Northwestern University Department of Neurosurgery

Paddle SCS Leads:

Advantages and LimitationsJoshua M. Rosenow, MD, FAANS, FACSDirector, Functional NeurosurgeryAssociate Professor of Neurosurgery, Neurology and Physical Medicine and RehabilitationNorthwestern Memorial Hospital

Northwestern University Department of Neurosurgery

DisclosuresCorporate Ownership, Equity, Stocks, Bonds None

Corporate Consultant Contracts – Boston Scientific Neuromodulation Yes

Corporate Fiduciary or Board Positions None

Non-Profit Board Positions –Medical Advisory Board, Epilepsy Foundation of Greater Chicago

Yes

Grants – Co-investigator on grants from brain research foundation, NMH Dixon Fund, DoD, NIDDR, Christopher Reeve Foundation

Yes

Patents None

Northwestern University Department of Neurosurgery

Disclosures

I place both paddle and percutaneous leads

I think the current generation of leads/IPGs are all actually

rather good

While I am not happy paying ARod to undergo another hip

surgery, the Yankees total OPS may have just increased. Of

course we still need a catcher and outfielder.

Northwestern University Department of Neurosurgery

Why use paddles?

Previous difficulties with perc leads

Preference of implanter

?lower current requirement

?less interference by epidural fat

Northwestern University Department of Neurosurgery

Paddle Trial

Lumbar fusion or laminectomy precluding

percutaneous insertion

Inability to access the epidural space

percutaneously Bony anatomy

Obesity

Prior procedure in the region of the implant Tumor resection, etc.

Northwestern University Department of Neurosurgery

Paddle Trial: Limitation

Limited ability to test multiple locations

For paddle trial – essentially have to guess

the level

If good coverage not achieved, the

procedure starts to turn into a big deal

Northwestern University Department of Neurosurgery

Limitation: Guess the level!

Northwestern University Department of Neurosurgery

Communication is key

T9

T10

Northwestern University Department of Neurosurgery

Paddle Lead: Innovation

Now possible to place 1x8

paddle via percutaneous

approach using epidural access

dilator

Long term data as to

issues/complications not

available

Northwestern University Department of Neurosurgery

Paddle leads: Fallacy

“Don’t worry that we didn’t cover that area in

the trial, the paddle lead will fix everything.”

Northwestern University Department of Neurosurgery

Paddle Leads: Contact Proliferation

Northwestern University Department of Neurosurgery

You CAN mess up a paddle Paddle placed under GETA

Awoke with right thoracic radicular pain

Never had good coverage with stim

Surgeon told him to “wait a year and see if the coverage and pain improve”

Northwestern University Department of Neurosurgery

Paddle Lead Injuries

Levy, et al Neuromodulation 2011 Data obtained from manufacturers’ database

3 years (2007-2010), 44,587 paddle lead implants

239 (0.54%) neurologic complications. 21 (0.05%) cases of CSF leak Epidural hematoma 83 of 44,587 cases (0.19%)

major motor deficit in 52/83 patients (63%)

Permanent motor deficit with or without EDH - ranges from 0.022% to 0.067%.

Northwestern University Department of Neurosurgery

Paddle Lead Injuries

Northwestern University Department of Neurosurgery

Paddle Lead Injuries

Northwestern University Department of Neurosurgery

Preop imaging is essential

You would never do any other spine case without adequate preop imaging – DON’T START NOW

Preop imaging makes sure something asymptomatic doesn’t become symptomatic

Aids in counseling patient preop if procedure needs to be altered to deal with anatomic issue

Northwestern University Department of Neurosurgery

Complication avoidance

Don’t be overzealous

Don’t push a bad situation If it won’t go, it won’t go…

Caution when dissecting laterally – epidural veins

Poor coverage despite radiographic adequacy check trial fluoros make sure c-arm aligned in both planes

Northwestern University Department of Neurosurgery

Paddle Implant – Anesthesia TechniqueMAC

Allows intraoperative testing

Quicker recovery

May be more difficult in chronic pain patients

General Anesthesia

Physiologic monitoring to verify midline placement

Does not allow geographic coverage verification

May be better for difficult patients or those requiring more extensive procedures

Northwestern University Department of Neurosurgery

SCS Electrodes 

Lead Location

Hardware Cervical Thoracolumbar Thoracic Total Percutaneous Initial 91 191 9 291 (74.2%)

Revision 33 67 1 101 (25.8%)Total 124 258 10 392 (81.3%)

 Resume Initial 12 15 1 28 (39.7%)

Revision 22 19 0 41 (60.3%)

Total 34 34 1 69 (14.1%)

 Specify Initial 1 7 0 8 (36.4%)

Revision 4 8 2 14 (63.6%)Total 5 15 2 22 (4.6%)

TOTAL Initial 104 213 10 327 (67.6%)

Revision 59 94 3 156 (32.4%)Total 163 307 13 483

Rosenow, et al JNS Spine 2006

Northwestern University Department of Neurosurgery

Electrode Migration

Location of electrode

Hardware Cervical Thoracolumbar Thoracic Total Percutaneous 21 (16.9) 28 (10.9) 0 47 (12.0) Resume II 7 (20.6) 4 (11.8) 1 12 (19.1) Specify 0 1 (6.7) 1 2 (9.1)

p=NS

Rosenow, et al JNS Spine 2006

Northwestern University Department of Neurosurgery

Poor Coverage

Lead Location (%)

Hardware Cervical Thoracolumbar Thoracic Total Percutaneous 13 (10.5) 43 (16.7) 2 58 (14.8) Resume II 2 (5.8) 4 (11.8) 0 6 (8.7) Specify 1 (20) 1 (6.7) 0 2 (9.1)

P<0.001

Rosenow, et al JNS Spine 2006

Northwestern University Department of Neurosurgery

Hardware Breakage

Hardware Location (%)

Hardware Cervical Thoracolumbar Thoracic Total Percutaneous 13 (10.5) 12 (4.7) 0 25 (6.4) Surgical 8 (20.5) 2 (4.1) 0 10 (11.0)

Extension 8 5 1 14

P=0.004Rosenow, et al JNS Spine 2006

Northwestern University Department of Neurosurgery

Conclusion

Paddle leads not perfect

With proper technique, complications can be minimized

Unknown if more contacts really improve outcome

Northwestern University Department of Neurosurgery

E-mail: jrosenow@nmff.org

Thank you for coming!

Phone: 312-695-0495

Northwestern University Department of Neurosurgery