space, begin tilting the C-arm image intensifier as caudally as possible to obtain the trajectory view.

Slightly oblique the C-arm contralateral to the symptomatic side so that the introducer will be set up to help guide the stimulator lead. The lead will have a tendency to travel contralateral to the side of entry, thereby making this technique an efficient method of facilitating proper lead positioning.

Anesthetize the skin over the targeted interlaminar space, and use an 18-gauge, 1.5 inch needle needle to dilate the skin. Remove the 18-gauge needle, and use the introducer needle to obtain the trajectory needle view. Because this is the trajectory view, the needle entry position should be parallel to the C-arm beam. Note that the angle of the needle is as shallow as possible as described in this chapter’s introduction (Figure 19–1).

Figure 19–1 A, Fluoroscopic image of trajectory view with the needle tip in position over the T12-L1 interlaminar space. Note the very shallow tilt angle relative to the patient; this is a much more caudad tilt than would be used for a standard interlaminar epidural steroid injection. B, Radiopaque structures, trajectory view. C, Radiolucent structures, trajectory view.

There are typically no other radiolucent structures that are safety considerations in this trajectory view aside from advancing the needle too far ventrally. Please use the other views for needle advancement to best visualize the corresponding landmarks.

Tags: Atlas of Image-Guided Spinal Procedures

Dec 23, 2015 | Posted by admin in INTERVENTIONAL RADIOLOGY | Comments Off

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