Spinal cord stimulation (SCS) is an effective treatment modality for refractory chronic neuropathic pain conditions.1–3 The most common indication for SCS in the United States is persistent back and leg pain after spine surgery, also known as failed back surgery syndrome.1,2 The placement of SCS leads for failed back surgery syndrome can be challenging because of adhesions from previous surgical interventions. We herein describe the retrograde cervical approach we used in a 55-year old female patient suffering from thoracic failed back surgery syndrome.
Written informed consent was obtained from the patient for publication of this case report.
A 55-year-old white woman was referred to our pain clinic in 2015 by her primary care physician. She had previously undergone a laminectomy for a herniated disc at L4-L5 in 2000, followed by surgical fusions at the T11-T12 and L4-L5 levels in 2001 for persistent severe low back pain and leg pain. She presented with low back pain and pain radiating to the bilateral legs on the posterior and lateral aspects into the toes. On physical examination, bilateral straight leg-raising tests were positive. Her medications included pregabalin 75 mg twice a day, gabapentin 30 mg thrice a day, and oxycodone 20 mg thrice a day. She had several epidural injections, lumbar medial branch blocks, and a radiofrequency ablation, all of which gave her some degree of short-term partial pain relief. Despite interventions and medications, pain limited her function dramatically. A new magnetic resonance imaging (MRI) demonstrated no significant changes from previous MRI scans. Importantly, there was no laminectomy defect noted at the T10-11 level on her most recent MRI.
SCS or an intrathecal pump trial was then discussed with her as treatment options. She initially was reluctant to proceed with the SCS trial, given her failure with multiple other spinal surgeries in the past. After several discussions, however, she agreed to proceed with the SCS trial and underwent the appropriate psychological clearance. The plan was to pass the lead in an anterograde fashion from the L1-2 level with 14-gauge Tuohy needles by the use of two 16 contact leads from Boston Scientific (Marlborough, MA).
The patient was prepped and draped in normal sterile fashion, appropriate antibiotics were given, and the procedure was attempted as planned. The results of a fluoroscopy examination, however, revealed an unexpected laminectomy defect at the T10-11 level. We were able on multiple attempts to pass the defect on either side but were unable to steer the leads back to the necessary midline position. Programming with the leads in multiple positions did not stimulate the back and only partially stimulated the legs. The patient did not find this to be satisfactory.
Because one of the authors (K.B.C.) had previously placed SCS leads retrograde from a cervical level, fluoroscopy was used to evaluate the cervical spine to assess whether this could be a treatment option. There appeared to be adequate space at the C7-T1 level to access the epidural space. Given the patient’s postsurgical changes in the low thoracic epidural space, the only other option for lead placement would be paddle lead placement. We discussed a referral for direct paddle lead placement, a retrograde cervical lead insertion trial, abandoning SCS as a treatment option altogether, as well as an intrathecal pump with the patient. The patient wished to proceed with retrograde cervical placement.
At this point, the drapes were removed and bandages placed over the needle sites. The cervical spine was then prepped and draped in normal sterile fashion. An 18-gauge RX Coudé needle (Epimed, Farmers Branch, TX) was used, which we felt could theoretically help reduce the risk of puncture. With fluoroscopic guidance, the patient was positioned to optimize the view of the C7-T1 interlaminar space and a local anesthetic was injected. Needle entry was at the level of the C7 lamina (Figure 1). The RX Coudé needle was directed to the C7 lamina until contact was made with bone. With an angle of approximately 75 degrees, the needle was then walked caudally and medially towards the interlaminar space. The epidural space was identified by loss of resistance with air.
A 16-contact Boston Scientific lead was then passed through the needle into the epidural space in the midline and passed caudally to the bottom of the T8 level in the midline (Figure 2). We were unable to pass the lead lower than that level. The lead was then connected to the adapter and passed to the representative from the company and testing of the lead was performed. We were able to get coverage of the patient’s pain in the lower back and legs bilaterally. Given the good coverage with a single lead, we decided not to place another lead. The lead was then anchored to the skin with an anchor and 2.0 silk sutures. Steri-Strips (Nexcare, 3M, Maplewood, MN), gauze, and Tegaderm (Nexcare, 3M) were placed over the site. The patient was given a prescription for antibiotics, and a follow-up was scheduled for 7 days after the trial.
Follow-up was uncomplicated, and the patient reported >80% pain relief at the conclusion of the SCS trial with concomitant increase in her function. She was able to stand and walk for prolonged periods of time, which had been impossible before the trial. The patient was then referred for surgical lead placement.
Retrograde placement of SCS leads is well described in the lumbar area to allow access to individual sacral nerve roots to cover the foot, buttock, or perineum.4 The “laterograde” approach described by Richter et al5 is a possible approach for access to the lumbar epidural space. Our approach to cervical placement was somewhat similar in that we took a slightly lateral approach and walked the needle inferiorly to allow the lead path through the needle into the epidural space as straight a path as possible.
There are marked anatomical differences, however, in the cervical spine versus the lumbar spine that change the technique of lead placement. Compared with the lumbar spine, the lamina and spinous processes in the upper thoracic and lower cervical spine form more of a protective shell over the interlaminar space. The interlaminar space is thus much smaller both in width and height. These anatomical factors require a greater angle to access the epidural space while having the needle angling caudally. Moreover, the needle has to be close to the midline to prevent the lead from traveling laterally into the gutter, irritating the nerve roots, or traveling anteriorly. All these factors make the retrograde cervical approach technically much more challenging than the antegrade lumbar approach. Therefore, retrograde lead placement rarely is performed in higher segments of the spine. Upon literature review, we found one case of cervical retrograde lead placement to treat lumbar radiculopathy. Perper6 reported a case similar to our case with entry in the cervical spine and lead placement retrograde to the T7-T8 level with optimal coverage.
Lead migration is a common complication associated with SCS lead placement.7 Lead migration occurs when directional forces and tensile load on the electrode exceed the stabilizing forces of the anchor.8 These are dependent on suturing technique, integrity of the strain relief loop, anchoring orientation, trajectory into the epidural space, and the site of the battery placement. During lumbar flexion with anterograde lead placement, the lead is likely to migrate in a caudad direction. Conversely, lead migration will favor cephalad displacement with retrograde lead placement and neck flexion, potentially leading to aberrant stimulation in thoracic dermatomes.
Because of the aforementioned risks, this technique should only be considered by experienced implanters as a last resort when anterograde placement is impossible because of adhesions or when entry in the lumbar area is undesirable because of local skin abnormalities. Cervical retrograde lead placement, however, may be a solution in the subset of patients with failed back surgery syndrome who have undergone multiple spine surgeries. These patients often refuse the option of surgical paddle lead placement because they perceive this surgery as “yet another one.”
Retrograde cervical insertion of leads is performed infrequently but may represent an efficient alternative method for successful placement of percutaneous leads for SCS in patients with abnormal anatomy due to postsurgical changes that would otherwise be untreatable with SCS. Further studies should clarify the applicability and safety of this approach.
The authors extend their gratitude to the patient described in this case for granting her permission to publish this instructive case report.
Name: Noud van Helmond, MD.
Contribution:This author helped prepare the figures, and write and revise the manuscript.
Name: Caroline N. Kardaszewski, MA.
Contribution: This author helped revise the manuscript, and assist with the procedure.
Name:Kenneth B. Chapman, MD.
Contribution:This author helped treat the patient in the case, perform the procedure in this case, and revise the manuscript.
This manuscript was handled by:Raymond C. Roy, MD.
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